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RESEARCH FINDINGS #34:
Transitions in Health Insurance Coverage for Non-Elderly Adults in the U.S. Civilian Noninstitutionalized Population: 2012-2013 through 2014-2015 and Selected Preceding Two-Year Periods

August 2017

G. Edward Miller, PhD and Jessica P. Vistnes, PhD

Highlights

Rates of gaining coverage for non-elderly adults who were uninsured for an entire year increased from 18.6 percent in 2012-2013 to 32.5 percent and 29.9 percent in 2013-2014 and 2014-2015, respectively.
Among uninsured adults, gains in Medicaid coverage were larger in 2013-2014 (10.2 percent) and 2014-2015 (8.4 percent) than in 2012-2013 (4.6 percent).
Among uninsured non-elderly adults, 5.7 percent of those uninsured throughout 2013 and 5.9 percent of those uninsured throughout 2014 gained Marketplace coverage in the following year.
The likelihood that insured, non-elderly adults would lose coverage was lower in 2014-2015 (2.3 percent) than in 2012-2013 (3.4 percent).

Introduction

In 2014, new sources of insurance coverage became available for previously uninsured adults. These new sources included premium subsidies for low and middle-income adults to purchase private insurance in new Marketplaces and the potential for states to expand Medicaid eligibility to include adults with incomes up to 138 percent of the federal poverty line. By the end of 2015, 29 states and the District of Columbia had expanded their Medicaid programs.

Using information from the Household Component of the Medical Expenditure Panel Survey (MEPS-HC) for the 6 two-year intervals from 2009-2010 through 2014-2015, this Research Findings provides detailed estimates of health insurance coverage transitions for non-elderly adults between the ages of 18 and 64. More specifically, this Findings presents estimates of the percentage of uninsured adults that 'gained' insurance and the percentage of insured adults that 'lost' coverage in each two-year period.¹ Individuals are considered to have gained coverage if they were uninsured for the entire first year of each period and were insured at any point in the second year. Individuals are considered to have lost coverage if they were insured at any point during the first year and were uninsured for the entire second year. Note that individuals that 'lost' coverage could be insured for all or any part of the first year, so they may have lost coverage before the second year began. For uninsured adults who gained coverage, this Findings further examines the contributions of three types of insurance—Marketplace coverage, Medicaid, and other private/public insurance—to overall gains in coverage. Estimates are presented for all non-elderly adults and for subgroups of adults defined by state Medicaid expansion status, age, race/ethnicity, and educational attainment. All differences between estimates discussed in the text are statistically significant at the 0.05 level.

Findings

All non-elderly adults
In 2014, newly-available Marketplace insurance and the expansion of Medicaid eligibility in many states provided new options for previously uninsured adults to obtain coverage. During that year, nearly one-third (32.5 percent) of non-elderly adults who had been uninsured throughout 2013 gained insurance coverage. In 2015, a similar percentage of adults who had been uninsured throughout 2014 gained coverage (29.9 percent). The gains in both of these periods are significantly higher than in any two-year period from 2009 through 2013, where rates of gaining insurance ranged from 15.6 percent to 18.6 percent (figure 1).

Most of the increase in the rate of gaining coverage in 2014 and 2015 can be attributed to increased rates of gaining Medicaid and Marketplace coverage. Among uninsured adults, gains in Medicaid coverage were larger in 2013–2014 (10.2 percent) and 2014–2015 (8.4 percent) than in 2012–2013 (4.6 percent). Also among uninsured adults, 5.7 percent and 5.9 percent gained Marketplace coverage in 2013–2014 and 2014–2015, respectively (figure 2). With respect to rates of insured adults losing coverage, there was no significant change between 2012–2013 and 2013–2014, but in 2014–2015 (2.3 percent) rates of losing coverage were lower than in any two-year period from 2009 through 2013 (figure 1).

The remaining figures in this Findings present estimates for different population subgroups for the periods 2012–2013 through 2014–2015.

Population subgroups
State Medicaid Expansion Status
In 2013–2014, the likelihood of gaining coverage increased for previously uninsured adults living in both Medicaid expansion and non-expansion states relative to rates in 2012–2013. However, there were no significant changes in these rates between 2013–2014 and 2014–2015 in either state category (figure 2). Furthermore, in 2014–2015, adults living in both expansion and non-expansion states had lower rates of losing coverage than in 2012–2013.

In 2012–2013, there was no significant difference between expansion and non-expansion states in rates of gaining any coverage, but uninsured adults in expansion states had a higher rate of gaining Medicaid than those in non-expansion states (5.6 versus 3.7 percent, respectively). However, in both 2013–2014 and 2014–2015, uninsured adults living in Medicaid expansion states were more likely to gain coverage than adults in non-expansion states (39.5 versus 26.4 percent in 2013–2014 and 35.8 versus 24.8 percent in 2014–2015, respectively). This is primarily due to the substantcially higher rates of gaining Medicaid coverage in expansion states in those years. In expansion states, the percentages of uninsured adults gaining Medicaid coverage were higher in 2013–2014 (17.4 percent) and in 2014–2015 (13.0 percent) than in 2012–2013 (5.6 percent). By contrast, there was no significant change over this period in Medicaid enrollment rates among uninsured adults in non-expansion states, and the rates of gaining Medicaid coverage in non-expansion states in 2013–2014 (4.0 percent) and 2014–2015 (4.4 percent) were substantially lower than in expansion states.

In 2014–2015, uninsured adults in non-expansion states had a higher rate of gaining Marketplace coverage than their counterparts in expansion states (8.1 versus 3.5 percent), but a lower rate of gaining other private/public insurance (12.3 versus 19.3 percent).

Age
In 2013–2014, the likelihood of gaining coverage increased for adults in all age categories compared to 2012–2013 rates. However, there were no significant changes in rates of gaining coverage for adults in any age category between 2013–2014 and 2014–2015 (figure 3). With respect to specific sources of coverage, the same pattern was observed for rates of gaining Medicaid coverage. For Marketplace coverage, uninsured adults ages 55–64 (14.8 percent) were much more likely to enroll in 2014 than adults ages 36–54 (5.5 percent) and 18–35 (2.9 percent). However, from 2014 to 2015, there were no significant differences by age in the rates at which previously uninsured adults gained Marketplace coverage.

With respect to other private/public coverage, the youngest uninsured adults (ages 18–35) were the only age group to experience an increase from 2012–2013 to 2013–2014 as their rate of gaining coverage rose from 14.7 to 19.9 percent. The youngest uninsured adults were also more likely than those ages 36–54 to gain this type of coverage in both 2013–2014 (19.9 percent versus 14.1 percent) and 2014–2015 (18.9 percent versus 12.3 percent).

In 2013–2014, adults ages 18–35 were more likely to lose coverage (4.6 percent) than those ages 36–54 (2.0 percent) and 55–64 (2.0 percent). In 2014–2015, the rate at which insured young adults lost coverage declined relative to their 2012–2013 rates. However, young adults were still more likely to lose coverage than older adults (3.3 percent for ages 18–25 versus 1.9 percent and 1.1 percent for ages 36–54 and 55–64 in 2014–2015, respectively).

Race/ethnicity
From 2012–2013 to 2013–2014, the likelihood of gaining some type of coverage increased for adults in all racial/ethnic groups. However, there were no significant changes in rates of gaining coverage for any racial/ethnic group between 2013–2014 and 2014–2015 (figure 4).

In nearly every comparison in the 2013–2014 and 2014–2015 periods, uninsured Hispanic adults were significantly less likely than other adults to gain insurance in the following year. In particular, in 2013–2014, 24.0 percent of uninsured Hispanic adults gained insurance compared to 34.3 percent to 40.8 percent for the other three racial-ethnic groups. In 2014–2015, Hispanic adults (22.1 percent) were again less likely than non-Hispanic white (36.4 percent) and non-Hispanic black adults (31.9 percent) to gain insurance, but the difference with Asian adults was not statistically significant.

There were also differences among racial/ethnic groups in the likelihoods of gaining different types of coverage. In 2013–2014, uninsured non-Hispanic whites (8.6 percent) were more likely than non-Hispanic blacks (3.8 percent) and Hispanics (2.9 percent) to gain Marketplace coverage, but in 2014–2015 there were no significant differences in the rates of gaining Marketplace coverage among these groups. Also, in 2014–2015, Hispanic adults (8.7 percent) were significantly less likely to gain other private/public insurance than other racial/ethnic groups (with rates ranging from 19.4 percent to 22.2 percent).

In most comparisons with other subgroups, Hispanic adults had a higher rate of losing coverage. Specifically, in 2013–2014, Hispanics (5.5 percent) had a higher rate of losing coverage than non-Hispanic whites (2.4 percent) and Asians (1.1 percent). In 2014–2015 Hispanics (4.5 percent) had a higher rate of losing coverage than non-Hispanic whites (1.6 percent) and non-Hispanic blacks (2.8 percent).

Education
In 2013–2014, the likelihood of gaining some type of coverage increased for adults in both education groups relative to 2012–2013. However, there were no significant changes in rates of gaining coverage for either education group between the 2013–2014 and 2014–2015 periods (figure 5). With respect to specific sources of coverage, the same patterns were observed for rates of gaining Medicaid coverage for adults in both education groups in these time periods. The pattern differed for Marketplace coverage, however, as rates increased in 2014–2015 relative to 2013–2014 for adults with a high-school diploma/GED or less education (5.9 percent versus 2.7 percent, respectively) and decreased for adults with some college or more education (from 10.1 to 6.1 percent). For rates of gaining other private/public insurance, there were increases for adults with a high school diploma/GED or less education in 2013–2014 relative to 2012–2013, but there were no significant changes for those with some college or more education.

Uninsured adults with a high-school diploma/GED or less education were less likely than adults with more education to gain any insurance coverage in 2013–2014 (27.0 versus 40.8 percent) and in 2014–2015 (24.5 versus 38.8 percent). In 2013–2014, adults with a high-school education or less were less likely to enroll in Marketplace coverage (2.7 versus 10.1 percent) and less likely to gain other private/public coverage (14.0 versus 20.7 percent). In 2014–2015, there was no longer a significant difference in the rates of gaining Marketplace coverage across education groups but uninsured adults with a high-school education or less were still substantially less likely to gain other private/public insurance (10.9 versus 23.1 percent for those with some college or more education).

Uninsured adults with a high-school diploma/GED or less education had a lower rate of losing coverage in 2014–2015 than they did in 2012–2013. However, they were still more likely to lose coverage in 2014–2015 than those with some college or more education (3.1 versus 1.9 percent) (figure 5).

Data Source

The estimates shown in this Research Findings are drawn from analyses conducted by the MEPS staff from the following public use files: HC-129, HC-138, HC-147, HC-155, HC-163, HC-171 and HC-174. For consistency with panel specific weights from the other data files, the analytic weight for Panel 19 from HC-174 was adjusted by post-stratifying by poverty status to the Current Population Survey.

Definitions

Uninsured
People who did not have coverage for the entire year were classified as uninsured. The uninsured were defined as people not covered by Medicaid, Medicare, TRICARE (Armed Forces-related coverage), other public hospital/physician programs, private hospital/physician insurance (including Medigap coverage) or insurance purchased through health insurance Marketplaces established in accordance with the Affordable Care Act. People covered only by non-comprehensive State-specific programs (e.g., Maryland Kidney Disease Program) or private single service plans such as coverage for dental or vision care only, or coverage for accidents or specific diseases, were considered uninsured.

Insured
People who had coverage at any point during the year were classified as insured. The insured were defined as people covered by Medicaid, Medicare, TRICARE (Armed Forces-related coverage), other public hospital/physician programs, private hospital/physician insurance (including Medigap coverage) or insurance purchased through health insurance Marketplaces established in accordance with the Affordable Care Act. People covered only by non-comprehensive State-specific programs (e.g., Maryland Kidney Disease Program) or private single service plans such as coverage for dental or vision care only, or coverage for accidents or specific diseases, were not considered to be insured.

Coverage type gained
Individuals who gained coverage from the first to the second year of the reference period were placed into one of three hierarchical insurance categories: Marketplace, Medicaid (no Marketplace or private coverage), and Other Public and Private Coverage that includes all sources of coverage except for those identified in the first two categories.

Population covered
Persons included in this analysis were in the survey for the entire two-year period of eligibility and were ages 18–64 for the entire two-year period of eligibility. This restriction excludes individuals who were institutionalized, left the country, or died during the two-year period and those who joined the household after January of the first year of the two-year period.

State Medicaid Expansion Status
For analyses of the 2013–2014 (2014–2015) period, Medicaid expansion states were defined as those states that implemented the Affordable Care Act's Medicaid expansion at any time before or during calendar year 2014 (2015). States that expanded Medicaid by the end of 2014 include Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Ohio, Oregon, Rhode Island, Vermont, Washington, and West Virginia. The states that expanded Medicaid during the 2015 calendar year include Alaska, Indiana and Pennsylvania. State Medicaid expansion status is based on individuals' state of residence in their second year in the survey.

Age
Individuals are included in the analysis if they were ages 18–64 for the entire two-year period of eligibility. Although this sample restriction ensures individuals are always in the target age range, it excludes those who were age 64 in the first year of the reference period (and turned 65 in the second year), and also excludes those who were 18 in the second year of their reference period. Age is categorized based on the person's age at the end of the person's first calendar year in the MEPS-HC.

Race/ethnicity
Classification by race/ethnicity was based on information reported for each family member. First, respondents were asked if the person's main national origin or ancestry was Puerto Rican; Cuban; Mexican, Mexican-American, or Chicano; other Latin American; or other Spanish. All persons whose main national origin or ancestry was reported in one of these Hispanic groups, regardless of racial background, were classified as Hispanic. All other persons were classified according to their reported race. For this analysis, the following classification by race and ethnicity was used Hispanic, non-Hispanic black only, non-Hispanic white only, and non-Hispanic Asian only. Adults who reported other races and/or multiple races were not included in the analysis due to insufficient sample size.

Education
Information on the highest level of schooling completed or the highest degree received by a person was recorded in the first round the person was included in the MEPS-HC. The categories included in this Research Findings are: 1) a high school diploma/ GED or less education and 2) some college or more education.

About MEPS-HC

MEPS-HC is a nationally representative longitudinal survey that collects detailed information on health care utilization and expenditures, health insurance, and health status, as well as a wide variety of social, demographic, and economic characteristics for the U.S. civilian noninstitutionalized population. It is cosponsored by the Agency for Healthcare Research and Quality and the National Center for Health Statistics.

For more information about MEPS, call the MEPS information coordinator at AHRQ (301-427-1406) or visit the MEPS Web site at http://meps.ahrq.gov/mepsweb/.

References

Carroll, W. The Uninsured in America, First Part of 2013: Estimates for the U.S. Civilian Noninstitutionalized Population under Age 65. Statistical Brief #447. August 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://meps.ahrq.gov/mepsweb/data_files/publications/st447/stat447.shtml.

Cohen, J. Design and Methods of the Medical Expenditure Panel Survey Household Component. MEPS Methodology Report No. 1. AHCPR Pub. No. 97-0026. Rockville, MD: Agency for Health Care Policy and Research, 1997. http://meps.ahrq.gov/mepsweb/data_files/publications/mr1/mr1.shtml.

Cohen, S. Transitions in Health Insurance Coverage Over Time, 2009–2013 (Selected Intervals): Estimates for the U.S. Civilian Noninstitutionalized Adult Population under Age 65. Statistical Brief #439. May 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://meps.ahrq.gov/mepsweb/data_files/publications/st439/stat439.shtml.

Ezzati-Rice, T.M., Rohde, F., Greenblatt, J. Sample Design of the Medical Expenditure Panel Survey Household Component, 1998–2007. Methodology Report No. 22. March 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://meps.ahrq.gov/mepsweb/data_files/publications/mr22/mr22.shtml.

Rhoades, J.A. and Cohen, S.B. The Long-Term Uninsured in America, 2008–2011 (Selected Intervals): Estimates for the U.S. Civilian Noninstitutionalized Population under Age 65. Statistical Brief #424. November 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://meps.ahrq.gov/mepsweb/data_files/publications/st424/stat424.shtml.

Roemer, M. The Uninsured in America, First Part of 2012: Estimates for the U.S. Civilian Noninstitutionalized Population under Age 65. Statistical Brief #422. September 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://meps.ahrq.gov/mepsweb/data_files/publications/st422/stat422.shtml.

Vistnes, J. and Cohen, S. Transitions in Health Insurance Coverage Over Time, 2012–2014 (Selected Intervals): Estimates for the U.S. Civilian Noninstitutionalized Adult Population under Age 65. Statistical Brief #467. February 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.meps.ahrq.gov/mepsweb/data_files/publications/st467/stat467.shtml.

Vistnes, J. and Lipton, B. Uninsured All Year, 2013–2015: Estimates for Non-Elderly Adults by Selected Population Sub-groups and State Medicaid Expansion. Research Findings #35. August 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://meps.ahrq.gov/mepsweb/data_files/publications/rf35/rf35.shtml

Vistnes, J. and Miller, G.E. Uninsurance and Insurance Transitions, 2012–2013 through 2014–2015: Estimates for U.S., Non-Elderly Adults by Health Status, Presence of Chronic Conditions and State Medicaid Expansion Status. Research Findings #36. August 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://meps.ahrq.gov/mepsweb/data_files/publications/rf36/rf36.shtml

Suggested Citation

Miller, G.E. and Vistnes, J. Transitions in Health Insurance Coverage for Non-Elderly Adults in the U.S. Civilian Noninstitutionalized Population: 2012–2013 through 2014–2015 and Selected Preceding Two-Year Periods. Research Findings #34. August 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://meps.ahrq.gov/mepsweb/data_files/publications/rf34/rf34.shtml

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AHRQ welcomes questions and comments from readers of this publication who are interested in obtaining more information about access, cost, use, financing, and quality of health care in the United States. We also invite you to tell us how you are using this Research Findings and other MEPS data and tools and to share suggestions on how MEPS products might be enhanced to further meet your needs. Please email us at MEPSProjectDirector@ahrq.hhs.gov or send a letter to the address below:

Joel W. Cohen, PhD, Director
Center for Financing, Access, and Cost Trends
Agency for Healthcare Research and Quality
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Rockville, MD 20857

¹For estimates of the percentage of adults ages 18 to 64 who were uninsured throughout the calendar year, see Vistnes and Lipton (2017). Note that the samples for the estimates in this Research Findings differ somewhat from those in Vistnes and Lipton (2017) because they use observations from one Panel in the MEPS-HC, not the combined two Panels used in Vistnes and Lipton (2017) and the age restrictions are based on a two-year, rather than a one-year period.

Figure data for accessible table follows the image

	2009-2010	2010-2011	2011-2012	2012-2013	2013-2014	2014-2015
Figure 1. Percentage of uninsured (insured) non-elderly adults¹ in year one that gained (lost) coverage in year two, 2009 to 2015
Gained Coverage	15.6	18.4	18.1	18.6	32.5	29.9
Lost Coverage	4.4	3.6	4.1	3.4	2.9	2.3
Source: Medical Expenditure Panel Survey- Household Component, 2009 to 2015. ¹The population of non-elderly adults includes individuals that were between the ages of 18 and 64 throughout the two-year period.

	Uninsured gaining insurance, by type
Figure 2. Percentage of uninsured (insured) non-elderly adults¹ in year one that gained (lost) coverage in year two: Comparison of 2012-13, 2013-14 and 2014-15, overall and by state Medicaid expansion status
	Total			Medicaid Expansion State			Non-Expansion State
	2012-13	2013-14	2014-15	2012-13	2013-14	2014-15	2012-13	2013-14	2014-15
Total	18.6	32.5	29.9	19.4	39.5	35.8	18.0	26.4	24.8
Marketplace	0.0	5.7	5.9	0.0	4.7	3.5	0.0	6.4	8.1
Medicaid	4.6	10.2	8.4	5.6	17.4	13.0	3.7	4.0	4.4
Other Private/Public	14.0	16.6	15.6	13.8	17.4	19.3	14.3	15.9	12.3
	Insured losing insurance
	Medicaid Expansion State	Non-Expansion State
2012-13	3.0	4.0
2013-14	2.3	3.7
2014-15	2.0	2.7
Source: Medical Expenditure Panel Survey - Household Component, 2009 to 2015 ¹The population of non-elderly adults includes individuals that were between the ages of 18 and 64 throughout the two-year period.

	Uninsured gaining insurance, by type
Figure 3. Percentage of uninsured (insured) non-elderly adults¹ in year one that gained (lost) coverage in year two: Comparison of 2012-13, 2013-14 and 2014-15, by age
		Total	Marketplace	Medicaid	Other private/public
Age 18-35	2012-13	20.6	0.0	5.9	14.7
	2013-14	33.8	2.9	11.0	19.9
	2014-15	32.9	4.9	9.2	18.9
Age 36-54	2012-13	14.8	0.0	3.3	11.5
	2013-14	29.6	5.5	10.0	14.1
	2014-15	27.0	6.3	8.5	12.3
Age 55-64	2012-13	22.9	0.0	3.8	19.1
	2013-14	36.5	14.8	8.1	13.6
	2014-15	27.3	8.8	5.4	13.1
	Insured losing insurance
	2012-13	2013-14	2014-15
Age 18-35	4.8	4.6	3.3
Age 36-54	2.8	2.0	1.9
Age 55-64	2.1	2.0	1.1
Source: Medical Expenditure Panel Survey - Household Component, 2009 to 2015 ¹The population of non-elderly adults includes individuals that were between the ages of 18 and 64 throughout the two-year period.

		Total	Marketplace	Medicaid	Other private/public
Figure 4. Percentage of uninsured (insured) non-elderly adults¹ in year one that gained (lost) coverage in year two: Comparison of 2012-13, 2013-14, and 2014-15, by race/ethnicity
Hispanic	2012-13	12.4	0.0	4.0	8.4
	2013-14	24.0	2.9	7.6	13.5
	2014-15	22.1	5.3	8.1	8.7
White	2012-13	21.1	0.0	3.7	17.5
	2013-14	38.0	8.6	10.9	18.5
	2014-15	36.4	7.4	9.7	19.4
Black	2012-13	24.7	0.0	8.5	16.1
	2013-14	34.3	3.8	12.5	18.0
	2014-15	31.9	4.5	7.4	20.1
Asian	2012-13	14.6	0.0	2.3	12.2
	2013-14	40.8	7.0	10.7	23.0
	2014-15	33.8	8.5	3.1	22.2
	Insured losing insurance
	2012-13	2013-14	2014-15
Hispanic	7.9	5.5	4.5
White	2.5	2.4	1.6
Black	4.4	4.2	2.8
Asian	3.4	1.1	2.8
Source: Medical Expenditure Panel Survey - Household Component, 2009 to 2015 ¹The population of non-elderly adults includes individuals that were between the ages of 18 and 64 throughout the two-year period.

	HS Diploma/GED or Less			Some College or More
Figure 5. Percentage of uninsured (insured) non-elderly adults¹ in year one that gained (lost) coverage in year two: Comparison of 2012-13, 2013-14 and 2014-15, by education
	2012-13	2013-14	2014-15	2012-13	2013-14	2014-15
Total	13.7	27.0	24.5	24.7	40.8	38.8
Marketplace	0.0	2.7	5.9	0.0	10.1	6.1
Medicaid	4.5	10.4	7.7	4.8	10.0	9.6
Other Private/Public	9.1	14.0	10.9	19.9	20.7	23.1
	Insured losing insurance
	2012-13	2013-14	2014-15
HS Diploma/GED or Less	5.3	4.3	3.1
Some College or More	2.5	2.3	1.9
Source: Medical Expenditure Panel Survey - Household Component, 2009 to 2015 ¹The population of non-elderly adults includes individuals that were between the ages of 18 and 64 throughout the two-year period.

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RESEARCH FINDINGS #34: Transitions in Health Insurance Coverage for Non-Elderly Adults in the U.S. Civilian Noninstitutionalized Population: 2012-2013 through 2014-2015 and Selected Preceding Two-Year Periods