The Coverage Gap

Feb 13, 2016 | Publisher: edocr | Category: Health & Medical |   | Views: 14 | Likes: 1

The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid – An Update Rachel Garfield and Anthony Damico One of the major coverage provisions of the Affordable Care Act (ACA) is the expansion of Medicaid eligibility to nearly all low-income individuals with incomes at or below 138 percent of poverty ($27,724 for a family of three in 20151). This expansion fills in historical gaps in Medicaid eligibility for adults and was envisioned as the vehicle for extending insurance coverage to low-income individuals, with premium tax credits for Marketplace coverage serving as the vehicle for covering people with moderate incomes. While the Medicaid expansion was intended to be national, the June 2012 Supreme Court ruling essentially made it optional for states. As of January 2016, 19 states were not expanding their programs. Medicaid eligibility for adults in states not expanding their programs is quite limited: the median income limit for parents in 2016 is just 44% of poverty, or an annual income of $8,840 a year for a family of three, and in nearly all states not expanding, childless adults remain ineligible.2 Further, because the ACA envisioned low-income people receiving coverage through Medicaid, it does not provide financial assistance to people below poverty for other coverage options. As a result, in states that do not expand Medicaid, many adults fall into a “coverage gap” of having incomes above Medicaid eligibility limits but below the lower limit for Marketplace premium tax credits (Figure 1). This brief presents estimates of the number of people in non-expansion states who could have been reached by Medicaid but instead fall into the coverage gap, describes who they are, and discusses the implications of them being left out of ACA coverage expansions. An overview of the methodology underlying the analysis can be found in the Methods box at the end of the report, and more detail is available in the Technical Appendices available here. Figure 1 Gap in Coverage for Adults in States that Do Not Expand Medicaid under the ACA as of October 2014 as of January 2016 44% FPL $8,840 for parents in a family of three $11,770 for an individual $47,080 for an individual The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid – An Update 2 Nationally, nearly three million3 poor uninsured adults fall into the “coverage gap” that results from state decisions not to expand Medicaid, meaning their income is above current Medicaid eligibility but below the lower limit for Marketplace premium tax credits. These individuals would have been newly-eligible for Medicaid had their state chosen to expand coverage. Adults left in the coverage gap due to current state decisions not to expand Medicaid are spread across the states not expanding their Medicaid programs but are concentrated in states with the largest uninsured populations. More than a quarter of people in the coverage gap reside in Texas, which has both a large uninsured population and very limited Medicaid eligibility (Figure 2). Twenty percent live in Florida, eleven percent in Georgia, and eight percent in North Carolina. There are no uninsured adults in the coverage gap in Wisconsin because the state is providing Medicaid eligibility to adults up to the poverty level under a Medicaid waiver. The geographic distribution of the population in the coverage gap reflects both population distribution and regional variation in state take-up of the ACA Medicaid expansion. As a whole, more people—and in particular more poor uninsured adults— reside in the South than in other regions.4 Further, the South has higher uninsured rates and more limited Medicaid eligibility than other regions.5 Southern states also have disproportionately opted not to expand their programs, and more than half (10 out of 19) of the states not expanding Medicaid are in the South. These factors combined mean nearly 90% of people in the coverage gap reside in the South (Figure 2). The characteristics of the population that falls into the coverage gap largely mirror those of poor uninsured adults. For example, because racial/ethnic minorities are more likely than White non-Hispanics to lack insurance coverage and are more likely to live in families with low incomes, they are disproportionately represented among poor uninsured adults and among people in the coverage gap. Nationally, 45% of uninsured adults in the coverage gap are White non-Hispanics, 23% are Hispanic, and 28% are Black (Figure 3). However, the race and ethnicity of people in the coverage gap also reflects differences in the racial/ethnic composition between states moving forward with the Medicaid expansion and states not planning to expand. Several states that have large Black populations (e.g., Florida, Georgia, and Texas) have not expanded Medicaid under the ACA. As a result, Blacks account for a slightly higher share of people in the coverage gap compared to Figure 2 TX 26% FL 20% GA 11% NC 8% Other States that Have Not Expanded Medicaid 35% Note: Totals may not sum to 100% due to rounding. Source: Kaiser Family Foundation analysis based on 2015 Medicaid eligibility levels updated to reflect state Medicaid expansion decisions as of January 2016 and 2015 Current Population Survey data. South 89% Midwest 7% Northeast 1% West 3% Distribution of Adults in the Coverage Gap, by State and Region Total = 2.9 Million in the Coverage Gap Distribution By Geographic Region: Distribution By State: The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid – An Update 3 the total poor adult uninsured population. The racial/ethnic characteristics of the population in the coverage gap vary widely by state, mirroring the underlying characteristics of the state population. Nonelderly adults of all ages fall into the coverage gap (Figure 3). Notably, over half are middle-aged (age 35 to 54) or near elderly (age 55 to 64). Adults of these ages are likely to have increasing health needs, and research has demonstrated that uninsured people in this age range may leave health needs untreated until they become eligible for Medicare at age 65.6 While half of people in the coverage gap report that their health is excellent or very good, nearly a fifth (18%) report that they are in fair or poor health (Figure 3). These individuals have known health problems that likely require medical attention. Studies repeatedly demonstrate that the uninsured are less likely than those with insurance to receive preventive care and services for major health conditions and chronic diseases.7 When they do seek care, the uninsured often face unaffordable medical bills.8 The characteristics of people in the coverage gap also reflect Medicaid program rules in states not expanding their programs. Because non-disabled adults without dependent children are ineligible for Medicaid coverage in most states not expanding Medicaid, regardless of their income, adults without dependent children account for a disproportionate share of people in the coverage gap (76%) (Figure 4). Still, nearly a quarter (24%) of people in the coverage gap are poor parents whose income places them above Medicaid eligibility levels. About a quarter of a million uninsured children have a parent in the coverage gap (data not shown). Research has found that parent coverage in public programs is associated with higher enrollment of eligible children,9 so these children may be hard to reach if their parents continue to be ineligible for coverage. The share of people in the coverage gap who are adults without dependent children (versus parents) varies by state (see Table 1) due to variation in current state eligibility. For example, Maine covers all parents up to at least poverty, so all people in the coverage gap in that state are adults without dependent children. Figure 3 White 45% Black 28% Hispanic 23% Other 4% 19-24 years 24% 25-34 years 24% 35-54 years 35% 55-64 years 17% Demographic Characteristics of Adults in the Coverage Gap Total = 2.9 Million in the Coverage Gap Distribution By Age: Distribution By Race/Ethnicity: Excellent or Very Good 50% Good 32% Fair or Poor 18% Distribution By Health Status: Note: Totals may not sum to 100% due to rounding. Source: Kaiser Family Foundation analysis based on 2015 Medicaid eligibility levels updated to reflect state Medicaid expansion decisions as of January 2016 and 2015 Current Population Survey data. Figure 4 Parent 24% Childless Adult 76% Parent Status and Gender of Adults in the Coverage Gap Parent Status Male 48% Female 52% Total = 2.9 Million in the Coverage Gap Gender Note: Totals may not sum to 100% due to rounding. Source: Kaiser Family Foundation analysis based on 2015 Medicaid eligibility levels updated to reflect state Medicaid expansion decisions as of January 2016 and 2015 Current Population Survey data. The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid – An Update 4 Even though women are more likely than men to qualify for Medicaid in states not expanding their programs, women account for slightly more than half (52%) of adults in the coverage gap (Figure 4). This pattern occurs because women make up the majority of poor uninsured adults in states not expanding their programs. The work status of people in the coverage gap indicates that there are limited coverage options available for people in this situation. More than six in ten (62%) people in the coverage gap are in a family with a worker, and half are working themselves (Figure 5). While workers could potentially have an offer of coverage through their employer, nearly half of workers in the coverage gap (48%) work for small firms (

The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid – An Update January 2016

One of the major coverage provisions of the Affordable Care Act (ACA) is the expansion of Medicaid eligibility to nearly all low-income individuals with incomes at or below 138 percent of poverty ($27,724 for a family of three in 20151). This expansion fills in historical gaps in Medicaid eligibility for adults and was envisioned as the vehicle for extending insurance coverage to low-income individuals, with premium tax credits for Marketplace coverage serving as the vehicle for covering people with moderate incomes. While the Medicaid expansion was intended to be national, the June 2012 Supreme Court ruling essentially made it optional for states.

As of January 2016, 19 states were not expanding their programs. Medicaid eligibility for adults in states not expanding their programs is quite limited: the median income limit for parents in 2016 is just 44% of poverty, or an annual income of $8,840 a year for a family of three, and in nearly all states not expanding, childless adults remain ineligible.2 Further, because the ACA envisioned low-income people receiving coverage through Medicaid, it does not provide financial assistance to people below poverty for other coverage options. As a result, in states that do not expand Medicaid, many adults fall into a “coverage gap” of having incomes above Medicaid eligibility limits but below the lower limit for Marketplace premium tax credits. #ACA #Obamacare #Medicaid

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