Targeted resources and Medicaid expansion are needed to cover the remaining uninsured

Millions of nonelderly residents of the United States who remain uninsured after the passage of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) will not gain coverage without additional policy changes like Medicaid expansion, according to a report from the Robert Wood Johnson Foundation (RWJF) and the Urban Institute. However, resources can be better targeted to increase coverage for 12.4 million uninsured individuals with the greatest potential to enroll in Medicaid or marketplace coverage. The report analyzes the socioeconomic and demographic characteristics of the remaining uninsured to identify uninsured individuals’ program eligibility and develop strategies to expand health insurance coverage further.

Method

The report relied on 2015 Current Population Survey—Annual Social and Economic Supplement (CPS-ASEC) data. The U.S. Census Bureau data includes information on health insurance coverage; income; household composition; and demographic, socioeconomic, and geographic characteristics for a nationally representative sample of U.S. households.

The uninsured

As of March 2015, 32.9 million nonelderly residents of the U.S. remained uninsured. Although roughly half of the uninsured individuals live in states that have expanded Medicaid, the rate of uninsurance is significantly higher in nonexpansion states. In nonexpansion states, 15.4 percent of the nonelderly are uninsured, as compared with only 10.1 percent in expansion states.

Program eligibility

Additionally, while 28 percent of the uninsured are eligible for Medicaid or the Children’s Health Insurance Program (CHIP) and 21 percent are eligible for the ACA’s marketplace tax credits, 12 percent of individuals fall into the “assistance gap.” Individuals in the assistance gap are those with very low incomes who are nevertheless ineligible for Medicaid because their states have not expanded Medicaid. Another 16 percent of the uninsured are undocumented individuals who, because of their status, do not qualify for any assistance under the ACA. The remaining 24 percent of the uninsured either do not qualify for assistance because their incomes are too high or because they are eligible for an affordable offer of coverage from an employer.

Outreach

RWJF and the Urban Institute believe that additional outreach and enrollment efforts are likely to be most successful for 12.4 million uninsured individuals who are eligible for the greatest amount of financial assistance under the ACA. Those individuals include 9.1 million people who are eligible for Medicaid or CHIP but not enrolled and 3.2 million people who are eligible for the ACA’s marketplace tax credits, lower premiums, and cost-sharing reductions.

Targeting

The report indicates that coverage gains are unlikely to occur for 20.6 million of the uninsured U.S. residents without substantial policy changes like Medicaid expansions in the current nonexpansion states, increased financial assistance, and expanded eligibility for assistance. However, RWJF and the Urban Institute suggest that the CPS-ASEC data can assist with resource targeting to help the 12.4 million uninsured individuals with the greatest likelihood of enrollment to actually become enrolled. According to the report, the populations of interest for resource targeting live primarily in metropolitan statistical areas, typically live in families in which at least one member is already receiving a public benefit, and have at least one school-aged child in the family.