A Closer Look at the Remaining Uninsured Population Eligible for Medicaid and CHIP

Medicaid has played a key role in providing health coverage to millions of people during the coronavirus pandemic. From March 2020 through March 31, 2023, states provided continuous enrollment in Medicaid in exchange for enhanced federal Medicaid funding. These protections resulted in millions of people gaining Medicaid coverage and drops in the overall number of uninsured. However, despite these gains, 27.5 million nonelderly people remained uninsured in 2021, and many of these people are eligible for assistance to purchase plans in the Marketplace or Medicaid but not enrolled in these programs. As states begin unwinding the Medicaid continuous enrollment provision, it is expected millions of people will be disenrolled, including many who remain eligible. The unwinding will likely drive up the number of people who are uninsured and could exacerbate existing disparities in health coverage. This issue brief examines the characteristics of the nonelderly uninsured population that is eligible for Medicaid or CHIP using the most recent available national survey data (from 2021) but more recent eligibility levels for Medicaid.

How many uninsured people are eligible for financial assistance for coverage?

A majority of people who remain uninsured are eligible for financial assistance for coverage through Medicaid/CHIP or the Marketplace. More than a quarter, or 7.4 million, of the total 27.5 million nonelderly people who remained uninsured are eligible for Medicaid or CHIP. Over one-third (37.0%) are eligible for subsidized coverage through the Marketplaces. Among the remaining uninsured, 7.0% fall into the “coverage gap” because they live in one of the 10 states that have not adopted the Medicaid expansion. People in the coverage gap have incomes too high to qualify for Medicaid in their state, but too low (below 100% of the poverty level) to qualify for subsidies in the Marketplaces (Figure 1). This analysis assumes that South Dakota and North Carolina are expansion states—both states have adopted expansion although they have not yet implemented the expanded coverage—which reduces the number of uninsured in the coverage gap and increases the share of the uninsured identified as eligible for Medicaid.

Who are uninsured people eligible for Medicaid/CHIP?

Most of the 7.4 million nonelderly uninsured and eligible for Medicaid or CHIP (referred to as the uninsured and eligible for the rest of this brief) are adults. Two-thirds of the uninsured and eligible, 4.9 million, are adults and one-third, 2.5 million, are children (Figure 2). Adults include those made eligible for the program by expansion and individuals who qualify under pre-ACA rules but had not enrolled.

Across all uninsured and eligible, over six in ten are people of color and nearly seven in ten live in working families (Figure 2). Nonelderly Hispanic people account for 34.9% of those uninsured and eligible, and Black people account for another 14.5%. Over three in ten (31.2%) of the uninsured and eligible are in families with no workers and over half (52.4%) are in families with one or more full-time workers. Both full- and part-time low-wage workers are less likely to report having an offer of coverage from their employer or the coverage offered is too expensive.

Over eight in ten of the 7.4 million uninsured and eligible (6.0 million people) reside in expansion states, which have more people living in them and have higher Medicaid income eligibility for adults than non-expansion states (Figure 2). The remaining 1.4 million people are in states that have not expanded Medicaid but are eligible for Medicaid or CHIP under traditional (not ACA expansion) pathways. Most of the uninsured and eligible in expansion states are adults, while children make up the majority of the uninsured and eligible in non-expansion states (Figure 2). Eligibility for adults was expanded to 138% of poverty ($20,120 for an individual and $34,307 for a family of three in 2023) and extended to adults without children in expansion states. In non-expansion states eligibility is limited for adults, often to below half of the federal poverty level, and generally only available for parents of dependent children. All states (both expansion and non-expansion) have opted to set eligibility thresholds for children in Medicaid and CHIP at higher levels, in most states above 200% of poverty. The differences in eligibility for adults across expansion and non-expansion states drives the variation in the shares of children and adults uninsured but eligible for Medicaid and CHIP for these states.

What are key policy issues to watch looking ahead?

Despite declines in the uninsured in 2021, many remained uninsured but eligible for Marketplace or Medicaid coverage. Enrollment in these public programs continued to grow largely due to enhanced subsidies and outreach for coverage in the Marketplace and the continuous enrollment provision that prohibited states from disenrolling people from Medicaid in exchange for additional federal funding. Data for 2022 may show further declines in the uninsured. However, as states begin the unwinding of the continuous enrollment provision and resume Medicaid disenrollments that have been paused since March 2020, millions are expected to lose Medicaid coverage. Those who remain eligible for Medicaid but face barriers to renewals or those who are no longer eligible and do not transition to other coverage will become uninsured. Data to document these changes in coverage are not likely to be available for about two years. Despite changes in the overall number of uninsured, the characteristics of those who are eligible but uninsured are likely to remain relatively stable. Understanding these characteristics can help inform outreach efforts as well as policy changes designed to maintain recent coverage gains and to reduce the uninsured.

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