QuickTake: Insurance Coverage Gains Cross Economic, Social, and Geographic Boundaries

 

Adele Shartzer, Sharon K. Long, Michael Karpman, Genevieve M. Kenney, and Stephen Zuckerman

April 27, 2015

 

The Urban Institute has been using the Health Reform Monitoring Survey (HRMS) to examine trends in health insurance coverage since the first quarter of 2013. Recent HRMS data show an estimated 15.0 million adults ages 18 to 64 (95% confidence interval [11.9 million, 18.1 million]) gained coverage between September 2013, just before the first open enrollment period for the Affordable Care Act’s (ACA) health insurance Marketplaces, and March 2015, just after the close of the second open enrollment period (Long et al. 2015). This QuickTake explores how coverage changed between September 2013 and March 20151 for different subgroups of nonelderly adults based on demographic, socioeconomic, and geographic characteristics, building upon previous analyses (Karpman, Skopec and Long 2015; Karpman et al. 2015; Shartzer, Kenney, and Zuckerman 2015). This QuickTake provides insight into the wide diffusion of coverage gains among nonelderly adults and highlights groups for whom uninsurance is still relatively high more than one year after implementation of the ACA’s major coverage provisions.

 

We find that significant declines in uninsurance were reported across demographic, socioeconomic, and geographic subgroups of nonelderly adults, with gains particularly large for subgroups with high levels of uninsurance before the coverage expansions (table 1).2 For example, the uninsurance rate dropped nearly 10 percentage points for young adults ages 18 to 30; roughly 15 percentage points for Hispanic adults, adults who are Spanish speakers or bilingual, and adults who are not citizens; and almost 20 percentage points for unemployed adults. All subgroups saw a decline in uninsurance of least 25 percent since September 2013.3 Some groups saw their uninsurance rate more than halved, including adults ages 50 to 64, college graduates, and adults in states that had implemented the ACA’s Medicaid expansion as of March 1, 2015. Despite these widespread gains in coverage, some subgroups continued to have uninsurance rates above 20 percent in March 2015. For example, 22.7 percent of adults with family income at or below 138 percent of the federal poverty level (the range targeted by the ACA’s Medicaid expansion) and 31.7 percent of noncitizens were uninsured in March 2015. The latter estimate likely reflects the lack of eligibility for Medicaid and Marketplace coverage for many noncitizens. Future HRMS work will provide an in-depth look at these remaining uninsured adults and outline both strategies to expand coverage for those who have coverage options available to them and the implications of eligibility gaps for those who do not.

 

Characteristics

Uninsurance Rate

Change in Uninsurance Rate between September 2013 and March 2015

September 2013
(%)

March 2015
(%)

Percentage-point change

Percent change

All nonelderly adults

17.6

10.1

-7.5

***

42.5

Age (years)

 

 

18–30

23.4

13.5

-9.8

***

42.1

31–49

17.6

11.1

-6.4

***

36.7

50–64

12.9

6.2

-6.7

***

52.1

Gender

 

 

Male

18.4

10.8

-7.6

***

41.5

Female

16.8

9.4

-7.3

***

43.7

Race/ethnicity

 

 

White, non-Hispanic

12.2

7.2

-5.0

***

40.7

Black non-Hispanic or other non-Hispanic

19.4

10.4

-9.1

***

46.7

Hispanic

35.5

20.7

-14.8

***

41.6

Primary language

 

 

English

14.4

8.1

-6.3

***

43.9

Spanish or bilingual

40.8

25.1

-15.8

***

38.6

Citizenship

 

 

US Citizen

15.3

8.4

-6.8

***

44.8

Not a US citizen

47.0

31.7

-15.3

***

32.6

Chronic condition status

 

 

Has one or more chronic conditions

13.2

6.5

-6.7

***

50.7

No reported chronic conditions

24.0

14.3

-9.6

***

40.2

Employment status

 

 

Employed

14.1

8.1

-6.0

***

42.5

Not employed

41.2

22.2

-19.0

***

46.1

Not in labor force

16.8

10.4

-6.3

***

37.8

Educational attainment

 

 

Less than high school

36.1

20.7

-15.4

***

42.6

High school or some college

16.9

8.6

-8.2

***

48.7

College

5.8

2.9

-2.9

***

50.3

Family income

 

 

At or below 138% of FPL

39.0

22.7

-16.2

***

41.7

Between 139 and 399% of FPL

15.9

8.2

-7.6

***

48.1

400% of FPL or higher

2.5

1.9

-0.7

25.7

Sexual orientationa

 

 

Lesbian, gay, or bisexual

21.7

11.1

-10.6

***

48.9

Not lesbian, gay, or bisexual

17.0

11.1

-5.9

***

35.0

Marital status

 

 

Married

12.2

6.8

-5.4

***

44.3

Not married

23.8

13.8

-10.0

***

42.0

State Medicaid expansion status

 

 

Medicaid expansion state

15.8

7.5

-8.2

***

52.2

Medicaid nonexpansion state

20.7

14.4

-6.3

***

30.6

Region

 

 

Northeast

12.0

5.5

-6.5

***

54.0

Midwest

12.4

7.1

-5.3

***

42.7

South

21.2

14.6

-6.7

***

31.5

West

21.5

10.2

-11.3

***

52.7

Metropolitan statusa

 

 

In metropolitan area

17.2

10.9

-6.3

***

36.6

Not in metropolitan area

21.6

14.4

-7.2

***

33.4

Sample size

7911

8039

 

 

 

Source: Health Reform Monitoring Survey quarter 3 2013 and quarter 1 2015.
Notes: FPL is federal poverty level. Estimates are regression adjusted. Medicaid expansion states are those that had expanded their income eligiblity standard for all adults to greater than or equal to 138 percent of FPL as of March 1, 2015 (28 states and the District of Columbia). Adults with chronic conditions includes those who report they have ever been diagnosed by a doctor with asthma, chronic bronchitis, or chronic obstructive pulmonary disorder; diabetes; epilepsy; heart attack; heart disease; or high blood pressure.
a Because of small sample sizes, the uninsurance estimates by sexual orientation and metropolitan status are based on combined quarters: December 2014/March 2015 compared with June/September 2013.
*/**/*** Estimate differs significantly from zero at the 0.10/0.05/0.01 level, using two-tailed tests.

 

Methods: Each round of the HRMS is weighted to be nationally representative. We use these weights and regression adjustment to control for differences in the demographic and socioeconomic characteristics of the respondents across the different rounds of the survey. This allows us to remove changes in insurance coverage caused by changes in the types of people responding to the survey over time rather than by changes in the health insurance landscape. The basic patterns shown for the regression-adjusted measures are similar to those based solely on simple weighted estimates. In presenting the regression-adjusted estimates, we use the predicted rate of uninsurance in each quarter for the same nationally representative population. For this analysis, we base the nationally representative sample on survey respondents from the most recent 12-month period from the HRMS (i.e., quarter 1 of 2015 and quarters 2–4 of 2014). We focus on statistically significant changes in uninsurance over time (defined as differences that are significantly different from zero at the 5 percent level or lower) and highlight changes relative to September 2013, just before the open enrollment period for the Marketplaces began.

 

Limitations to the analysis: The HRMS is designed to provide early feedback on ACA implementation to complement the more robust assessments that will be possible as more federal survey data become available. Though HRMS estimates capture the changes in insurance coverage from the first open enrollment period under the ACA, the estimates understate the full effects of the ACA because the estimates do not reflect the effects of some important ACA provisions (such as the ability to keep dependents on health plans until age 26 and early state Medicaid expansions) that were implemented before 2013. In addition, these change estimates might not reflect only the effects of the ACA, because they do not control for long-term trends in health insurance coverage that predate the ACA nor do they control for changes in the business cycle. Further, the difference in coverage gains between the states that did and did not expand Medicaid should not be entirely attributed to the ACA; there were other policy choices that likely affected enrollment. For example, many of the nonexpansion states did not set up their own Marketplaces and therefore did not get the same access to outreach and enrollment assistance funding.

 

References

 

Karpman, Michael, Laura Skopec, and Sharon K. Long. 2015. “QuickTake: Uninsurance Rate Nearly Halved for Lesbian, Gay, and Bisexual Adults since Mid-2013.” Washington, DC: Urban Institute.

 

Karpman, Michael, Stephen Zuckerman, Genevieve M. Kenney, and Yvette Odu. 2015. “QuickTake: Substantial Gains in Health Insurance Coverage Occurring for Adults in Both Rural and Urban Areas.” Washington, DC: Urban Institute.

 

Long, Sharon K., Michael Karpman, Genevieve M. Kenney, Stephen Zuckerman, Douglas Wissoker, Adele Shartzer, Nathaniel Anderson, and Katherine Hempstead. 2015. “Taking Stock: Health Insurance Coverage under the ACA as of March 2015.” Washington, DC: Urban Institute.

 

Shartzer, Adele, Genevieve M. Kenney, and Stephen Zuckerman. 2015. “QuickTake: Uninsurance Rate Halved for Adults with Chronic Conditions.” Washington, DC: Urban Institute.

 

About the Series

 

This QuickTake is part of a series drawing on the HRMS, a quarterly survey of the nonelderly population that explores the value of cutting-edge Internet-based survey methods to monitor the Affordable Care Act before data from federal government surveys are available. The QuickTakes provide information on health insurance coverage, access to and use of health care, health care affordability, and self-reported health status, as well as timely data on important implementation issues under the ACA. Funding for the core HRMS is provided by the Robert Wood Johnson Foundation and the Urban Institute.

 

For more information on the HRMS and for other QuickTakes in this series, visit www.urban.org/hrms.

 

Notes


1 For some subgroups with small sample sizes, we use pooled survey quarters to increase sample size and the reliability of estimates, comparing June/September 2013 with December 2014/March 2015.

2 The March 2015 uninsurance rates are also significantly lower that the rates at the end of the first open enrollment period in June 2014 for all of the demographic and socioeconomic subgroups examined except adults with family income of 400 percent of the federal poverty level or higher and adults in rural areas (data not shown).

3 The 25.7 percent reduction for adults with incomes at or above 400% of FPL is not statistically significant at the 0.1 level

 

 

Urban Institute Robert Wood Johnson Foundation