QuickTake: Trends in Uninsurance and State Marketplace and Medicaid Expansion Decisions


Michael Karpman, Genevieve M. Kenney, and Stephen Zuckerman

April 16, 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 (95% CI [11.9 million, 18.1 million]) adults ages 18 to 64 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).


We have been tracking uninsurance rate changes in states that have and have not expanded Medicaid under the ACA (Long et al. 2015). This QuickTake further explores how uninsurance rates changed during this period for adults in three different state groups: states, including the District of Columbia, that operate their own state-based Marketplaces (SBMs; 17 states, all but one of which has expanded Medicaid under the ACA); states with a federally facilitated or partnership Marketplace (FFM) that expanded Medicaid by March 2015 (13 states); and states with a federally facilitated or partnership Marketplace that did not expand Medicaid by March 2015 (21 states).1


We find significant declines in uninsurance in all three state groups between September 2013 and March 2015. The share of uninsured adults in SBM states declined 8.9 percentage points (95% CI [6.1, 11.7]), from 16.7 percent in September 2013 to 7.8 percent in March 2015 (figure 1). Uninsurance fell 7.2 percentage points (95% CI [5.3, 9.1]) in FFM expansion states, from 14.7 percent to 7.5 percent, and 6.3 percentage points (95% CI [4.9, 7.8]) in FFM nonexpansion states, from 20.7 percent to 14.3 percent. FFM nonexpansion states, which started out with the highest rate of uninsurance in September 2013, continued to have the highest rate of uninsurance in March 2015: 14.3 percent, nearly double that of SBM states and FFM expansion states (7.8 percent and 7.5 percent, respectively).


Low-income adults (those with family income at or below 138 percent of the federal poverty level [FPL]) in SBM states and FFM expansion states saw particularly large declines in uninsuranceover 19 percentage points in each group, compared with just over 12 percentage points in FFM nonexpansion states (data not shown). However, the coverage gains in the FFM nonexpansion states were significant, in part because adults with family income as low as 100 percent of FPL are eligible for Marketplace subsidies in states that did not expand Medicaid.


Though Medicaid expansion may be an important factor affecting the different trends in uninsurance across the three state groups, the differences may also be partially caused by variation in outreach and enrollment assistance efforts. To date, SBM states have received more federal funding for outreach and enrollment assistance compared with states that do not operate their own Marketplace (Hill et al. 2014). In addition, it is likely that FFM expansion states invested more resources in outreach and enrollment than FFM nonexpansion states. These estimates suggest that several state policy choices, such as whether to expand Medicaid, whether to develop a state-based Marketplace, and how much to invest in outreach and enrollment efforts, are contributing to coverage changes under the ACA.


Clearly, expanding Medicaid offers a significant opportunity for coverage gains in states that have not already done so. But continued outreach and enrollment efforts in both expansion and nonexpansion states are also promising given the low levels of knowledge of key ACA provisions among the remaining uninsured (Karpman, Zuckerman, and Blavin 2015). Though the Centers for Medicare and Medicaid Services fiscal year 2016 budget request calls for support of consumer outreach in FFM states through user fees (Centers for Medicare and Medicaid Services 2015), funding levels will remain uncertain until a federal budget is approved. User fees on health plans offered in the Marketplaces will also be an increasingly important source of funding for outreach in SBM states because of the expiration of federal start-up funding for state-based Marketplaces (Dash et al. 2014).



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 coverage 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 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.


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’s Medicaid expansion; there were other policy choices that likely affected enrollment. For example, as noted above, 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.




Buettgens, Matthew, Genevieve M. Kenney, and Hannah Recht. 2014. Eligibility for Assistance and Projected Changes in Coverage Under the ACA: Variation Across States. Washington, DC: Urban Institute.


Centers for Medicare and Medicaid Services. 2015. Fiscal Year 2016 Justification of Estimates for Appropriations Committees. Baltimore, MD: Centers for Medicare and Medicaid Services.


Dash, Sarah J., Justin Giovannelli, Kevin Lucia, and Sean Miskell. 2014. State Marketplace Approaches to Financing and Sustainability. New York: Commonwealth Fund.


Hill, Ian, Margaret Wilkinson, and Brigette Courtot. 2014. The Launch of the Affordable Care Act in Selected States: Outreach, Education, and Enrollment Assistance. Washington, DC: Urban Institute.


Karpman, Michael, Stephen Zuckerman, and Fredric Blavin. 2015. QuickTake: As of December, Most Uninsured Adults Who Planned to Obtain Coverage through the Marketplace Were Not Aware of the Open Enrollment Deadline. 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: Gains in Health Insurance Coverage under the ACA as of March 2015. 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.



1 We categorize 17 states as SBMs: CA, CO, CT, DC, HI, ID, KY, MD, MA, MN, NM, NV, NY, OR, RI, VT, and WA. Of the 17 SBM states, ID, NV, NM, and OR have relied on or currently rely on healthcare.gov for eligibility and enrollment, ID had not expanded Medicaid under the ACA as of March 2015, and several states expanded Medicaid under the ACA before 2013. We categorize the 34 FFM states according to their Medicaid expansion status as of March 1, 2015. The 13 FFM expansion states are AR, AZ, DE, IA, IL, IN, MI, ND, NH, NJ, OH, PA, and WV. The 21 FFM nonexpansion states are AK, AL, FL, GA, KS, LA, ME, MO, MS, MT, NC, NE, OK, SC, SD, TN, TX, UT, VA, WI and WY. Of the FFM nonexpansion states, WI extended Medicaid eligibility to adults with income up to 100 percent of FPL in April 2014 under a Section 1115 Demonstration Waiver to reform its BadgerCare program, and a large share of WI residents who were uninsured in May 2014 were likely to be qualified for financial assistance through either Medicaid, the Children's Health Insurance Program, or the Marketplaces (Buettgens et al. 2014). Therefore, some of the reduction in uninsurance in FFM nonexpansion states between September 2013 and March 2015 may reflect the expanded eligibility for Medicaid among adults in WI.



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