As I was flying back from Atlanta the other night, I read a fascinating new paper by researchers at the Urban Institute (a team led by the esteemed Genevieve Kenney), which looks at adult uninsured rates and participation rates in Medicaid. In particular, the researchers examine how the number of uninsured parents and childless adults changed from 2013 to 2014 – the first year of implementation of much of the Affordable Care Act (with close attention of course paid to the impact of Medicaid expansion).
There are lots of great takeaways from this report and I encourage you to read it. The essential role of Medicaid expansion in reducing the rate of uninsured parents and adults is clear – and the paper has lots of detailed state data to support this. Nine of the 10 states with the lowest uninsured rates for parents are expansion states while eight of the 10 states with the highest uninsured parent rate are non expansion states.
In general, uninsured rates for parents declined in almost every state – with a few exceptions: DC (where 95% of parents where already covered so it was hard to make more progress), Alaska, Maine, New Hampshire, and Wisconsin. Some parents in non-expansion states likely gained coverage through the new tax subsidies available for use in the marketplace and some may have enrolled in Medicaid that they were already eligible for (more on that coming up!).
But it is clear that the fastest way to reduce the number of low-income uninsured parents in non-expansion states would be to expand Medicaid. Those states that did expand Medicaid saw a decline in the rate of uninsured parents of 3.9% as compared to states that didn’t which saw a smaller decline of 2.8%. It is likely that this differential will grow over time as more newly-eligible parents enroll in Medicaid in expansion states.
However, even in states that have not expanded Medicaid, there are many poor parents who are eligible for Medicaid but are not enrolled. The Urban Institute’s new report, for the first time, calculates state-by-state participation rates for parents eligible for Medicaid as of 2014.
Participation rates in Medicaid/CHIP are much higher for children than their parents as a result of many years of outreach, application assistance, and strategic enrollment and retention efforts for kids since the advent of CHIP. The new Urban Institute research suggests that some of these efforts – especially in states that have not expanded Medicaid – should be targeted to very poor parents.
As the Urban Institute researchers point out, states that have not expanded Medicaid have actually seen a very small increase in income eligibility due to the ACA’s requirement that states move to a (now not so new) method to count income and household size — known affectionately as MAGI (modified adjusted gross income). States were first required to adjust their eligibility levels to account for a hodgepodge of disregards for certain kinds of income or expenses (such as child support received or child care expenses paid). Additionally, the ACA added an across-the-board 5 percentage point income disregard, which resulted in a slight boost in eligibility. The ACA also required states to get rid of asset tests. For states with very low parent eligibility levels (unfortunately these are many of the same states that have not expanded Medicaid yet), my best guess is that this change was likely more impactful as those states were more likely to have had asset tests and earned income disregards in place. The median eligibility level for parents in non-expansion states in 2014 was 47% of the federal poverty line.
Yet many of these parents are not covered in Medicaid. The study finds a striking difference in participation in expansion v. non expansion states – with expansion states averaging almost 80% parent participation rates and non-expansion states at just over 63% participation. Considerable state variation exists with the worst participation rate in Texas of just 48% (it actually declined from 51% between 2013 to 2014) and the highest rate of 95.6% in the District of Columbia. Other states with participation rates below 60% include Alabama, Alaska, Georgia, Kansas, Louisiana, Missouri and South Dakota. (See Table 3 on p. 15 of the report for states’ rates).
This means that some of the very poorest families in the US – those with incomes below 50 percent of the federal poverty line – could be enrolling in Medicaid but they are not. According to unpublished tabulations from the Urban Institute, of the estimated 2.5 million eligible but uninsured parents in 2014, an estimated 1.9 million (or 74 percent) are below 50 percent of FPL. Thirty-one percent of these parents live in four Southern states that still haven’t expanded Medicaid – Texas, Florida, Georgia and North Carolina.
The benefits of Medicaid coverage could be enormous for a very poor parent – who is likely to suffer from health challenges such as maternal depression (see our paper with CLASP which highlights the very high rates of maternal depression in women below the poverty line. Moreover, these families suffer from very high rates of residential instability and homelessness – so being uninsured adds yet another barrier and economic drag on parents’ efforts to stabilize their families.
 Close watchers of expansion states will note that this list includes two non expansion states (ME, WI – which has a unique coverage option) and two states AK and NH which had not expanded coverage as of the beginning of 2014 (New Hampshire expanded as of July 1st).
 In 2014 the overall number of uninsured parents declined by 2.1 million, and 1.1 million additional parents were covered by Medicaid. The researchers note that almost all of this Medicaid enrollment growth came from expansion states.
 Two of these states, Alaska and Louisiana have expanded Medicaid since 2014 so their participation rates are likely to go up.