1. The Uninsured in Virginia: An Update Nathaniel Anderson, Laura Skopec, and Genevieve M. Kenney The Urban Institute

2. Source Material Huntress M, GM Kenney, and N Anderson. “Profile of Virginia’s Uninsured, 2012.” The Urban Institute. April 2014. http://www.vhcf.org/wp-content/uploads/2010/10/2014- Profile-of-Virginias-Uninsured.pdf.http://www.vhcf.org/wp-content/uploads/2010/10/2014- Profile-of-Virginias-Uninsured.pdf Huntress M and GM Kenney. “Profile of Virginia’s Uninsured, 2011.” The Urban Institute, October 2013. http://www.vhcf.org/wp- content/uploads/2010/10/Uninsurance-in-Virginia-for-VHCF-with-tables-and-maps- FINAL-10-7-13.pdfhttp://www.vhcf.org/wp- content/uploads/2010/10/Uninsurance-in-Virginia-for-VHCF-with-tables-and-maps- FINAL-10-7-13.pdf Macri J, V Lynch, and GM Kenney. “Profile of Virginia’s Uninsured, 2010.” The Urban Institute, March 2012. http://www.vhcf.org/wp-content/uploads/2010/10/VHCF- Profile-of-the-Uninsured-Final.pdfhttp://www.vhcf.org/wp-content/uploads/2010/10/VHCF- Profile-of-the-Uninsured-Final.pdf Buettgens M, GM Kenney, and H Recht. “Eligibility for Assistance and Projected Changes in Coverage Under the ACA: Variation Across States: May 2014 Update.” The Urban Institute, May 2014. http://www.urban.org/UploadedPDF/413129- Eligibility-for-Assistance-and-Projected-Changes-in-Coverage-Under-the-ACA- Variation-Across-States.pdfhttp://www.urban.org/UploadedPDF/413129- Eligibility-for-Assistance-and-Projected-Changes-in-Coverage-Under-the-ACA- Variation-Across-States.pdf Blumberg LJ, J Holahan, GM Kenney, M Buettgens, N Anderson, H Recht, and S Zuckerman. “Measuring Marketplace Enrollment Relative to Enrollment Projections: Update.” The Urban Institute, May 2014. http://www.urban.org/UploadedPDF/413112-Measuring-Marketplace-Enrollment- Relative-to-Enrollment-Projections-Update.pdf http://www.urban.org/UploadedPDF/413112-Measuring-Marketplace-Enrollment- Relative-to-Enrollment-Projections-Update.pdf

3. Methods All data are from the 2013 American Community Survey (ACS) and therefore reflect uninsurance in Virginia prior to the first open enrollment period for the health insurance Marketplaces. The family structures and corresponding income estimates used in this analysis are based on Health Insurance Units (HIUs), or groups of individuals who would likely be considered a family unit for the purposes of eligibility for Medicaid or the Marketplaces. HIUs are generally smaller than Census-reported families, and their income is generally lower than the Census estimates of family-based income. Therefore, more Virginians fall below the Federal Poverty Level (FPL) when estimates are based on HIU income than would be the case if estimates were based on Census-reported family income.

4. Main Takeaways Number of Uninsured in VA is about one million Uninsured rates in VA are typically lower than in the nation as a whole, but difference narrowed between 2008-2013 69.5 percent of uninsured Virginians (684,000) live in families with income at or below 200 percent of the Federal Poverty Level (FPL) Most uninsured Virginians are adults; the majority are white and in working families Uninsured rates are higher in Southern and Western parts of the state

5. Main Takeaways (2) Uninsured adults in VA are much more likely than insured adults to have unmet needs and less likely to receive preventive services, even when controlling for observed differences between the two groups An estimated 366,000 adults with incomes below 138 percent of the Federal Poverty Level (FPL) could qualify for coverage under the Medicaid expansion

6. Almost 1 million Virginians lack health insurance coverage, 89 percent of whom are adults Total Nonelderly 997,000 uninsured nonelderly Source: Urban Institute, May 2015. Based on the 2013 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 888,000 uninsured nonelderly adults

7. Adults are 3.2 times more likely to be uninsured than children in Virginia Source: Urban Institute, May 2015. Based on the 2013 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.

11. Uninsurance among the nonelderly was lower in VA than the United States as a whole, during 2008-2013 Note: * indicates the 2012 uninsured rate is statistically different from 2013 at the.10 level. # indicates the 2008 uninsured rate is statistically different from 2013 at the.10 level. Source: Urban Institute, May 2015. Based on the 2008, 2009, 2010, 2011, 2012, and 2013 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.

12. Uninsurance in Virginia increased among adults and decreased among children between 2008 and 2013 but remained steady between 2012 and 2013 Note: * indicates the 2012 uninsured rate is statistically different from 2013 at the.10 level. # indicates the 2008 uninsured rate is statistically different from 2013 at the.10 level. Source: Urban Institute, May 2015. Based on the 2008, 2009, 2010, 2011, 2012, and 2013 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. Adults Total Nonelderly Children

13. Over forty percent of all uninsured Virginians live below the poverty level Notes: Family poverty level estimates are based on health insurance unit gross income and use the 2013 Federal Poverty Levels (FPLs) defined by the U.S. Census Bureau. Estimates may not sum to 100% due to rounding. Source: Urban Institute, May 2015. Based on the 2013 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.

14. Over two-thirds of Virginians who are uninsured live in families with income at or below 200 percent of the FPL Individuals at or below 200% Federal Poverty Level Notes: Family poverty level estimates are based on health insurance unit gross income and use the 2013 Federal Poverty Levels (FPLs) defined by the U.S. Census Bureau. Estimates may not sum to 100% due to rounding. Source: Urban Institute, May 2015. Based on the 2013 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.

15. Virginians living below poverty are over 10 times more likely to be uninsured as Virginians living at or above 401 percent of FPL Total Nonelderly Notes: Family poverty level estimates are based on health insurance unit gross income and use the 2013 Federal Poverty Levels (FPLs) defined by the U.S. Census Bureau. Source: Urban Institute, May 2015. Based on the 2013 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.

16. 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 the head or spouse of the health insurance unit. Estimates may not sum to 100% due to rounding. Source: Urban Institute, May 2015. Based on the 2013 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.

17. Full-time workers and their families make up 50.5 percent of the uninsured in Virginia and are distributed over all income levels Notes: Family poverty level estimates are based on health insurance unit gross income and use the 2013 Federal Poverty Levels (FPLs) defined by the U.S. Census Bureau. Family work status is based on the highest level of employment among the adults in the health insurance unit. Estimates may not sum to 100% due to rounding. Source: Urban Institute, May 2015. Based on the 2013 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. $23,550 for a family of four $32,499 for a family of four $47,100 for a family of four $70,650 for a family of four $94,200 for a family of four

18. Just under half of the uninsured in Virginia are white, non-Hispanic Share of Nonelderly Uninsured Notes: Estimates may not sum to 100% due to rounding. Source: Urban Institute, May 2015. Based on the 2013 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.

19. Nearly four-fifths of the uninsured in Virginia are U.S. citizens Share of Nonelderly Uninsured Notes: Estimates may not sum to 100% due to rounding. Source: Urban Institute, May 2015. Based on the 2013 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.

20. Uninsurance declined for young adults (19-26) in Virginia between both 2008 and 2013, and between 2010 and 2013 Note: # indicates the 2008 uninsured rate is statistically different from 2013 at the.10 level. Source: Urban Institute, May 2015. Based on the 2008, 2009, 2010, 2011, 2012, and 2013 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. #

21. Note: Adults are age 19-64. Measures refer to access or utilization over the past 12 months. Estimates marked with * indicate the difference between the insured and uninsured estimates is significant at the.01 percent level. Source: Urban Institute, June 2015. Based on the 2013 Behavioral Risk Factor Surveillance System.

22. Note: Adults are age 19-64. Measures refer to access or utilization over the past 12 months. Estimates marked with * indicate the difference between the insured and uninsured estimates is significant at the.01 percent level. Adjusted differences use a linear model controlling for age, sex, race, education, and health status. Source: Urban Institute, July 2015. Based on the 2013 Behavioral Risk Factor Surveillance System.

23. Medicaid Expansion Under the ACA An estimated 221,000 uninsured Virginians below 100% of FPL would become eligible for public coverage should Virginia expand Medicaid  47.4% of these are between the ages of 19-34 Overall, 366,000 Virginians who were uninsured in 2013 with incomes below 138% of FPL would become eligible for public coverage should Virginia expand Medicaid  As of March 2015, HHS reported that 127,307 adults in Virginia with incomes between 100 and 138 percent of the FPL were enrolled in the Health Insurance Marketplace.