QuickTake: Uninsured Nonelderly Adults Were More Concentrated in Medicaid Nonexpansion States and in the South in March 2015 than in September 2013


Between September 2013 and March 2015, the uninsurance rate among nonelderly adults (ages 18 to 64) declined from 17.6 to 10.1 percent, representing a gain in coverage for an estimated 15 million nonelderly adults (Long et al. 2015). These gains crossed demographic and socioeconomic groups, and gains were particularly pronounced among groups such as young adults, racial and ethnic minorities, and low-income adults, who historically had the highest rates of uninsurance. As of March 2015, however, 10.1 percent of nonelderly adults remained uninsured following two open enrollment periods for coverage through the health insurance Marketplaces and ongoing enrollment in Medicaid expansions under the Affordable Care Act (ACA) to adults with family income at or below 138 percent of the federal poverty level (FPL) in states that are implementing the Medicaid expansion. This QuickTake uses data from the Health Reform Monitoring Survey (HRMS) to examine changes in the geographic distribution of uninsured nonelderly adults, comparing the distribution in September 2013, just before the first Marketplace open enrollment, to March 2015.1 


Uninsured adults are increasingly concentrated in Medicaid nonexpansion states.2 In March 2015, just over half (53.1 percent) of uninsured adults lived in Medicaid nonexpansion states, a significant increase from the share living in nonexpansion states in September 2013 (44.5 percent). Many nonexpansion states are in the South, so there has been a related shift in the distribution of uninsured adults to the South, though other factors (such as differences in outreach for Marketplace enrollment) could also explain the southern shift. In March 2015, 48.4 percent of uninsured adults lived in the South, rising from 41.5 percent in September 2013.


The geographic shifts in the distribution of uninsured adults could strain health care safety net resources in those areas; federal support for safety net services was scaled back in anticipation of higher levels of insurance coverage among the population, and pre-ACA formulas for the allocation of safety net funding may be misaligned with the current distribution of uninsured adults (Neuhausen, Spivey, and Kellermann 2013). Additionally, though some uninsured adults in nonexpansion states may be eligible for subsidized coverage through the Marketplace or for Medicaid coverage based on pre-ACA eligibility standards, many will fall into the “coverage gap” and have few options for insurance coverage. The efficient targeting of resources—both for outreach and enrollment as well as support for the health care safety net—can help meet the health care needs of adults who remain uninsured in March 2015.




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: Gains in Health Insurance Coverage under the ACA as of March 2015.” Washington, DC: Urban Institute.


Neuhausen, Katherine, Michael Spivey, and Arthur L. Kellermann. 2013. “State Politics and the Fate of the Safety Net.” New England Journal of Medicine 369: 1675–77.



1 In this analysis, we compare the remaining uninsured adults in March 2015 to those adults who were uninsured in September 2013, just before Marketplace open enrollment began. Because our goal is to measure how the composition of the uninsured has changed, we have not used regression analysis to stabilize the composition of the sample over time, unlike the HRMS analysis of changes in insurance coverage over time. Consequently, some small portion of the estimated difference in the uninsured population between September 2013 and March 2015 may be attributable to differences in sample characteristics between the two periods that are not fully captured by the survey weights. The HRMS weights reflect the probability of sample selection from the KnowledgePanel® and poststratification to the characteristics of nonelderly adults and children in the United States. Because the KnowledgePanel® collects in-depth information on panel members, the poststratification weights are based on gender, age, race or ethnicity, education, household income, homeownership, Internet access, primary language (English or Spanish), residence in a metropolitan area, and region.

2 For this analysis, we focus on state decisions to expand Medicaid by March 1, 2015. The states that had expanded Medicaid by this date are AZ, AR, CA, CO, CT, DE, DC, HI, IL, IN, IA, KY, MD, MA, MI, MN, NH, NV, NJ, NM, NY, ND, OH, OR, PA, RI, VT, WA, and WV.



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