The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid
U.S. Department of Health and Human Services, Office of The Assistant Secretary for Planning and Evaluation, 2017 Poverty Guidelines. Available at: https://aspe.hhs.gov/poverty-guidelines
Of the states not moving forward with the expansion, only Wisconsin provides full Medicaid coverage to adults without dependent children as of 2014. 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, 2017, collected through a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured with the Georgetown University Center for Children and Families. Accessed on October 18, 2017. Available at: http://kff.org/health-reform/state-indicator/medicaid-income-eligibility-limits-for-adults-as-a-percent-of-the-federal-poverty-level/
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.
Stephens, J., S. Artiga, and J. Paradise. Health Coverage and Care in the South in 2014 and Beyond. (Washington, DC: The Kaiser Commission on Medicaid and the Uninsured), April 2014, available at: http://kff.org/report-section/health-coverage-and-care-in-the-south-in-2014-and-beyond-health-coverage-and-care-in-the-south-today/
McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. “Use of Health Services by Previously Uninsured Medicare Beneficiaries.” New England Journal of Medicine. 2007 July 12, 357(2): 143-53.
For a review of findings on access to care for the uninsured, see: Kaiser Commission on Medicaid and the Uninsured. The Uninsured: A Primer. (Washington, DC: Kaiser Family Foundation. Available at: http://kff.org/uninsured/report/the-uninsured-a-primer/
Sommers BD. “Insuring children or insuring families: do parental and sibling coverage lead to improved retention of children in Medicaid and CHIP?” J Health Econ. 2006 Nov;25(6):1154-69. Epub 2006 Jun 5.
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.
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.
Antonisse, L., Garfield R., Rudowitz R. and Artiga S. 2017 The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review. (Washington, DC: Kaiser Family Foundation), available at: https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review/
See https://www.kff.org/infographic/employer-responsibility-under-the-affordable-care-act/ for a review of these requirements.
The methods for arriving at this estimate can be found on the Kaiser Family Foundation Subsidy Calculator, available here: https://www.kff.org/interactive/subsidy-calculator/
Gifford, K., Ellis, E., Edwards, B.C., et al. 2017. Medicaid Moving Ahead in Uncertain Times: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2017 and 2018.(Washington, DC: Kaiser Family Foundation), available at: https://www.kff.org/medicaid/report/medicaid-moving-ahead-in-uncertain-times-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2017-and-2018/
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
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.
Based on state-reported eligibility levels as of January 1, 2017. Eligibility levels are updated to reflect state implementation of the Medicaid expansion as of October 2017 and 2016 Federal Poverty Levels but may not reflect other eligibility policy changes since January 2017. 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 2017: Findings from a 50-State Survey, (Washington, DC: Kaiser Family Foundation, January 12, 2017), Available at: https://www.kff.org/medicaid/report/medicaid-and-chip-eligibility-enrollment-renewal-and-cost-sharing-policies-as-of-january-2017-findings-from-a-50-state-survey
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 CPS 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