The Coverage Gap

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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Coverage Gap Medicaid state eligible adult Medicaid eligible Kaiser family Foundation
The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid – An Update January 2016
About edocr

Coverage Gap Medicaid state eligible adult Medicaid eligible Kaiser family Foundation
<p> 
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 (<50 
employees) that are not subject to ACA penalties 
for not offering coverage. Further, many firms do 
not offer coverage to part-time workers.  A 
majority of workers in the coverage gap also work 
in industries with historically low insurance 
rates, such as the agriculture and service industries.  
Nearly four in ten (38%) adults in the coverage gap are in a family with no workers. Since the Medicaid 
expansion was designed to reach those left out of the employer-based system, and because people in the 
coverage gap by definition are poor, it is not surprising that most are unlikely to have access to health coverage 
through a job.   
If states that are currently not expanding their 
programs adopt the Medicaid expansion, all of 
the 2.9 million adults in the coverage gap would 
gain Medicaid eligibility. In addition, 1.8 million 
adults who are currently eligible for Marketplace 
coverage (those with incomes between 100 and 
138% of poverty10) would also gain Medicaid 
eligibility (Figure 6 and Table 2). Though most of 
these adults are eligible for tax credits to 
purchase Marketplace coverage,11 Medicaid 
coverage may provide lower premiums or cost-
sharing than they would face under Marketplace 
coverage.  
A small number (a little more than 500,000) of uninsured adults in non-expansion states are already eligible 
for Medicaid under eligibility pathways in place before the ACA. If all states expanded Medicaid, those in the 
Figure 5
No worker
38%
Part-time 
worker
21%
Full-time 
worker
41%
Notes: Industry classifications: Agriculture/Service includes agriculture, construction, leisure and hospitality services, wholesale and retail trade. 
Education/Health includes education and health services. Professional/Public Admin includes finance, professional and business services, 
information, and public administration. Manufacturing/Infrastructure includes mining, manufacturing, utilities, and transportation. 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.
48%
55%
6%
14%
46%
17%
8%
6%
Work Status of Adults in the Coverage Gap
Family work status :
Total = 2.9 Million in the Coverage Gap
Firm size and industry among those working:
<50 employees
50-99 
employees
100+ 
employees
Agriculture/ 
Service
Education/
Health
Professional/ 
Public Admin
Manufacturing
/Infrastructure
Other
Total = 1.5 Million Workers in the Coverage Gap
Figure 6
Uninsured Adults in Non-Expansion States Who Would be 
Eligible for Medicaid if Their States Expanded
Total = 5.2 Million Uninsured Adults
Note: Total may not sum to 100% due to rounding. 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.
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.
Currently in the 
Coverage Gap
2.9 Million (56%)
Currently Eligible 
for Marketplace
1.8 Million (35%)
Currently Eligible 
for Medicaid
0.5 Million (10%)
Income 100-138% FPL
Income between Medicaid 
eligibility and 100% FPL
Income below 
current Medicaid 
eligibility
  
 
The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid – An Update 
5 
 
coverage gap and those who are instead eligible for Marketplace coverage would bring the number of uninsured 
adults eligible for Medicaid to 5.2 million people. The potential scope of Medicaid varies by state (Table 2).  
The ACA Medicaid expansion was designed to address the high uninsured rates among low-income adults, 
providing a coverage option for people who had limited access to employer coverage and limited income to 
purchase coverage on their own. However, with many states opting not to implement the Medicaid expansion, 
millions of uninsured adults remain outside the reach of the ACA and continue to have limited, if any, option 
for affordable health coverage: they are ineligible for publicly-financed coverage in their state, most do not have 
access to employer-based coverage through a job, and all have limited income available to purchase coverage 
on their own.  
The majority of people in the coverage gap are in poor working families—that is, either they or a family 
member is employed either part-time or full-time but still living below the poverty line. Given the 
characteristics of their employment, it is likely that many will continue to lack access to coverage through their 
job even with ACA provisions for employer responsibility for coverage are effective in 2016.12  Further, even if 
they do receive an offer from their employer that meets ACA requirements, many will find their share of the 
cost to be unaffordable. Because this population is generally exempt from the individual mandate, and because 
firms will not face a penalty for these workers remaining uninsured, they will continue to fall between the 
cracks in the employer-based system.  
It is unlikely that people who fall into the coverage gap will be able to afford ACA coverage without financial 
assistance: in 2016, the national average unsubsidized premium for a 40-year-old non-smoking individual 
purchasing coverage through the Marketplace was $299 per month for a silver plan and $236 per month for a 
bronze plan,13 which equates to more than half of income for those at the lower income range of people in the 
gap and about a quarter of income for those at the higher income range of people in the gap. Further, people in 
the coverage gap are ineligible for cost-sharing subsidies for Marketplace plans and could face additional out-
of-pocket costs up to $6,850 a year if they were to purchase single individual Marketplace coverage. Given the 
limited budgets of people in the coverage gap, these costs are likely prohibitively expensive.    
If they remain uninsured, adults in the coverage gap are likely to face barriers to needed health services or, if 
they do require medical care, potentially serious financial consequences. Many are in fair or poor health or are 
in the age range when health problems start to arise, but lack of coverage may lead them to postpone needed 
care due to the cost. While the safety net of clinics and hospitals that has traditionally served the uninsured 
population will continue to be an important source of care for the remaining uninsured under the ACA, this 
system has been stretched in recent years due to increasing demand and limited resources.  
Further, the racial and ethnic composition of the population that falls into the coverage gap indicates that state 
decisions not to expand their programs disproportionately affect people of color, particularly Black Americans. 
This disproportionate effect occurs because the racial and ethnic composition of states not expanding their 
Medicaid programs differs from the ones that are expanding. As a result, state decisions about whether to 
expand Medicaid have implications for efforts to address disparities in health coverage, access, and outcomes 
among people of color. In addition, the population in the coverage gap shows that, as a result of state decisions 
  
 
The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid – An Update 
6 
 
not to expand their Medicaid programs, many remaining uninsured under the ACA will reflect the legacy of the 
system linking Medicaid coverage to only certain categories of people. Many people who fall outside these 
categories—such as adults without dependent children—still have a need for health coverage. The ACA 
Medicaid expansion was designed to end categorical eligibility for Medicaid, but in states not implementing the 
expansion, the vestiges of categorical eligibility will remain.    
State decisions about Medicaid expansion have implications for the potential scope of Medicaid under the ACA. 
If all states expanded their Medicaid programs, eligibility for Medicaid in non-expansion states would grow 
from just over half a million to 5.2 million. Though some of these people can currently purchase subsidized 
coverage through the Marketplace, there are advantages and disadvantages to Medicaid and private coverage in 
different states. For example, enrollees may face higher out-of-pocket costs and limited networks for 
Marketplace coverage than they would for Medicaid, whereas access to specialist care may be problematic in 
some state Medicaid programs. In addition, while people can enroll in Medicaid throughout the year, 
Marketplace enrollment is only available during a limited open enrollment period. Medicaid is designed to 
provide a safety net of coverage for low-income people, with benefits and provider networks targeted to this 
population and coverage available throughout the year as people’s circumstances change. There is no deadline 
for states to opt to expand Medicaid under the ACA, and debate continues in some states about whether to 
expand. If more states adopt the expansion, the coverage gap will shrink and more low-income adults will gain 
access to Medicaid eligibility.  
 
 
Rachel Garfield is with the Kaiser Family Foundation. Anthony Damico is an independent consultant 
to the Kaiser Family Foundation. 
  
 
The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid – An Update 
7 
 
 
 
Alabama 
 139,000  
46% 
60% 
47% 
64% 
Florida 
 567,000  
57% 
82% 
50% 
54% 
Georgia 
 305,000  
74% 
72% 
51% 
57% 
Idaho 
 30,000  
35% 
72% 
47% 
72% 
Kansas 
 49,000  
NA 
79% 
42% 
77% 
Maine 
 24,000  
NA 
100% 
58% 
88% 
Mississippi 
 108,000  
52% 
77% 
54% 
58% 
Missouri 
 109,000  
40% 
69% 
60% 
71% 
Nebraska 
 27,000  
NA 
74% 
63% 
57% 
North Carolina 
 244,000  
48% 
82% 
53% 
66% 
Oklahoma 
 91,000  
38% 
73% 
46% 
62% 
South Carolina 
 123,000  
41% 
90% 
60% 
51% 
South Dakota 
 13,000  
46% 
80% 
43% 
59% 
Tennessee 
 118,000  
NA 
98% 
47% 
NA 
Texas 
 766,000  
67% 
66% 
55% 
69% 
Utah 
 41,000  
NA 
80% 
41% 
65% 
Virginia 
 131,000  
52% 
82% 
62% 
65% 
Wisconsin* 
0 
- 
- 
- 
- 
Wyoming 
 11,000  
NA 
92% 
36% 
NA 
NOTES: * Wisconsin is provides Medicaid eligibility to adults up to the poverty level under a Medicaid waiver. As a result, 
there is no one in the coverage gap in Wisconsin.  
NA: Sample size too small for reliable estimate.   
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 
8 
 
 
 
 
 
Alabama 
 241,000 
 
 NA 
 
 139,000 
 
 81,000 
 
Florida 
 948,000 
 
 75,000 
 
 567,000 
 
 306,000 
 
Georgia 
 521,000 
 
 47,000 
 
 305,000 
 
 169,000 
 
Idaho 
 48,000 
 
 NA 
 
 30,000 
 
 16,000 
 
Kansas 
 104,000 
 
 NA 
 
 49,000 
 
 46,000 
 
Maine 
 44,000 
 
 NA 
 
 24,000 
 
 14,000 
 
Mississippi 
 181,000 
 
 24,000 
 
 108,000 
 
 49,000 
 
Missouri 
 173,000 
 
 NA 
 
 109,000 
 
 58,000 
 
Nebraska 
 41,000 
 
 NA 
 
 27,000 
 
 NA 
 
North Carolina 
 463,000 
 
 NA 
 
 244,000 
 
 186,000 
 
Oklahoma 
 173,000 
 
 22,000 
 
 91,000 
 
 60,000 
 
South Carolina 
 224,000 
 
 36,000 
 
 123,000 
 
 66,000 
 
South Dakota 
 22,000 
 
 NA 
 
 13,000 
 
 NA 
 
Tennessee 
 218,000 
 
 NA 
 
 118,000 
 
 68,000 
 
Texas 
 1,314,000 
 
 80,000 
 
 766,000 
 
 468,000 
 
Utah 
 91,000 
 
 NA 
 
 41,000 
 
 40,000 
 
Virginia 
 266,000 
 
 NA 
 
 131,000 
 
 119,000 
 
Wisconsin* 
 113,000 
 
 86,000 
 
 -   
 
 26,000 
 
Wyoming 
 18,000 
 
 NA 
 
 11,000 
 
 6,000 
 
NOTES: * Wisconsin is provides Medicaid eligibility to adults up to the poverty level under a Medicaid waiver. As a result, 
there is no one in the coverage gap in Wisconsin. ^ 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. 
NA: Sample size too small for reliable estimate.   
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 
9 
 
This analysis uses data from the 2015 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 for ACA 
eligibility purposes.   
The CPS asks respondents about coverage at the time of the interview (for the 2015 CPS, February, March, or April 2015) 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 2014 (and thus were uninsured at the start of 2015). We use this measure of insurance coverage, 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. Based 
on other survey data, as well as administrative data on ACA enrollment, it is likely that a small number of people included in this 
analysis gained coverage in 2015.  
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 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.14,15 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 Department of Homeland Security. 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 do not directly indicate whether workers have access to ESI, we draw on the methods comparable to our imputation of 
authorization status and use SIPP to develop a model that predicts offer of ESI, then apply the model to CPS. For more detail on 
the offer imputation used in this analysis, see the technical Appendix C available here.   
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, 2015, 
updated to reflect state Medicaid expansion decisions as of January 2016 and 2015 Federal Poverty Levels.16 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.  
 
  
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Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005  |  Phone 202-347-5270  
 
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Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California. 
 
                                                        
1
 The 2015 federal poverty guideline for a family of three was $20,090. See: http://aspe.hhs.gov/2015-poverty-guidelines.    
2
 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, 2015, 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 16, 2015. Available at: http://kff.org/health-reform/state-
indicator/medicaid-income-eligibility-limits-for-adults-as-a-percent-of-the-federal-poverty-level/    
3
 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. 
4
 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/  
5
 Ibid. 
6
 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. 
7
 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/  
8
 Ibid. 
9
 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. 
10
 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. 
11
 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.   
12
 See http://www.kff.org/infographic/employer-responsibility-under-the-affordable-care-act/ for a review of these requirements.  
13
 The methods for arriving at this estimate can be found on the Kaiser Family Foundation Subsidy Calculator, (available here: 
http://www.kff.org/interactive/subsidy-calculator/). 
14
 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   
15
 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.  
16
 Based on state-reported eligibility levels as of January 1, 2015. Eligibility levels are updated to reflect state implementation of the 
Medicaid expansion as of September 2015 and 2015 Federal Poverty Levels, but may not reflect other eligibility policy changes since 
January 2015.  The Kaiser Family Foundation State Health Facts. Data Source: Kaiser Commission on Medicaid and the Uninsured with the 
Georgetown University Center for Children and Families: Modern Era Medicaid: Findings from a 50-State Survey of Eligibility, Enrollment, 
Renewal, and Cost-Sharing Policies in Medicaid and CHIP as of January 2015, Kaiser Family Foundation, January 20, 2015. 
17
 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 15% of 
poverty in states that are not expanding Medicaid, and most states not expanding Medicaid do not provide coverage above SSI levels for 
individuals with disabilities. (See: O’Mally-Watts, M and K Young.  The Medicaid Medically Needy Program: Spending and Enrollment 
Update.  (Washington, DC: Kaiser Family Foundation), December 2012. Available at: http://www.kff.org/medicaid/issue-brief/the-
medicaid-medically-needy-program-spending-and/. And Kaiser Commission on Medicaid and the Uninsured, “Medicaid Financial Eligibility: 
Primary Pathways for the Elderly and People with Disabilities,” February 2010. Available at: http://www.kff.org/medicaid/issue-
brief/medicaid-financial-eligibility-primary-pathways-for-the-elderly-and-people-with-disabilities/.  
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