Health Insurance Coverage in 2013: Gains in Public Coverage Continue to Offset Loss of Private Insurance
The coverage provisions of the ACA that went into effect on January 1, 2014 were primarily designed to increase health insurance coverage among low-to middle-income adults. These provisions include both the establishment of Health Insurance Marketplaces to provide subsidized private non-group health insurance and, in 28 states and the District of Columbia, an expansion of Medicaid eligibility to adults up to 138 percent of the FPL. The 2013 American Community Survey does not capture these expansions, though it does capture early expansions of Medicaid by four states and the expansion of dependent coverage to young adults. Despite capturing some of the early coverage expansions under the ACA, the 2013 ACS serves as a final, albeit imperfect, baseline against which to measure the coverage shifts resulting from the major coverage expansions in the ACA. In addition, the 2013 ACS provides the opportunity to clarify trends in coverage during the economic recovery that preceded the major ACA coverage expansions.
The Great Recession led to a significant increase in the uninsured rate and accelerated the decline in ESI coverage, particularly among those with incomes below 138 percent of the FPL. Since 2010, the recovery has steadily improved uninsured rates, but ESI coverage has continued to decline, albeit at a slower rate, for children and adults aged 26 and older. Adults aged 19 to 25 experienced significant growth in ESI from 2010 to 2013 due to the ACA policy allowing young adults to continue receiving insurance through their parents’ plan until age 26. In addition, most of the growth in employment between 2010 and 2013 was in low ESI industries, and the average ESI coverage rate in those industries was 20 percentage points below that for high ESI industries in 2013 (63.2 percent and 83.2 percent, respectively).
The increases in the uninsured rate during the Great Recession occurred mostly among low-income families, and the reductions in the uninsured rate during the recovery have primarily been through growth in Medicaid and CHIP. Coverage for children, in particular, was stabilized by growth in Medicaid and CHIP enrollment that offset losses in ESI coverage. While adult enrollment in Medicaid grew by 2.6 percentage points between 2008 and 2013, the effect was less pronounced than the 8.1 percentage point growth for children, likely due to lower eligibility levels for adults than for children.
As the ACA is fully implemented, ESI will remain the largest source of insurance coverage for Americans. However, much of the growth in coverage under the ACA is expected to come from Medicaid enrollment and increases in private non-group health insurance coverage purchased through the Health Insurance Marketplaces. It is therefore important to continue to track trends in ESI coverage alongside coverage gains in Medicaid and private non-group health insurance under the ACA to fully understand the effects of the ACA on health insurance coverage.
This issue brief was prepared by Laura Skopec, John Holahan, and Megan McGrath of the Urban Institute.