In States Without Medicaid Expansion, Millions More Will Be Uninsured

A demographic analysis of the effect of Medicaid expansion on the number of uninsured residents of the United States shows that more than 1.2 million people will be uninsured who would have been insured if their states accepted the Medicaid expansion under the Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148). The study, published online in Health Affairs on June 6, 2013, found that 29.8 million people would be uninsured if every state adopted Medicaid expansion, and 31.0 million would be uninsured if the states that reject expansion and all the undecided states do not adopt it.

The demographic composition of the uninsured would be about the same as it is now. About 59 percent would be employed, 10.5 percent unemployed. Half a million people not in the labor force at all would be covered if states opted in, but not if they opted out. With or without Medicaid expansion, the same percentage of the uninsured would be white (74.0 percent), black (16.4 percent), and Hispanic (about 32 percent), although one million more people from these three groups would be insured with Medicaid expansion.

The analysts did not assume that everyone who was eligible for Medicaid would apply. Rather, they used the “take-up” rates from previous expansions; they assumed that 40 percent of individuals with incomes at or below 138 percent of the federal poverty level (FPL), the upper limits for Medicaid eligibility, would remain uninsured, as would 60 percent of the uninsured who incomes were between 138 and 400 percent of FPL.

The true number of uninsured is likely to be higher because the authors assumed that every state with a governor in favor of expansion would adopt it. In fact, that has not proven to be the case. The Kaiser Foundation reports that the legislatures of Florida, Missouri, and Montana all have rejected the Medicaid expansion. There will be one million more uninsured people in Florida alone. The debate is ongoing in Arizona, Michigan, and Ohio.