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Estimates of Eligibility for ACA Coverage among the Uninsured in 2016

Despite historic coverage gains under the Affordable Care Act (ACA), more than 27 million people in the United States remain without insurance coverage.1 Recent debate over the future of the ACA has led to uncertainty about whether and how ACA coverage will be maintained. The public reports confusion about the future of the law, and outreach to help inform people about coverage options is more limited than in past years. Still, millions of currently uninsured people are eligible for ACA coverage under current law, and given upcoming open enrollment, it is helpful to understand how many people could potentially gain ACA coverage. In addition, the administration has indicated to states that it is open to state Medicaid waiver proposals, which may lead some states that have not yet expanded Medicaid under the ACA to develop Medicaid expansion waivers and further extend coverage. Understanding how many people might be eligible for coverage under the ACA or could be reached with policy changes can inform these policy discussions.

This analysis provides national and state-by-state estimates of eligibility for ACA coverage options among those who remained uninsured. An overview of the methodology underlying the analysis is in the Methods box at the end of the data note and in the Technical Appendices available here.

Background: How Does the ACA Expand Health Coverage?

Under the ACA, Medicaid coverage is extended to nearly all nonelderly adults with incomes at or below 138% of the federal poverty level (FPL) ($28,676 for a family of three in 2018)2 in the 34 states (including DC) that had expanded as of June 2018.3 Under rules in place before the ACA, all states extend public coverage to poor and low-income children, with a median income eligibility level of 255% of poverty in 2018.4 The ACA also established health insurance marketplaces where individuals can purchase insurance and allows for federal tax credits for such coverage for people with incomes from 100% to 400% FPL ($20,420 to $81,680 for a family of three in 2017).5,6 Tax credits are generally only available to people who are not eligible for other coverage.

Because the ACA envisioned low-income people receiving coverage through Medicaid, people with incomes below poverty are not eligible for Marketplace subsidies. Thus, in the 17 states that have not implemented the Medicaid expansion, some adults fall into a “coverage gap” of earning too much to qualify for Medicaid but not enough to qualify for premium tax credits. In addition, undocumented immigrants are ineligible for Medicaid coverage and barred from purchasing coverage through a Marketplace. In most cases, lawfully present immigrants are subject to a five-year waiting period before they may enroll in Medicaid, though they can purchase coverage through a Marketplace and may receive tax credits for such coverage.

How Many Uninsured Are Eligible for Assistance under the ACA?

In 2016, 27.5 million nonelderly people lacked health coverage in the U.S. Nationally, we estimate 54% of this population, or 14.8 million people, is eligible for financial assistance to gain coverage through either Medicaid or subsidized Marketplace coverage (Figure 1 and Tables 1 and 2). One quarter are either adults eligible for Medicaid7 (4.3 million, or 16%) or children eligible for Medicaid or the Children’s Health Insurance Program (CHIP) (2.7 million, or 10%). Those who are Medicaid eligible include people who were previously eligible as well as those newly eligible under the ACA. More than a quarter (7.8 million, or 28%) of the nonelderly uninsured is eligible for premium tax credits to purchase coverage through the Marketplace.8

Figure 1: Eligibility for ACA Coverage Among Nonelderly Uninsured, 2016

More than two million uninsured people (2.2 million) fall into the coverage gap due to their state’s decision not to expand Medicaid. These individuals have incomes below poverty but do not qualify for Medicaid in their state, nor do they qualify for Marketplace tax credits. An additional 14% of the uninsured (3.9 million) are undocumented immigrants who are ineligible for ACA coverage under federal law.

The remainder of the uninsured either has an offer of ESI (3.7 million, or 13%) or has an income above the limit for premium tax credits but could purchase unsubsidized Marketplace coverage (2.9 million, or 10%). We cannot determine from available survey data if the offer of ESI would be considered unaffordable under the law, which would make the individual eligible for a Marketplace premium subsidy.

Patterns of eligibility vary by state (Tables 1 and 2), depending on state decisions about expanding Medicaid, premiums in the exchange, and underlying demographic factors such as poverty rates and access to employer coverage. In states that expanded Medicaid, 37% of the nonelderly uninsured population is eligible for Medicaid, versus just 13% in states that have not expanded Medicaid (Figure 2). No one in Medicaid expansion states falls into a coverage gap; in non-expansion states, nearly one in five (17%) uninsured people falls into the coverage gap, a larger share than the share who are eligible for Medicaid under pathways in place before the ACA. Because adults with incomes from 100% to 138% of poverty in non-expansion states can receive tax credits for Marketplace coverage, a larger share of the uninsured population in those states is eligible for Marketplace tax credits than in expansion states (34% versus 23%).

Figure 2: Eligibility for ACA Coverage Among Nonelderly Uninsured by State Medicaid Expansion Status, 2016

Discussion

Going without health insurance has adverse implications for people’s health and financial well-being and has negative consequences for providers and the health system. Survey results indicate that a very small share of the uninsured population—about 2% in 2016—say that the reason they go without insurance is because they don’t want coverage.9 Rather, people remain uninsured due to limits on eligibility, ongoing concerns about cost, or lack of awareness of affordable options.

The ACA extended health insurance to millions of previously uninsured Americans and, despite ongoing debate about the future of the ACA, has the potential to reach more uninsured people. We estimate that more than half of the uninsured population are eligible for Medicaid or subsidized Marketplace coverage. For these individuals, outreach and education about coverage and financial assistance will be important to continuing coverage gains that were seen in the early years of full ACA implementation. Data from other sources indicate that misperceptions about cost, lack of awareness of financial assistance, and confusion about eligibility rules were initial barriers to gaining coverage for some eligible uninsured.10,11,12 Others report that they found coverage to be too expensive, even with the availability of financial assistance. Recent policy changes and debate, such as cuts to funding for ACA enrollment assistance, uncertainty about federal payments for cost-sharing reductions, and debate over the future of Medicaid coverage, may exacerbate these challenges and make continued coverage gains difficult.

Nearly one in ten of the remaining uninsured population is outside the reach of the ACA due to their state’s decision not to expand Medicaid. People in the coverage gap would be eligible for Medicaid should their state opt to expand Medicaid but are otherwise likely to remain uninsured, as they have limited incomes, are unlikely to have an affordable offer of coverage from an employer, and do not have access to affordable coverage options under the ACA. While there is no deadline for states to expand Medicaid under the ACA, several non-expansion states have reported that consideration of the Medicaid expansion is on hold due to uncertainty about the future of the Medicaid expansion option.

In addition, 14 percent of the uninsured population is ineligible for coverage due to their immigration status. Most uninsured undocumented immigrants will likely remain without coverage, though there are some state or locally-funded programs that provide coverage or assistance to immigrants regardless of immigration status.13 Recent actions by the Administration to increase immigration enforcement activities could deter people from enrolling in these programs. They also have spillover effects of deterring eligible immigrants in mixed status families from enrolling in coverage.

Approximately a quarter of the uninsured population is not eligible for any assistance under the ACA because they have access to employer coverage that may be considered affordable or have incomes too high to qualify for Medicaid or Marketplace subsidies. Some of these people may face a financial penalty under the ACA’s so-called “individual mandate.” However, notable shares of uninsured adults are either unaware that the mandate is in effect or are misinformed about its scale, and a minority of those who have purchased ACA coverage say the mandate was a major motivating factor.14

In the months leading to open enrollment for 2019 Marketplace coverage, there are substantial opportunities to increase coverage by reaching those who are eligible for help under the ACA. However, given confusion and misinformation about the ACA, many may be difficult to reach without targeted and effective outreach to explain coverage options and assist with enrollment.

Rachel Garfield, Kendal Orgera, Gary Claxton, and Larry Levitt are with the Kaiser Family Foundation. Anthony Damico is an independent consultant to the Kaiser Family Foundation.

Table 1: Number of Nonelderly People Eligible for ACA Coverage Among the Uninsured, 2016
State Total Uninsured Medicaid/Other Public Eligible Tax Credit Eligible Ineligible for Financial Assistance due to Income, ESI Offer, or Citizenship In Medicaid Coverage Gap
US Total 27,453,000 7,018,000 7,767,000 10,446,000 2,223,000
Alabama 411,000 50,000 188,000 98,000 75,000
Alaska 96,000 52,000 22,000 21,000
Arizona 811,000 291,000 200,000 320,000
Arkansas 224,000 86,000 37,000 100,000
California 2,948,000 1,124,000 480,000 1,343,000
Colorado 507,000 150,000 144,000 214,000
Connecticut 217,000 63,000 74,000 80,000
Delaware 83,000 24,000 29,000 31,000
DC 35,000 22,000 N/A 11,000
Florida 2,419,000 160,000 911,000 964,000 384,000
Georgia 1,234,000 190,000 375,000 429,000 240,000
Hawaii 72,000 32,000 20,000 19,000
Idaho 145,000 13,000 67,000 44,000 22,000
Illinois 912,000 338,000 199,000 375,000
Indiana 423,000 197,000 77,000 149,000
Iowa 162,000 60,000 54,000 48,000
Kansas 239,000 32,000 70,000 89,000 48,000
Kentucky 265,000 114,000 77,000 74,000
Louisiana 476,000 207,000 147,000 121,000
Maine 93,000 36,000 34,000 22,000 N/A
Maryland 365,000 127,000 61,000 177,000
Massachusetts 367,000 85,000 56,000 226,000
Michigan 611,000 234,000 159,000 219,000
Minnesota 316,000 94,000 94,000^ 129,000
Mississippi 348,000 30,000 108,000 111,000 99,000
Missouri 478,000 74,000 193,000 124,000 87,000
Montana 72,000 25,000 23,000 24,000
Nebraska 130,000 N/A 51,000 45,000 16,000
Nevada 252,000 82,000 59,000 111,000
New Hampshire 83,000 25,000 17,000 40,000
New Jersey 675,000 189,000 149,000 336,000
New Mexico 225,000 83,000 38,000 104,000
New York 1,071,000 374,000 264,000^ 433,000
North Carolina 1,049,000 124,000 347,000 369,000 208,000
North Dakota 57,000 21,000 18,000 18,000
Ohio 631,000 258,000 152,000 221,000
Oklahoma 409,000 N/A 127,000 133,000 84,000
Oregon 214,000 74,000 53,000 87,000
Pennsylvania 589,000 236,000 180,000 173,000
Rhode Island 50,000 18,000 N/A N/A
South Carolina 439,000 59,000 179,000 110,000 92,000
South Dakota 66,000 N/A 25,000 15,000 15,000
Tennessee 737,000 94,000 264,000 215,000 163,000
Texas 4,155,000 583,000 1,277,000 1,657,000 638,000
Utah 369,000 90,000 140,000 93,000 46,000
Vermont 33,000 10,000 10,000 13,000
Virginia 807,000 346,000 185,000 276,000
Washington 498,000 175,000 97,000 226,000
West Virginia 131,000 51,000 42,000 38,000
Wisconsin 400,000 107,000 162,000 131,000 *
Wyoming 55,000 10,000 19,000 19,000 6,000
NOTES: Numbers may not sum to totals due to rounding. Medicaid/Other Public also includes CHIP and some state-funded programs for immigrants otherwise ineligible for Medicaid. ^ Tax credit-eligible population in Minnesota and New York include uninsured adults who are eligible for coverage through the Basic Health Plan. * Wisconsin covers adults up to 100% FPL in Medicaid under a waiver but did not adopt the ACA expansion. Cells marked “N/A” indicate that point estimates do not meet minimum standards for statistical reliability.
SOURCE: Kaiser Family Foundation analysis based on 2017 Medicaid eligibility levels and 2017 Current Population Survey.
Table 2: Distribution of Nonelderly Eligibility for ACA Coverage Among the Uninsured, 2016
State Total Uninsured Medicaid/Other Public Eligible Tax Credit Eligible Ineligible for Financial Assistance due to Income, ESI Offer, or Citizenship In Medicaid Coverage Gap
US Total 27,453,000 26% 28% 38% 8%
Alabama 411,000 12% 46% 24% 18%
Alaska 96,000 55% 23% 22% 0%
Arizona 811,000 36% 25% 39% 0%
Arkansas 224,000 38% 17% 45% 0%
California 2,948,000 38% 16% 46% 0%
Colorado 507,000 30% 28% 42% 0%
Connecticut 217,000 29% 34% 37% 0%
Delaware 83,000 29% 34% 37% 0%
DC 35,000 64% N/A 33% 0%
Florida 2,419,000 7% 38% 40% 16%
Georgia 1,234,000 15% 30% 35% 19%
Hawaii 72,000 45% 28% 27% 0%
Idaho 145,000 9% 46% 30% 15%
Illinois 912,000 37% 22% 41% 0%
Indiana 423,000 47% 18% 35% 0%
Iowa 162,000 37% 33% 30% 0%
Kansas 239,000 13% 29% 37% 20%
Kentucky 265,000 43% 29% 28% 0%
Louisiana 476,000 44% 31% 26% 0%
Maine 93,000 39% 37% 24% 0%
Maryland 365,000 35% 17% 48% 0%
Massachusetts 367,000 23% 15% 62% 0%
Michigan 611,000 38% 26% 36% 0%
Minnesota 316,000 30% 30%^ 41% 0%
Mississippi 348,000 9% 31% 32% 28%
Missouri 478,000 16% 40% 26% 18%
Montana 72,000 35% 31% 33% 0%
Nebraska 130,000 14% 39% 34% 12%
Nevada 252,000 32% 23% 44% 0%
New Hampshire 83,000 31% 21% 49% 0%
New Jersey 675,000 28% 22% 50% 0%
New Mexico 225,000 37% 17% 46% 0%
New York 1,071,000 35% 25%^ 40% 0%
North Carolina 1,049,000 12% 33% 35% 20%
North Dakota 57,000 37% 31% 31% 0%
Ohio 631,000 41% 24% 35% 0%
Oklahoma 409,000 16% 31% 32% 21%
Oregon 214,000 35% 25% 41% 0%
Pennsylvania 589,000 40% 31% 29% 0%
Rhode Island 50,000 35% 23% 43% 0%
South Carolina 439,000 13% 41% 25% 21%
South Dakota 66,000 N/A 37% 23% 22%
Tennessee 737,000 13% 36% 29% 22%
Texas 4,155,000 14% 31% 40% 15%
Utah 369,000 24% 38% 25% 12%
Vermont 33,000 29% 32% 39% 0%
Virginia 807,000 43% 23% 34% 0%
Washington 498,000 35% 19% 45% 0%
West Virginia 131,000 39% 32% 29% 0%
Wisconsin 400,000 27% 40% 33% *
Wyoming 55,000 18% 35% 36% 11%
NOTES: Numbers may not sum to totals due to rounding. Medicaid/Other Public also includes CHIP and some state-funded programs for immigrants otherwise ineligible for Medicaid. ^ Tax credit-eligible population in Minnesota and New York include uninsured adults who are eligible for coverage through the Basic Health Plan. * Wisconsin covers adults up to 100% FPL in Medicaid under a waiver but did not adopt the ACA expansion. Cells marked “N/A” indicate that point estimates do not meet minimum standards for statistical reliability.
SOURCE: Kaiser Family Foundation analysis based on 2017 Medicaid eligibility levels and 2017 Current Population Survey.
Table 3: Number and Distribution of Nonelderly Uninsured Ineligible for Financial Assistance due to Income, Offers of Employer Coverage, or Citizenship Status as of 2016, in States with Sufficient Sample Size
  Number of Nonelderly Uninsured Ineligible due to: Share of Nonelderly Uninsured Ineligible due to:
State Total Ineligible due to Income, ESI Offer, or Citizenship Income Employer Offer Citizenship Total Ineligible due to Income, ESI Offer, or Citizenship Income Employer Offer Citizenship
US Total 10,446,000 2,870,000 3,656,000 3,920,000 38% 10% 13% 14%
Arizona 320,000 58,000 117,000 145,000 39% 7% 14% 18%
Arkansas 100,000 35,000 33,000 33,000 45% 15% 15% 15%
California 1,343,000 317,000 322,000 705,000 46% 11% 11% 24%
Florida 964,000 306,000 318,000 340,000 40% 13% 13% 14%
Georgia 429,000 84,000 153,000 192,000 35% 7% 12% 16%
Illinois 375,000 126,000 100,000 149,000 41% 14% 11% 16%
Indiana 149,000 49,000 54,000 47,000 35% 11% 13% 11%
Louisiana 121,000 32,000 48,000 41,000 26% 7% 10% 9%
Mississippi 111,000 36,000 57,000 18,000 32% 10% 16% 5%
Nevada 111,000 41,000 23,000 48,000 44% 16% 9% 19%
New Jersey 336,000 75,000 119,000 143,000 50% 11% 18% 21%
New York 433,000 122,000 111,000 200,000 40% 11% 10% 19%
North Carolina 369,000 92,000 107,000 170,000 35% 9% 10% 16%
South Carolina 110,000 32,000 44,000 34,000 25% 7% 10% 8%
Tennessee 215,000 64,000 98,000 53,000 29% 9% 13% 7%
Texas 1,657,000 440,000 450,000 767,000 40% 11% 11% 18%
Utah 93,000 25,000 40,000 28,000 25% 7% 11% 8%
Virginia 276,000 66,000 113,000 98,000 34% 8% 14% 12%
Washington 226,000 73,000 73,000 79,000 45% 15% 15% 16%
NOTES: States not included above do not have sufficient sample size to show distribution of uninsured nonelderly ineligible for financial assistance in at least one of the three categories (income, ESI, and/or citizenship). Numbers may not sum to totals due to rounding.
SOURCE: Kaiser Family Foundation analysis based on 2017 Medicaid eligibility levels and 2017 Current Population Survey.

Methods

This analysis uses data from the 2017 Current Population Survey (CPS) Annual Social and Economic Supplement (ASEC). The CPS ASEC provides socioeconomic and demographic information for the United Sates population and specific subpopulations. Importantly, the CPS ASEC provides detailed data on families and households, which we use to determine income and household composition for ACA eligibility purposes.

Medicaid and Marketplaces have different rules about household composition and income for eligibility. For this analysis, we calculate household membership and income for both Medicaid and Marketplace premium tax credits for each person individually, using the rules for each program. For more detail on how we construct Medicaid and Marketplace households and count income, see the detailed technical Appendix A available here.

Undocumented immigrants are ineligible for federally-funded Medicaid and Marketplace coverage. Since CPS data do not directly indicate whether an immigrant is lawfully present, we draw on the methods underlying the 2013 analysis by the State Health Access Data Assistance Center (SHADAC) and the recommendations made by Van Hook et. al.15,16 This approach uses the Survey of Income and Program Participation (SIPP) to develop a model that predicts immigration status; it then applies the model to CPS, controlling to state-level estimates of total undocumented population from Pew Research Center. For more detail on the immigration imputation used in this analysis, see the technical Appendix B available here.

Individuals in tax-filing units with access to an affordable offer of Employer-Sponsored Insurance are still potentially MAGI-eligible for Medicaid coverage, but they are ineligible for advance premium tax credits in the Health Insurance Exchanges. Since CPS data indicate whether a worker held an offer of ESI at the time of interview (for the 2017 CPS, February, March, or April 2017) but not during the prior year (which serves as our basis for type of insurance coverage), we developed a model that predicts offer of ESI for any individuals with a change in employment status across the period. Additionally, for families with a Marketplace eligibility level below 250% FPL, we assume any reported worker offer does not meet affordability requirements and therefore does not disqualify the family from Tax Credit eligibility on the Exchanges. For more detail on the offer imputation used in this analysis, see the technical Appendix C available here.

The CPS asks respondents about coverage at the time of the interview as well as throughout the preceding calendar year. People who report any type of coverage throughout the preceding calendar year are counted as “insured.” Thus, the calendar year measure of the uninsured population captures people who lacked coverage for the entirety of 2016 (and thus were uninsured at the start of 2017). We use this measure of insurance coverage in 2016, rather than the measure of coverage at the time of interview, because the latter lacks detail about coverage type that is used in our model.

As of January 2014, Medicaid financial eligibility for most nonelderly adults is based on modified adjusted gross income (MAGI). To determine whether each individual is eligible for Medicaid, we use each state’s reported eligibility levels as of January 1, 2017, updated to reflect state Medicaid expansion decisions as of October 2017 and 2016 Federal Poverty Levels.15 Some nonelderly adults with incomes above MAGI levels may be eligible for Medicaid through other pathways; however, we only assess eligibility through the MAGI pathway.17

An individual’s income is likely to fluctuate throughout the year, impacting his or her eligibility for Medicaid. Our estimates are based on annual income and thus represent a snapshot of the number of people in the coverage gap at a given point in time. Over the course of the year, a larger number of people are likely to move and out of the coverage gap as their income fluctuates.

Appendix A: Household Construction

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