QuickTake: Health Insurance Coverage for Childless Adults under the ACA as of September 2014


Michael Karpman, Sharon K. Long, Nathaniel Anderson, Douglas Wissoker, and Genevieve M. Kenney

March 5, 2015


The Urban Institute has been using the Health Reform Monitoring Survey (HRMS) to examine trends in health insurance coverage for nonelderly adults (ages 18 to 64) and their families under the Affordable Care Act (ACA) since the first quarter of 2013 (Long, Kenney, et al. 2014). Between September 2013, just before the first open enrollment period for the ACA’s health insurance Marketplaces, and September 2014, just before the second open enrollment period began, the uninsurance rate for nonelderly adults fell 30.1 percent (Long, Karpman, et al. 2014). This QuickTake shows that coverage increases were even larger for childless adults, particularly those who have low income, live in rural areas, or are single.


Between September 2013 and September 2014, the uninsurance rate fell sharply for childless adults.


The uninsurance rate for childless adults fell 6.5 percentage points (95% CI [5.0, 7.9]), from 18.4 percent in September 2013 to 11.9 percent in September 2014, a decline of 35.2 percent (figure 1). The uninsurance rate fell 6.7 percentage points (95% CI [4.9, 8.5]) (or 39.5 percent) for childless adults in Medicaid expansion states and 6.2 percentage points (95% CI [3.9, 8.5]) (or 30.9 percent) for childless adults in Medicaid nonexpansion states.



Both low- and middle-income childless adults experienced large coverage gains.


The share of childless adults in the income range targeted by the ACA’s Medicaid expansion (i.e., those with family income at or below 138 percent of the federal poverty level [FPL]) with insurance increased 14.8 percentage points (95% CI [11.2, 18.3]) between September 2013 and September 2014 (figure 2), from 60.4 percent to 75.2 percent (data not shown). Insurance coverage also increased 7.0 percentage points (95% CI [4.2, 9.7]) for childless adults in the income range targeted by the ACA’s health insurance Marketplace subsidies (between 139 percent and 399 percent of FPL). These changes represent declines in uninsurance of 37.3 percent for low-income childless adults and 35.9 percent for middle-income childless adults.



Coverage increases were larger among single childless adults and those living in rural areas.


Insurance coverage increased an estimated 8.3 percentage points for single childless adults (95% CI [6.1, 10.5]) and 4.7 percentage points for married childless adults (95% CI [2.9, 6.4]). Coverage gains for childless adults were 8.2 percentage points for adults in rural areas (95% CI [4.2, 12.3]) and 6.1 percentage points for childless adults in urban areas (95% CI [4.5, 7.7]). An earlier analysis shows that the rural-urban coverage gap narrowed among all nonelderly adults during this period under the ACA (Karpman 2015).


Methods: Each round of the HRMS is weighted to be nationally representative. We use these weights along with a 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 any variation 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 each coverage type 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., quarters 4 of 2013 and quarters 1–3 of 2014). We focus on statistically significant changes in insurance coverage 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. We provide a 95 percent confidence interval for key estimates. In some rounds of the survey, the interview month starts a few days before or lasts a few days after the target month.


Our definition of childless adults is based on information provided in the child supplement to the HRMS. The child supplement was added to the HRMS in the second quarter of 2013 to ask questions about a randomly selected child in respondents’ households, if the household included children. Our definition of childless adults includes all adults who are not parents or guardians living with a dependent child age 17 or under; the definition includes noncustodial parents whose children live outside of the household. Our definition of single childless adults includes those who are widowed, divorced, separated, or never married, and it excludes those who are married or living with a partner. In discussing changes by state Medicaid expansion status, we focus on expansion status as of September 1, 2014. States that expanded Medicaid by this date include AZ, AR, CA, CO, CT, DE, DC, HI, IL, IA, KY, MD, MA, MI, MN, NH, NV, NJ, NM, NY, ND, OH, OR, RI, VT, WA, and WV. New Hampshire had begun its expansion just before this date, but Indiana and Pennsylvania have expanded since that time and are therefore not classified as expanding for this analysis. We define urban adults as those living in metropolitan statistical areas and rural adults as those not living in metropolitan statistical areas.


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 these HRMS estimates capture the changes in insurance coverage under the first open enrollment period of 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 estimates will reflect changes beyond 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 Medicaid expansion; 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.




Long, Sharon K., Michael Karpman, Adele Shartzer, Douglas Wissoker, Genevieve M. Kenney, Stephen Zuckerman, Nathaniel Anderson, and Katherine Hempstead. 2014. “Taking Stock: Health Insurance Coverage under the ACA as of September 2014.” Washington, DC: Urban Institute.


Long, Sharon K., Genevieve M. Kenney, Stephen Zuckerman, Dana E. Goin, Douglas Wissoker, Fredric Blavin, Linda J. Blumberg, Lisa Clemans-Cope, John Holahan, and Katherine Hempstead. 2014. “The Health Reform Monitoring Survey: Addressing Data Gaps to Provide Timely Insights into the Affordable Care Act.” Health Affairs 33 (1): 161–67.


Karpman, Michael. 2015. “QuickTake: Thirty-Six Percent Drop in Uninsurance Rate for Adults in Rural Areas Narrows Rural-Urban Coverage Gap.” 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 is exploring the value of cutting-edge Internet-based survey methods to monitor the ACA before data from federal government surveys are available. Funding for the core HRMS is provided by the Robert Wood Johnson Foundation and the Urban Institute. The HRMS-Kids was conducted in partnership with the Center for Children and Families at Georgetown University and is currently funded by the David and Lucile Packard Foundation.


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

Urban Institute Robert Wood Johnson Foundation