Filling the need for trusted information on national health issues

The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid

Issue Brief
  1. U.S. Department of Health and Human Services, Office of The Assistant Secretary for Planning and Evaluation, 2019 Poverty Guidelines. Available at: https://aspe.hhs.gov/poverty-guidelines.

    ← Return to text

  2. Kaiser Family Foundation State Health Facts, “Status of State Action on the Medicaid Expansion Decision,” accessed February 2019, https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/.

    ← Return to text

  3. $9,172 a year for a family of three in 2019.

    ← Return to text

  4. Of the states not moving forward with the expansion, only Wisconsin provides full Medicaid coverage to adults without dependent children. For state-by-state information on Medicaid eligibility, see The Kaiser Family Foundation State Health Facts. “Medicaid Income Eligibility Limits for Adults as a Percent of the Federal Poverty Level.” Data Source: Based on state-reported eligibility levels as of January 1, 2018, collected through a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured with the Georgetown University Center for Children and Families. Available at: https://www.kff.org/health-reform/state-indicator/medicaid-income-eligibility-limits-for-adults-as-a-percent-of-the-federal-poverty-level/.  

    ← Return to text

  5. National and state-by-state estimates of the number of people in the coverage gap may change from year to year due to several factors, including differences in the underlying data, small changes in state Medicaid eligibility, and declines in the number of uninsured people by state as economic conditions improve.

    ← Return to text

  6. Kaiser Family Foundation analysis of the 2017 American Community Survey (ACS), 1-Year Estimates.

    ← Return to text

  7. The "100%-138% FPL" category presented here uses a Marketplace eligibility determination for the lower bound (100% FPL) and a Medicaid eligibility determination for the upper bound (138% FPL) in order to appropriately isolate individuals within the range of potential Medicaid expansions but also with sufficient resources to avoid the coverage gap.

    ← Return to text

  8. The vast majority of these people are eligible for tax credits to subsidize the cost of coverage in the Marketplace, though some (e.g., people with an offer of employer coverage) may not qualify for tax credits.

    ← Return to text

  9. Ken Cannon, Jenna Burton, and MaryBeth Musumeci, Adult Behavioral Health Benefits in Medicaid and the Marketplace (Washington, D.C.: Kaiser Family Foundation, June 11, 2015), https://www.kff.org/medicaid/report/adult-behavioral-health-benefits-in-medicaid-and-the-marketplace/.

    ← Return to text

  10. MaryBeth Musumeci, Julia Paradise, Erica L. Reaves, and Henry Claypool, Benefits and Cost-Sharing for Working People with Disabilities in Medicaid and the Marketplace (Washington, D.C.: Kaiser Family Foundation, October 15, 2014), https://www.kff.org/medicaid/issue-brief/benefits-and-cost-sharing-for-working-people-with-disabilities-in-medicaid-and-the-marketplace/.

    ← Return to text

  11. Larisa Antonisse, Rachel Garfield, Robin Rudowitz, and Samantha Artiga, The Effects of Medicaid Expansion on the ACA: Updated Findings From a Literature Review (Washington, D.C.: Kaiser Family Foundation, March 2018), https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-march-2018/.

    ← Return to text

  12. Ibid.

    ← Return to text

  13. Kaiser Family Foundation, Key Facts about the Uninsured Population (Washington, D.C.: Kaiser Family Foundation, December 2018), https://www.kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/.

    ← Return to text

  14. The methods for arriving at this estimate can be found on the Kaiser Family Foundation Subsidy Calculator and the Kaiser Family Foundation “Change in Average Marketplace Premiums by Metal Tier”, available here: http://www.kff.org/interactive/subsidy-calculator/ and https://www.kff.org/health-reform/state-indicator/change-in-average-marketplace-premiums-by-metal-tier/.

    ← Return to text

  15. Samantha Artiga, Kendal Orgera, and Anthony Damico, Changes in Health Coverage by Race and Ethnicity since Implementation of the ACA, 2013-2017 (Washington, D.C.: Kaiser Family Foundation, February 2019), https://www.kff.org/disparities-policy/issue-brief/changes-in-health-coverage-by-race-and-ethnicity-since-implementation-of-the-aca-2013-2017/.

    ← Return to text

  16. Kaiser Family Foundation, What Does the outcome of the Midterm Elections Mean for Medicaid Expansion? (Washington, D.C.: Kaiser Family Foundation, November 2018), https://www.kff.org/medicaid/fact-sheet/what-does-the-outcome-of-the-midterm-elections-mean-for-medicaid-expansion/.

    ← Return to text

  17. Robin Rudowitz and MaryBeth Musumeci, “Partial Medicaid Expansion” with ACA Enhanced Matching Funds: Implications for Financing and Coverage (Washington, D.C.: Kaiser Family Foundation, February 2019), https://www.kff.org/medicaid/issue-brief/partial-medicaid-expansion-with-aca-enhanced-matching-funds-implications-for-financing-and-coverage/.

    ← Return to text

  18. Elizabeth Hinton, MaryBeth Musumeci, Robin Rudowitz, Larisa Antonisse, and Cornelia Hall, Section 1115 Medicaid Demonstration Waivers: The Current Landscape of Approved and Pending Waivers (Washington, D.C.: Kaiser Family Foundation, February 12, 2019), https://www.kff.org/medicaid/issue-brief/section-1115-medicaid-demonstration-waivers-the-current-landscape-of-approved-and-pending-waivers/.

    ← Return to text

Data and Methods
  1. State Health Access Data Assistance Center. 2013. “State Estimates of the Low-income Uninsured Not Eligible for the ACA Medicaid Expansion.” Issue Brief #35. Minneapolis, MN: University of Minnesota. Available at: http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf404825.

    ← Return to text

  2. Van Hook, J., Bachmeier, J., Coffman, D., and Harel, O. 2015. “Can We Spin Straw into Gold? An Evaluation of Immigrant Legal Status Imputation Approaches” Demography. 52(1):329-54.

    ← Return to text

  3. Based on state-reported eligibility levels as of January 1, 2018. Eligibility levels are updated to reflect state implementation of the Medicaid expansion as of December 2018 and 2017 Federal Poverty Levels but may not reflect other eligibility policy changes since January 2018. The Kaiser Family Foundation State Health Facts. Data Source: Kaiser Family Foundation with the Georgetown University Center for Children and Families. Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost Sharing Policies as of January 2018: Findings from a 50-State Survey, (Washington, DC: Kaiser Family Foundation, March 21, 2018), Available at: https://www.kff.org/medicaid/report/medicaid-and-chip-eligibility-enrollment-renewal-and-cost-sharing-policies-as-of-january-2018-findings-from-a-50-state-survey/.

    ← Return to text

  4. Non-MAGI pathways for nonelderly adults include disability-related pathways, such as SSI beneficiary; Qualified Severely Impaired Individuals; Working Disabled; and Medically Needy. We are unable to assess disability status in the ACS sufficiently to model eligibility under these pathways. However, previous research indicates high current participation rates among individuals with disabilities (largely due to the automatic link between SSI and Medicaid in most states, see Kenney GM, V Lynch, J Haley, and M Huntress. “Variation in Medicaid Eligibility and Participation among Adults: Implications for the Affordable Care Act.” Inquiry. 49:231-53 (Fall 2012)), indicating that there may be a small number of eligible uninsured individuals in this group. Further, many of these pathways (with the exception of SSI, which automatically links an individual to Medicaid in most states) are optional for states, and eligibility in states not implementing the ACA expansion is limited. For example, the median income eligibility level for coverage through the Medically Needy pathway is 18% of poverty in states that are not expanding Medicaid. (See: MACPAC, Medicaid Income Eligibility Levels as a Percentage of the FPL for Individuals Age 65 and Older and Persons with Disabilities by State, 2016. Available at: https://www.macpac.gov/wp-content/uploads/2015/01/EXHIBIT-36.-Medicaid-Income-Eligibility-Levels-as-a-Percentage-of-the-FPL-for-Individuals-Age-65-and-Older-and-Persons-with-Disabilities-by-State-2016.pdf.

    ← Return to text

Appendix A: Household Construction
  1. Steven Ruggles, Sarah Flood, Ronald Goeken, Josiah Grover, Erin Meyer, Jose Pacas, and Matthew Sobek. IPUMS USA: Version 8.0 [dataset]. Minneapolis, MN: IPUMS, 2018. https://doi.org/10.18128/D010.V8.0

    For a detailed description of how IPUMS constructs family interrelationships variables, see https://usa.ipums.org/usa/chapter5/chapter5.shtml

    ← Return to text

  2. Medicaid eligibility in 2017 is based on 2017 poverty guidelines, available at: U.S. Department of Health and Human Services, Office of The Assistant Secretary for Planning and Evaluation, Poverty Guidelines. https://aspe.hhs.gov/poverty-guidelines. Tax credit eligibility in 2017 is based on 2016 poverty guidelines, available at: U.S. Department of Health and Human Services, Office of The Assistant Secretary for Planning and Evaluation, 2016 Poverty Guidelines. https://aspe.hhs.gov/computations-2016-poverty-guidelines.

    ← Return to text

  3. See Internal Revenue Service, Publication 501, Table 1.2018: Filing Requirements Chart for Most Taxpayers. Available at: https://www.irs.gov/publications/p501#en_US_2018_publink1000196863.

    ← Return to text

  4. See Internal Revenue Service, Publication 501, Qualifying Relative. Available at: https://www.irs.gov/publications/p501#en_US_2018_publink1000196863.

    ← Return to text

  5. A detailed explanation of Medicaid and Marketplace income counting rules can be found in Center on Budget and Policy Priorities webinar available at: http://www.healthreformbeyondthebasics.org/wp-content/uploads/2013/08/Income-Definitions-Webinar-Aug-28.pdf

    ← Return to text

  6. A detailed explanation of Medicaid and Marketplace HIU size calculations can be found in the Center on Budget and Policy Priorities webinar available at http://www.healthreformbeyondthebasics.org/wp-content/uploads/2013/08/Household-Definitions-Webinar-7Aug13.pdf

    ← Return to text

  7. This is the same underlying data as the 2019 Health Insurance Marketplace Calculator. Available at: https://www.kff.org/interactive/subsidy-calculator/ For a more detailed examination of plans available in the Health Insurance Marketplaces in 2019, see Kaiser Family Foundation, 2019 Premium Changes on ACA Exchanges. Available at:

    ← Return to text

  8. See Congressional Budget Office, Economic Projections. Available at: https://www.cbo.gov/system/files/2018-08/51137-2018-08-potentialgdp.xlsx

    ← Return to text

  9. See Internal Revenue Service, Publication 501, Table 1. 2018: Filing Requirements Chart for Most Taxpayers. Available at: https://www.irs.gov/publications/p501#en_US_2018_publink1000196863.

    ← Return to text

  10. See Internal Revenue Service, Publication 501, Qualifying Relative. Available at: https://www.irs.gov/publications/p501#en_US_2018_publink1000196863.

    ← Return to text

Appendix B: Immigration Status Imputation
  1. State Health Access Data Assistance Center. 2013. “State Estimates of the Low-income Uninsured Not Eligible for the ACA Medicaid Expansion.” Issue Brief #35. Minneapolis, MN: University of Minnesota. Available at: http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf404825

    ← Return to text

  2. Van Hook, J., Bachmeier, J., Coffman, D., and Harel, O. 2015. “Can We Spin Straw into Gold? An Evaluation of Immigrant Legal Status Imputation Approaches” Demography. 52(1):329-54.

    ← Return to text

  3. This data source is a change from previous KFF analyses, which used estimates from the Department of Homeland Security.

    ← Return to text

  4. Pew updates these estimates periodically. We use the most recent estimates available at the time of our analysis. We draw on Pew directly for all published data and interpolate years missing from their trend. Our analysis uses the year applicable to the year for the data sets to which we apply the regression model, The most recent estimates as of the time of our analysis were: J Passel, D Cohn. U.S. Unauthorized Immigrant Total Dips to Lowest Level in a Decade. (Pew Research Center), November 2018. Available at: http://www.pewhispanic.org/2018/11/27/u-s-unauthorized-immigrant-total-dips-to-lowest-level-in-a-decade/.

    ← Return to text

  5. Indicators that imply legal status include: (i) respondent entered the US prior to 1980, or (ii) respondent is enrolled in any of the following public programs: Medicare, military health insurance, public assistance, Supplemental Security Income, or Social Security Income.

    ← Return to text

  6. For more information, see SHADAC 2013, footnote 6. The table created for this function contains estimates of the undocumented across 2012-2015.

    ← Return to text

  7. For more detail, see documentation available at: National Health Interview Survey. 2017 Imputed Income Files. October 23, 2018. Available at: https://www.cdc.gov/nchs/nhis/nhis_2017_data_release.htm

    ← Return to text

  8. As an example of this calculation, we found that approximately 58% of undocumented uninsured individuals did not have health coverage in 2013. We allow the undocumented rate to drop slightly after 2013. We base the percent drop in the uninsured rate that we see in the Kaiser Family Foundation's Survey of the Low-Income Population and the ACA (which has a direct measure of citizenship) for 2013 to 2014, which is an 11% decline, to estimate an uninsured rate in 2014 for the undocumented (52%). We use the ratio of that drop relative to the drop for citizens (less than half the scale of the drop for citizens) to estimate a 6% drop from 2014 to 2015, getting us to a 46% uninsured rate in 2015 and repeat this until 2017, resulting in the final undocumented uninsured rate of 45% in calendar year 2017. Prior to implementing this new sampling dimension, we found unrealistic drops in the uninsured rate of the undocumented population that we largely attributed to our prediction model's inability to discern this group from legally-present non-citizens, many of whom are eligible for assistance under the ACA's coverage expansions. Although a few states have implemented programs that allow for coverage of the undocumented population, these programs are state-funded and relatively small in scale compared to the nationwide coverage expansions accompanying the ACA.

    ← Return to text

Appendix C: Imputation of Offer of Employer-Sponsored Insurance
  1. For example, anyone who did not work during 2017 who then held an offer of ESI in early 2018 would appear incongruous in our CPS-based eligibility model. In the other direction, workers covered by health insurance through their own employer in 2017 who lost their offer of ESI during the early months of 2018 (perhaps due to a job change) would also appear incongruous due to the discrepancy across the two time periods.

    ← Return to text

  2. Available at: https://www.census.gov/data/datasets/time-series/demo/health-insurance/cps-asec-research-files.html For more detail about these microdata, see: J. Abramowitz, B. O'Hara. New Estimates of Offer and Take-up of Employer-Sponsored Insurance (US Census Bureau), 2016. Available at: https://www.census.gov/library/working-papers/2016/demo/Abramowitz-2016.html.

    ← Return to text

  3. For an explanation of affordability, see: Kaiser Family Foundation. Employer Responsibility Under the Affordable Care Act. September 2016. Available at: https://www.kff.org/infographic/employer-responsibility-under-the-affordable-care-act/

    ← Return to text