Tuesday, September 12, 2017

Census: ACA cut uninsured rate in half in Medicaid expansion states by 2016

The Census Bureau released its report on health insurance coverage in the U.S. for 2016 today. One striking trend was flagged by Matt Broaddus at the Center for Budget and Policy Priorities: the gap between states that expanded Medicaid and those that refused continues to widen:

Uninsured Rate Gap Between Medicaid Expansion States and Others Widening

To this let me add a sidelight: in expansion states, the uninsured rate has been cut in half since the main ACA programs were implemented in 2014 -- from 12.9% in 2013 to 6.5% in 2016.

The Census report breaks down this widening gap between expansion and nonexpansion states by income group. In the expansion states, in every broad income group the uninsured rate was cut in half or close to it from 2013-2016. Because the 2013 rates among the poor are so high, the gains there are enormous. Because those with incomes below the poverty line are left out in the cold in nonexpansion states -- ineligible for both Medicaid and subsidized marketplace coverage -- the more limited gains in nonexpansion states are sharper in the 100-400% FPL band than for those under 100% FPL.

It should be noted that according to the Current Population Survey*, the uninsured rate rose in 2016 for those roughly in the upper range of subsidy eligibility in the ACA marketplace. For those with incomes in the 200-299% FPL range, the uninsured rate rose from 9.8% to 10.8% from 2015 to 2016. In the 300-400% FPL band, the uninsured rate upticked from 7.3% to 7.5%. If this is partly the result of rising out-of-pocket costs and narrowing networks for marketplace enrollees not eligible for strong Cost Sharing Reduction subsidies (available to enrollees up to 200% FPL), the decline may be sharper in 2017, not to say 2018 -- and may extend to the over 400% FPL bracket, as unsubsidized premiums rose sharply in 2017 and will again this year.

It's worth noting that the Kaiser Family Foundation's annual survey of marketplace enrollees recorded a marked decline in  satisfaction in 2016; that the decline correlated with rising deductibles; and that the increase in enrollment in high deductible plans was concentrated among enrollees with incomes over 200% FPL. On the other hand, marketplace enrollees are a small percentage of the insured, particularly in income brackets above 200% FPL, and the Census surveys define household income somewhat differently from the ACA marketplace -- counting everyone who lives under one roof as a household, rather than everyone included in one tax return. Thus some of those in the Census's 200-299%  FPL bracket may in fact be eligible for strong CSR. It may not be warranted to attribute the rise in the uninsured rate among those with incomes from 200-399% FPL to marketplace woes.

* That is, the Current Population Survey, 2016 and 2017 Annual Social and Economic Supplements (CPS ASEC). The breakout of the uninsurance rate in expansion and nonexpansion states is based on the American Community Survey (ACS).

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