Who is Impacted by the Coverage Gap in States that Have Not Adopted the Medicaid Expansion? June 2015

An estimated 41.3 million nonelderly individuals were uninsured in 2013. 268.9 M Nonelderly NOTES: Medicaid and other public coverage includes: CHIP, other state programs, Medicare and military related coverage. The federal poverty level for a family of three in 2013 was $19,530. SOURCE: Kaiser Family Foundation analysis of the 2014 ASEC Supplement to the CPS.

The majority of the uninsured are low-income adults, and more than half are people of color. Asian/Native Hawaiian or Pacific Islander Other Children White non-Hispanic Childless Adults Hispanic Parents Black Total = 41.3 Million Uninsured NOTES: The federal poverty level was $19,530 for a family of three in 2013. Data may not total 100% due to rounding. SOURCE: Kaiser Family Foundation analysis of the 2014 ASEC Supplement to the CPS.

Prior to the ACA, Medicaid eligibility was limited to specific low-income groups. Not Eligible

Expanding Medicaid to low-income adults is a core component of the ACA coverage expansions. Universal Coverage Marketplaces With Subsidies For Moderate Income Individuals Medicaid Coverage For Low-Income Individuals Individual Mandate Health Insurance Market Reforms Employer-Sponsored Coverage

As enacted, the ACA Medicaid expansion would cover adults up to 138% FPL in all states, filling long-standing gaps in coverage. NOTES: 138% FPL = $16,242 for an individual and $27,724 for a family of three in 2015.

But, the Supreme Court effectively made the Medicaid expansion a state option. Status of Medicaid Expansion Decisions, May 26, 2015 WY WI* WV WA VA VT UT TX TN SD SC RI PA* OR OK OH ND NC NY NM NJ NH* NV NE MT** MO MS MN MI* MA MD ME LA KY KS IA* IN* IL ID HI GA FL DC DE CT CO CA AR* AZ AK AL Adopted (30 States including DC) Adoption under discussion (3 States) Not Adopting At This Time (18 States) NOTES: Under discussion indicates executive activity supporting adoption of the Medicaid expansion. **MT has passed legislation adopting the expansion; it requires federal waiver approval. *WI covers adults up to 100% FPL in Medicaid, but did not adopt the ACA expansion. SOURCE: “Status of State Action on the Medicaid Expansion Decision,” KFF State Health Facts, updated May 26, 2015. http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

Medicaid eligibility for adults remains limited in states that have not adopted the Medicaid expansion. Median Medicaid/CHIP Income Eligibility Thresholds, April 2015 NOTES: State-reported eligibility levels as of January 2015, updated to reflect Medicaid expansion decisions as of April 2015. Eligibility levels are based on 2015 federal poverty levels (FPLs) for children, pregnant women, and parents in a family of three and for individual childless adults. In 2015,the FPL was $20,090 for a family of three and $11,770 for an individual. Thresholds include the standard five percentage point of the federal poverty level (FPL) disregard. *Montana has adopted the Medicaid expansion but implementation is pending waiver approval. SOURCE: Based on results from a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2015.

In states that have not adopted the Medicaid expansion, poor adults fall into a coverage gap, earning too much to qualify for Medicaid but too little for subsidies for Marketplace coverage. 44% FPL $8,840 for parents in a family of three $11,770 for an individual $47,080 for an individual as of April 2015 as of October 2014

An estimated 3.7 million nonelderly adults fall into the coverage gap, most of whom reside in the South. Distribution By State: Distribution By Geographic Region: Total = 3.7 Million in the Coverage Gap NOTES: Excludes legal immigrants who have been in the country for five years or less and immigrants who are undocumented. The poverty level for a family of three in 2015 is $20,090. Totals may not sum to 100% due to rounding. SOURCE: Kaiser Family Foundation analysis based on 2014 Medicaid eligibility levels , updated to reflect state Medicaid expansion decisions as of March 2015, and 2014 Current Population Survey data.

More than half of adults in the coverage gap are adults of color More than half of adults in the coverage gap are adults of color. Adults in the coverage gap are of varying age and health status. Distribution By Race/Ethnicity: Distribution By Age: Distribution By Health Status: Total = 3.7 Million in the Coverage Gap NOTES: Excludes legal immigrants who have been in the country for five years or less and immigrants who are undocumented. Totals may not sum to 100% due to rounding. SOURCE: Kaiser Family Foundation analysis based on 2014 Medicaid eligibility levels , updated to reflect state Medicaid expansion decisions as of March 2015, and 2014 Current Population Survey data.

Two-thirds of adults in the coverage gap are in a family with a worker, but most work in jobs that are unlikely to offer insurance. Family work status : Firm size and industry among those working: Other Manufacturing/Infrastructure 100+ employees Education/ Health Professional/ Public Admin 50-99 employees Agriculture/ Service <50 employees Total = 3.7 Million in the Coverage Gap Total = 2.0 Million Workers in the Coverage Gap NOTES: Excludes legal immigrants who have been in the country for five years or less and immigrants who are undocumented. Industry classifications: Agriculture/Service includes agriculture, construction, leisure and hospitality services, wholesale and retail trade. Education/Health includes education and health services. Professional/Public Admin includes finance, professional and business services, information, and public administration. Manufacturing/Infrastructure includes mining, manufacturing, utilities, and transportation. SOURCE: Kaiser Family Foundation analysis based on 2014 Medicaid eligibility levels , updated to reflect state Medicaid expansion decisions as of March 2015, and 2014 Current Population Survey data.

Total Nonelderly Uninsured Adults If all states expanded Medicaid, nearly six in ten uninsured Black adults would be eligible. Share of Uninsured Adults Who Would be Eligible if All States Expanded Medicaid, by Race/Ethnicity: Total Nonelderly Uninsured Adults 35.4 M 16.6 M 5.1 M 10.8 M 2.9 M 18.7 M SOURCE: Kaiser Family Foundation analysis based on 2014 Medicaid eligibility levels, updated to reflect state Medicaid expansion decisions as of March 2015, and 2014 Current Population Survey data.

Total Nonelderly Uninsured Adults However, uninsured Black adults are more likely to fall into the coverage gap than other racial/ethnic groups. Share of Uninsured Adults Who Fall into the Coverage Gap, by Race/Ethnicity: Total Nonelderly Uninsured Adults 35.4 M 16.6 M 5.1 M 10.8 M 2.9 M 18.7 M SOURCE: Kaiser Family Foundation analysis based on 2014 Medicaid eligibility levels, updated to reflect state Medicaid expansion decisions as of March 2015, and 2014 Current Population Survey data.

If all states adopted the Medicaid expansion, the coverage gap would be eliminated and 64% of the nonelderly uninsured would be eligible for financial assistance. Ineligible due to Immigration Status, 13% Ineligible due to Immigration Status, 13% Unsubsidized Marketplace/ESI Offer Unsubsidized Marketplace/ESI Offer Tax-Credit Eligible Tax-Credit Eligible Eligible for Financial Assistance 53% Medicaid-Eligible Child, 10% Eligible for Financial Assistance 64% Medicaid-Eligible Child, 9% Medicaid-Eligible Adult 20% Medicaid-Eligible Adult In the Coverage Gap, 9% Based on Current Medicaid Expansion Decisions If All States Expanded Medicaid Total = 41.3 Million Nonelderly Uninsured NOTES: Those ineligible for financial assistance include people with an affordable offer of ESI, individuals eligible to purchase unsubsidized Marketplace coverage, and individuals ineligible for coverage due to immigration status. SOURCE: Kaiser Family Foundation analysis based on 2014 Medicaid eligibility levels, current expansion decisions (as of March 2015) and 2014 Current Population Survey.