1. The Uninsured in Virginia: An Update for the Virginia Health Care Foundation May 2016 Laura Skopec, Jason Gates, Michael Karpman, and Genevieve M. Kenney The Urban Institute

2. Methods All data are from the American Community Survey (ACS), the Behavioral Risk Factor Surveillance System (BRFSS), and the Current Population Survey (CPS) The family structures and corresponding income and employment estimates presented in the ACS analyses are based on tax units, or groups of individuals whose income would likely be counted together for the purposes of eligibility for Medicaid or the Marketplace. Tax units are generally smaller than Census-reported families, and their income is generally lower than the Census estimates of family-based income. Therefore, the ACS estimates of the number of uninsured by income may not match those from other sources that are based on alternative family and income units. ACS estimates reflect additional Urban Institute adjustments for potential misreporting of Medicaid/CHIP coverage developed by Victoria Lynch under a grant from the Robert Wood Johnson Foundation. for the Virginia Health Care Foundation

3. Main Takeaways The uninsured rate for the nonelderly in VA fell 1.8 percentage points between 2013 and 2014, from 14.3 percent to 12.5 percent There were about 878,000 nonelderly uninsured in VA in 2014 73.3 percent of uninsured Virginians (643,000) live in families with income at or below 200 percent of the Federal Poverty Level (FPL) 64.9 percent of uninsured children in Virginia (75,000) live in families with income at or below 200 percent of the Federal Poverty Level (FPL) Most uninsured Virginians are adults; a plurality are white and a majority are in working families for the Virginia Health Care Foundation

4. Main Takeaways (continued) Uninsured rates are higher in five regions of the state, two in the north and three in the south Uninsured adults in VA are much more likely than insured Virginians to have unmet needs and less likely to receive preventive services, even when controlling for observed differences between the two groups Estimates in early 2015 from the CPS show that the uninsured rate in Virginia fell by 2.8 percentage points from March 2014 to March 2015, to 11.0 percent*, and that it remained below the uninsured rate for the nonelderly in the US as a whole. for the Virginia Health Care Foundation *Due to differences in survey questions, survey methods, survey timing, sample size, and sample characteristics, estimates from the 2014 CPS do not match estimates from the 2014 ACS.

5. Almost 880,000 Virginians lack health insurance coverage, 87.5 percent of whom are adults Total Nonelderly 874,000 uninsured nonelderly Source: Urban Institute, March 2016. Based on the 2014 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). The estimates reflect Urban Institute adjustments for potential misreporting of coverage, based on a simulation model developed by Victoria Lynch under a grant from the Robert Wood Johnson Foundation. Nonelderly Uninsured 759,000 uninsured nonelderly adults for the Virginia Health Care Foundation

6. Adults are 2.6 times more likely to be uninsured than children in Virginia Source: Urban Institute, March 2016. Based on the 2014 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). The estimates reflect Urban Institute adjustments for potential misreporting of coverage, based on a simulation model developed by Victoria Lynch under a grant from the Robert Wood Johnson Foundation. for the Virginia Health Care Foundation

7. Source: Urban Institute, March 2016. Based on the 2014 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). The estimates reflect Urban Institute adjustments for potential misreporting of coverage, based on a simulation model developed by Victoria Lynch under a grant from the Robert Wood Johnson Foundation. For area definitions, see “Guide to Regions of Virginia”. Uninsured rate for all nonelderly (0-64) in Virginia in 2014, by region for the Virginia Health Care Foundation

8. Source: Urban Institute, March 2016. Based on the 2014 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). The estimates reflect Urban Institute adjustments for potential misreporting of coverage, based on a simulation model developed by Victoria Lynch under a grant from the Robert Wood Johnson Foundation. For area definitions, see “Guide to Regions of Virginia”. Uninsured rate for nonelderly adults (19-64) in Virginia in 2014, by region for the Virginia Health Care Foundation

9. Source: Urban Institute, March 2016. Based on the 2014 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). The estimates reflect Urban Institute adjustments for potential misreporting of coverage, based on a simulation model developed by Victoria Lynch under a grant from the Robert Wood Johnson Foundation. For area definitions, see “Guide to Regions of Virginia”. Uninsured rate for children (0-18) in Virginia in 2014, by region for the Virginia Health Care Foundation

10. Uninsured rate for all nonelderly (0-64) with family incomes below 200 percent of the FPL in Virginia in 2014, by region Source: Urban Institute, March 2016. Based on the 2014 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). The estimates reflect Urban Institute adjustments for potential misreporting of coverage, based on a simulation model developed by Victoria Lynch under a grant from the Robert Wood Johnson Foundation. For area definitions, see “Guide to Regions of Virginia”. for the Virginia Health Care Foundation

11. Source: Urban Institute, March 2016. Based on the 2014 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). The estimates reflect Urban Institute adjustments for potential misreporting of coverage, based on a simulation model developed by Victoria Lynch under a grant from the Robert Wood Johnson Foundation. For area definitions, see “Guide to Regions of Virginia”. Uninsured rate for children (0-18) with family incomes below 200 percent of the FPL in Virginia in 2014, by region for the Virginia Health Care Foundation

12. Uninsurance among the nonelderly was lower in VA than the United States as a whole during 2009-2014, but the gap narrowed Note: * indicates the 2014 uninsured rate is statistically different from 2013 at the.10 level. # indicates the 2009 uninsured rate is statistically different from 2014 at the.10 level. Source: Urban Institute, March 2016. Based on the 2009, 2010, 2011, 2012, 2013, and 2014 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). The estimates reflect Urban Institute adjustments for potential misreporting of coverage, based on a simulation model developed by Victoria Lynch under a grant from the Robert Wood Johnson Foundation. for the Virginia Health Care Foundation

13. Uninsurance in Virginia decreased among adults, but held steady among children between 2013 and 2014 Note: * indicates the 2014 uninsured rate is statistically different from 2013 at the.10 level. # indicates the 2009 uninsured rate is statistically different from 2014 at the.10 level. Source: Urban Institute, March 2016. Based on the 2009, 2010, 2011, 2012, 2013, and 2014 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). The estimates reflect Urban Institute adjustments for potential misreporting of coverage, based on a simulation model developed by Victoria Lynch under a grant from the Robert Wood Johnson Foundation. Nonelderly adults Total Nonelderly Children for the Virginia Health Care Foundation

14. Over forty percent of all uninsured Virginians live below the federal poverty level Notes: Family poverty level estimates are based on tax unit Modified Adjusted Gross Income and use the 2014 Federal Poverty Levels (FPLs) defined by the US Department of Health and Human Services. Source: Urban Institute, March 2016. Based on the 2014 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). The estimates reflect Urban Institute adjustments for potential misreporting of coverage, based on a simulation model developed by Victoria Lynch under a grant from the Robert Wood Johnson Foundation. for the Virginia Health Care Foundation

15. Just over 70 percent of Virginians who are uninsured live in families with income at or below 200 percent of the FPL Notes: Family poverty level estimates are based on tax unit Modified Adjusted Gross Income and use the 2014 Federal Poverty Levels (FPLs) defined by the US Department of Health and Human Services. Source: Urban Institute, March 2016. Based on the 2014 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). The estimates reflect Urban Institute adjustments for potential misreporting of coverage, based on a simulation model developed by Victoria Lynch under a grant from the Robert Wood Johnson Foundation. for the Virginia Health Care Foundation

16. Virginians living below poverty are nearly 10 times more likely to be uninsured compared to Virginians living at or above 401 percent of FPL Notes: Family poverty level estimates are based on tax unit Modified Adjusted Gross Income and use the 2014 Federal Poverty Levels (FPLs) defined by the US Department of Health and Human Services. Source: Urban Institute, March 2016. Based on the 2014 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). The estimates reflect Urban Institute adjustments for potential misreporting of coverage, based on a simulation model developed by Victoria Lynch under a grant from the Robert Wood Johnson Foundation. for the Virginia Health Care Foundation

17. Over 70 percent of uninsured Virginians live in families with at least one full or part-time worker Share of Nonelderly Uninsured Notes: Family work status is based on the work status of adults in the tax unit. Estimates may not sum to 100% due to rounding. Source: Urban Institute, March 2016. Based on the 2014 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). The estimates reflect Urban Institute adjustments for potential misreporting of coverage, based on a simulation model developed by Victoria Lynch under a grant from the Robert Wood Johnson Foundation. for the Virginia Health Care Foundation

18. Full-time workers and their families make up 58.5 percent of the uninsured in Virginia and are distributed over all income levels Notes: Family work status is based on the work status of adults in the tax unit. Family poverty level estimates are based on tax unit Modified Adjusted Gross Income and use the 2014 Federal Poverty Levels (FPLs) defined by the US Department of Health and Human Services. Estimates may not sum to 100% due to rounding. Source: Urban Institute, March 2016. Based on the 2014 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). The estimates reflect Urban Institute adjustments for potential misreporting of coverage, based on a simulation model developed by Victoria Lynch under a grant from the Robert Wood Johnson Foundation. for the Virginia Health Care Foundation

19. Just over 40 percent of the nonelderly uninsured in Virginia are white, non-Hispanic Notes: Estimates may not sum to 100% due to rounding. Source: Urban Institute, March 2016. Based on the 2014 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). The estimates reflect Urban Institute adjustments for potential misreporting of coverage, based on a simulation model developed by Victoria Lynch under a grant from the Robert Wood Johnson Foundation. for the Virginia Health Care Foundation

20. Nearly four-fifths of the nonelderly uninsured in Virginia are U.S. Citizens Notes: Estimates may not sum to 100% due to rounding. Source: Urban Institute, March 2016. Based on the 2014 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). The estimates reflect Urban Institute adjustments for potential misreporting of coverage, based on a simulation model developed by Victoria Lynch under a grant from the Robert Wood Johnson Foundation. for the Virginia Health Care Foundation

21. Uninsurance declined for young adults (19-26) in Virginia between 2013 and 2014 Note: * indicates the 2014 uninsured rate is statistically different from 2013 at the.10 level. Source: Urban Institute, March 2016. Based on the 2009, 2010, 2011, 2012, 2013 and 2014 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS). The estimates reflect Urban Institute adjustments for potential misreporting of coverage, based on a simulation model developed by Victoria Lynch under a grant from the Robert Wood Johnson Foundation. for the Virginia Health Care Foundation

22. Uninsurance among all nonelderly (0-64) in Virginia and the US continued to decline between early 2014 and 2015 (CPS) Note: Estimates shown are percentage point decreases. The change in the uninsured rate between 2014 and 2015 was not statistically different between Virginia and the United States. Source: Urban Institute, March 2016. Based on the 2014 and 2015 Current Population Survey. for the Virginia Health Care Foundation

23. Note: Adults are age 18-64. Measures refer to access or utilization over the past 12 months. */** Estimate is significantly different from estimate for Virginia at the 0.05/0.01 percent level Source: Urban Institute, March 2016. Based on the 2014 Behavioral Risk Factor Surveillance System. for the Virginia Health Care Foundation

24. Note: Adults are age 18-64. Measures refer to access or utilization over the past 12 months. */** Estimate is significantly different from estimate for Virginia at the 0.05/0.01 percent level Source: Urban Institute, March 2016. Based on the 2014 Behavioral Risk Factor Surveillance System. for the Virginia Health Care Foundation