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Wide Local Variation in Numbers of Poor Uninsured Americans Who Would Be Eligible for Medicaid if States Opt for ACA Expansion

 
 

In June 2012, the Supreme Court ruling on the Affordable Care Act (ACA) put the decision to expand Medicaid coverage to nonelderly adults with incomes below 138 percent of the federal poverty level (FPL) in the hands of the states. In states that do not expand Medicaid, uninsured adults with incomes between 100 and 138 percent of FPL may qualify for subsidies to purchase coverage through the new Marketplaces. Poor uninsured adults with incomes below the poverty level, however, will not have access to any new coverage options. As of January 2014, 25 states and the District of Columbia had chosen to expand Medicaid coverage under the ACA.1

Nationwide, an estimated 10.3 million poor uninsured adults would have new options for insurance coverage if all states were to expand Medicaid. These estimates are derived from Urban Institute analysis of the 2009, 2010, and 2011 American Community Survey and take into account income, family structure, immigration status, and other factors that determine eligibility and reflect current Medicaid eligibility requirements for adults in each state.2

This map provides the first local estimates of the number of poor uninsured adults who could be made eligible for Medicaid under the ACA. It displays estimates of the number of poor uninsured adults in the coverage gap (for non-expanding states) and the number of poor uninsured adults newly eligible for Medicaid coverage (for expanding states). The map also shows the total number of low-income uninsured who could be newly eligible for Medicaid if their states expanded under the ACA option.

We include estimates for 781 mutually exclusive local areas in this map. Forty percent of these local areas are counties; the other 60 percent comprise local areas that have been constructed by Census in conjunction with state and local governments. For local areas that are not counties, we assign names based on the cities, towns, and (in some cases) neighborhoods in the larger metropolitan area containing that locality.3

Based on current information, an estimated 4.4 million poor uninsured adults will become newly eligible for Medicaid in the 25 states and the District of Columbia that have opted to expand Medicaid; an estimated 5.8 million will not be eligible because they live in one of the 25 states that had not committed to expand Medicaid by January 2014 (state-level estimates are available here). Poor uninsured adults who would be newly eligible for Medicaid under the ACA expansion constitute 24.3 percent of all uninsured adults nationwide, and 21.2 and 27.2 percent, respectively, in the states that are and are not expanding Medicaid. If states make choices that change how they are characterized in this map, we will update it to keep our estimates as current as possible.
The accompanying table provides state-by-state and local estimates of

  • the number of poor uninsured adults who would be eligible for Medicaid only if their state expands the program under the ACA;
  • the share of all uninsured adults who are poor and would be eligible for Medicaid only if their state expands the program;4
  • the number of uninsured adults with incomes below 138 percent of FPL who would be eligible for Medicaid only if their state expands the program;5 and
  • the share of all uninsured adults who have incomes below 138 percent of FPL and would be eligible for Medicaid only if their state expands the program, as a share of all uninsured adults.

1 Based on http://medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/Downloads/Medicaid-and-CHIP-Eligibility-Levels-Table.pdf. The 25 expanding states are Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, North Dakota, Ohio, Oregon, Rhode Island, Vermont, Washington, and West Virginia.

2 These estimates are derived using similar methods to those used to produce the estimates released by the Urban Institute in summer 2012, directly after the Supreme Court ruling on the Affordable Care Act (http://www.urban.org/publications/412607.html and http://www.urban.org/publications/412630.html). These updated estimates are based on data from the 2009, 2010, and the 2011 American Community Survey that have been aged to 2014 to reflect current conditions. The ACS allows us to estimate reliable local-level estimates, given that its annual sample has over 1.8 million adults nationwide, drawn from each county in the country. These estimates reflect the most current federal and state-level information available on how income and household units will be defined for determining Medicaid eligibility under both ACA and pre-ACA rules. This analysis builds on the Urban Institute’s ACS Medicaid and CHIP Eligibility Model, which was developed by Victoria Lynch with funding from the Robert Wood Johnson Foundation.

3 Metropolitan areas used here for naming are Combined Statistical Areas (see http://www.census.gov/geo/reference/gtc/gtc_cbsa.html).

4 Income below 100 percent of FPL is based on definition of modified adjusted gross income used to determine eligibility for subsidized coverage in the ACA health insurance marketplaces (26 U.S. Code § 36B ). Except for legally resident immigrant adults, those with incomes below this threshold are ineligible for subsidized coverage.

5 Income below 138 percent of FPL is based on the definition of modified adjusted gross income used to determine Medicaid eligibility under the ACA (CMS-2334-F: Medicaid, Exchanges, and Children's Health Insurance Programs: Eligibility, Appeals, and Other Provisions Under the Affordable Care Act).



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