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RESEARCH FINDINGS #35:
The Uninsured in America, 2013-2015: Estimates for Non-Elderly Adults Uninsured Throughout Each Calendar Year, by Selected Population Sub-groups and State Medicaid Expansion Status

August 2017

Jessica P. Vistnes, Ph.D. and Brandy J. Lipton, Ph.D.

Highlights

The percentage of non-elderly adults, ages 18-64, uninsured for the entire calendar year (the "uninsured rate") declined from 18.8 percent (35.6 million adults) in 2013 to 14.4 percent (27.4 million adults) in 2014 and then to 11.7 percent (22.4 million adults) in 2015.
Uninsured rates were lower in Medicaid expansion than non-expansion states throughout the 2013 to 2015 period for adults ages 18-35, 36-54 and 55-64. Between 2013 and 2014, uninsured rates declined for adults in each age group at the national level and in both Medicaid expansion and non-expansion states. Between 2014 and 2015, uninsured rates declined for adults ages 18-35 and 36-54 at the national level and in both state categories.
Uninsured rates declined in 2014 and then again in 2015 for Hispanic, white, and black non-elderly adults. For Asians, there was a significant decline in the uninsured rate from 2013 to 2014, but no significant change from 2014 to 2015. The percentage point difference in uninsured rates between Hispanic non-elderly adults and white non-Hispanic adults narrowed in both 2014 and 2015, overall and in Medicaid expansion states.

Beginning in 2014, new sources of health insurance became available for uninsured adults. These include premium tax credits for the purchase of private insurance through Marketplaces for low- and middle-income adults and, in participating states, expanded Medicaid eligibility for adults with incomes up to 138 percent of the federal poverty level. By the end of 2015, 29 states and the District of Columbia had expanded their Medicaid programs. In addition, individual and employer mandates were introduced in 2014 and 2015 that established financial incentives promoting coverage.

Using information from the Household Component of the Medical Expenditure Panel Survey (MEPS-HC), this Research Findings examines changes in calendar-year uninsured rates between 2013 and 2015 for non-elderly adults in various demographic groups, overall and by state Medicaid expansion status. To provide context, this Research Findings begins with annual estimates for 2009–2015 of the percentage and number of non-elderly adults, ages 18–64, in the U.S. civilian noninstitutionalized population, who were uninsured for the entire calendar year. All differences between estimates discussed in the text are statistically significant at the 0.05 level unless otherwise noted.

Findings

Year-to-year changes in calendar-year uninsured rates for non-elderly adults were not significant between 2009 and 2013. However, in 2014, the uninsured rate declined from its 2013 level and then declined again in 2015. Between 2013 and 2015, the uninsured rate declined from 18.8 percent in 2013 (35.6 million adults) to 14.4 percent (27.4 million adults) in 2014 and 11.7 percent (22.4 million adults) in 2015 (figures 1 and 2). The remainder of this Research Findings examines changes in the calendar-year uninsured rate between 2013 and 2015 for non-elderly adults in various demographic groups, nationally and by state Medicaid expansion status.

Sex
Uninsured rates for non-elderly men were higher than for women, both overall and in Medicaid expansion and non-expansion states in each year from 2013 to 2015 (figures 3 and 4). For example, 21.6 percent of men and 16.1 percent of women were uninsured at the national level in 2013. Uninsured rates declined for both sexes in 2014 and then again in 2015.

Uninsured rates for men, women and for all non-elderly adults were significantly lower in Medicaid expansion than non-expansion states in 2013 and remained lower in 2014 and 2015. Uninsured rates declined for men, women and all non-elderly adults in expansion and non-expansion states in 2014 and then again in 2015. While there were no significant differences in the percentage point declines for men and women by whether or not they lived in a Medicaid expansion state, in Medicaid expansion states the percentage point decline in uninsured rates from 2014 to 2015 was larger for men than for women (3.1 percentage points versus 1.3 percentage points). In non-expansion states, there were no significant differences in the percentage point declines for men versus women in either 2014 or 2015.

Age
In 2013, the percentage of non-elderly adults uninsured throughout the year declined as age increased, both overall and in Medicaid expansion and non-expansion states (figures 5 and 6). At the national level, 22.5, 18.3, and 13.2 percent of adults ages 18–35, 36–54, and 55–64, respectively, were uninsured throughout 2013. In the following two years, uninsured rates decreased from their 2013 levels in each age group, first in 2014 and then again in 2015 (p < 0.10 for adults ages 55–64 in 2015).

Between 2013 and 2014, uninsured rates declined for adults in each age group in both Medicaid expansion and non-expansion states. Between 2014 and 2015, uninsured rates declined for adults ages 18–35 and 36–54 in both expansion and non-expansion states. In Medicaid expansion states, the percentage point decline in uninsured rates between 2013 and 2015 was larger for 18-35 year olds (9.6 percentage points) than for 55-64 year olds (3.5 percentage points).

Uninsured rates were lower in Medicaid expansion than non-expansion states for adults in all age categories in 2013. For example, in 2013, 19.9 and 10.8 percent of adults ages 18–35 and 55–64 were uninsured in expansion states, while 25.7 percent and 16.3 percent of their counterparts in non-expansion states were uninsured, respectively. Uninsured rates remained lower in expansion than non-expansion states for adults in all age categories in both 2014 and 2015.

Race/ethnicity
In 2013, non-Hispanic white adults had a lower uninsured rate than Hispanic, non-Hispanic black and non-Hispanic Asian adults (13.2 percent for whites, 39.3 percent for Hispanics, 21.1 percent for blacks, and 17.4 percent for Asians) (figures 7 and 8). Between 2013 and 2014, uninsured rates declined for non-elderly adults in all racial/ethnic groups. Between 2014 and 2015, there were statistically significant declines in uninsured rates for all racial/ethnic groups except for Asians.

The percentage point difference in uninsured rates between Hispanics and whites narrowed in both 2014 and 2015 from 26.1 percentage points in 2013 to 22.5 and 18.7 percentage points in the following two years, respectively. The percentage point difference in uninsured rates between Asians and whites narrowed in 2014 (p < 0.10) so that there was no longer a significant difference in rates between these groups. In 2015, there was also no significant difference in uninsured rates for Asian and white adults. The differences in rates for blacks compared to whites did not narrow significantly at the national level in either year.

Uninsured rates for adults in each racial/ethnic category were lower in Medicaid expansion states than non-expansion states in 2013. This remained true in 2014 and 2015, except for Asian adults in 2015 where there was no significant difference in uninsured rates by state category. Similar to findings at the national level, uninsured rates declined for all racial/ethnic groups in Medicaid expansion and non-expansion states between 2013 and 2014. Declines in uninsured rates between 2014 and 2015 were significant for Hispanics and blacks in both expansion and non-expansion states, but for whites the decline was significant in non-expansion states only. There was no significant change in uninsured rates for Asians in either group of states between 2014 and 2015. While there were no statistically significant differences in the year-to-year percentage point declines for each racial/ethnic category when comparing adults living in states that did and did not expand Medicaid, in Medicaid expansion states, the percentage point declines in uninsured rates were larger for Hispanic adults than for white adults in both 2014 and in 2015. Also, for adults living in Medicaid expansion states, the percentage point decline in 2015 was larger for black adults than for white adults (p < 0.10). As seen above for the nation as a whole, there were no statistically significant differences in uninsured rates for Asian and white adults in either state category in 2014 and 2015.

Educational attainment
Nationally, uninsured rates in 2013 were lower for adults with higher levels of educational attainment (figures 9 and 10). In 2013, uninsured rates were 37.4, 24.7, 17.9, and 6.3 percent for individuals with no high school diploma, a high school diploma or GED, some college, and a college degree or more, respectively. In 2014 and then again in 2015, uninsured rates declined for each education category (p < 0.10 for the 2014 to 2015 decline for those with a college degree or more). The percentage point differences between adults with a college degree or more and those in all three other educational categories narrowed in 2014 and then again in 2015.

Uninsured rates were significantly lower in states that expanded Medicaid than in non-expansion states for non-elderly adults in each education category in 2013. This remained true in 2014 and 2015, except for those with a college degree or more. Between 2013 and 2014, uninsured rates declined for adults in all education groups in both state categories, except for those with a college degree or more in expansion states. Between 2014 and 2015, uninsured rates declined for most education groups in both expansion and non-expansion states. The exceptions included those with less than a high school diploma in non-expansion states and those with a college degree or more in either group of states.

In Medicaid expansion states, the percentage point differences in uninsured rates between adults with a college degree or more and those with less educational attainment narrowed significantly in 2014 and then again in 2015 for most education groups. The only exception was for adults with some college education in 2015. In non-expansion states, differences in uninsured rates also narrowed significantly for adults with a college education or more and (1) those with some college education (in 2014 and 2015, p < 0.10 for 2015), and (2) those with a high school diploma or GED (in 2015, p < 0.10).

Data Source

The estimates shown in this Research Findings for 2013 through 2015 are drawn from analyses conducted by the MEPS staff from files HC-163, HC-171, and HC-174. The 2013 through 2015 files are augmented with information on the person's state of residence and the 2015 file is augmented with a weight that is post-stratified by poverty status to the Current Population Survey. Data for estimates for 2009 through 2012 are drawn from files HC-129, HC-138, HC-147 and HC-155.

Definitions

Age
People were in the sample if they were between the ages of 18 and 64 throughout the calendar year and present in the MEPS-HC for the entire calendar year. This restriction excludes individuals who were institutionalized, left the country, or died during the year and those who joined the household after January. Age is categorized based on the person's age at the end of the calendar year.

Uninsured
People who did not have health insurance coverage for the entire calendar 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. 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.

Race/ethnicity/nativity
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/ethnicity was used: Hispanic (any race), black non-Hispanic only, white non-Hispanic only, and Asian non-Hispanic only. Individuals who did not fit into one of these categories were excluded from the analysis.

Education
Information on the highest level of schooling completed or the highest degree received by a person was asked in the first round that the person was included in the MEPS-HC. The categories included in this Research Findings include 12 or fewer years of school (no high school diploma), high school diploma or GED, some college, and a college degree or more.

Medicaid expansion states
When analyzing 2013 and 2014 data, this Research Findings defined Medicaid expansion states as those states that implemented the expansion at any time during calendar year 2014. For these years, Medicaid expansion states included 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. For 2015, Medicaid expansion states included all states that expanded during 2014 in addition to the three states that expanded during 2015: Alaska, Indiana, and Pennsylvania.

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 co-sponsored 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://www.meps.ahrq.gov/.

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://www.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 Healthcare Policy and Research, 1997. http://www.meps.ahrq.gov/mepsweb/data_files/publications/mr1/mr1.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://www.meps.ahrq.gov/mepsweb/data_files/publications/mr22/mr22.shtml

Kaiser Family Foundation. Status of State Action on the Medicaid Expansion Decision. Kaiser Family Foundation, 2016. Accessed on March 31, 2016. Available from: http://kff.org/medicaid/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/.)

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://www.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://www.meps.ahrq.gov/mepsweb/data_files/publications/st422/stat422.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://www.meps.ahrq.gov/mepsweb/data_files/publications/rf36/rf36.shtml

Suggested Citation

Vistnes, J. and Lipton, B. The Uninsured in America, 2013–2015: Estimates for Non-Elderly Adults Uninsured Throughout Each Calendar Year, by Selected Population Sub-groups and State Medicaid Expansion Status. Research Findings #35. August 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.meps.ahrq.gov/mepsweb/data_files/publications/rf35/rf35.shtml *** 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 Statistical Brief 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
5600 Fishers Lane, Mailstop 07W41A
Rockville, MD 20857

Figure data for accessible table follows the image

	2009	2010	2011	2012	2013	2014	2015
Figure 1. Percentage of non-elderly adults ages 18 to 64, who were uninsured for the entire calendar year, 2009-2015
Uninsured, calendar year	19.1%	18.4%	17.8%	18.5%	18.8%	14.4%	11.7%
Source: Medical Expenditure Panel Survey - Household Component: 2009-2015

	2009	2010	2011	2012	2013	2014	2015
Figure 2. Non-elderly adults ages 18-64 who were uninsured for the entire calendar year or with insurance at some point in the calendar year, 2009-2015 (in millions)
Uninsured	35.5	34.3	33.4	34.9	35.6	27.4	22.4
Insured	150.2	152.1	154.3	153.6	153.8	163.5	169.4
Source: Medical Expenditure Panel Survey - Household Component: 2009-2015

	2013	2014	2015
Figure 3. Percentage of non-elderly adults, ages 18-64, who were uninsured for the entire calendar year, by sex: 2013-2015
Men	21.6%	16.8%	13.7%
Women	16.1%	12.0%	9.7%
Source: Medical Expenditure Panel Survey - Household Component, 2013-2015

	Medicaid Expansion State			Non-Expansion State
Figure 4. Percentage of non-elderly adults, ages 18-64, who were uninsured for the entire calendar year, by sex and state Medicaid expansion status: 2013-2015.
	2013	2014	2015	2013	2014	2015
All	16.3%	11.2%	9.0%	21.9%	18.2%	15.7%
Men	19.5%	14.0%	10.9%	24.2%	20.2%	18.1%
Women	13.2%	8.5%	7.2%	19.8%	16.2%	13.5%
Source: Medical Expenditure Panel Survey - Household Component, 2013-2015

	2013	2014	2015
Figure 5. Percentage of non-elderly adults, ages 18-64, who were uninsured for the entire calendar year, by age: 2013-2015
Ages 18-35	22.5%	17.6%	13.9%
Ages 36-54	18.3%	13.6%	11.2%
Ages 55-64	13.2%	10.0%	8.8%
Source: Medical Expenditure Panel Survey - Household Component, 2013-2015

	Medicaid Expansion State			Non-Expansion State
Figure 6. Percentage of non-elderly adults, ages 18-64, who were uninsured for the entire calendar year, by age and state Medicaid expansion status: 2013-2015
	2013	2014	2015	2013	2014	2015
Ages 18-35	19.9%	13.7%	10.3%	25.7%	22.3%	19.3%
Ages 36-54	15.7%	10.5%	8.8%	21.4%	17.4%	14.8%
Ages 55-64	10.8%	7.8%	7.3%	16.3%	12.7%	10.9%
Source: Medical Expenditure Panel Survey - Household Component, 2013-2015

	2013	2014	2015
Figure 7. Percentage of non-elderly adults, ages 18-64, who were uninsured for the entire calendar year, by race/ethnicity: 2013-2015
Hispanic	39.3%	31.8%	26.2%
Non-Hispanic black	21.1%	17.2%	13.5%
Non-Hispanic Asian	17.4%	10.8%	8.7%
Non-Hispanic white	13.2%	9.3%	7.5%
Source: Medical Expenditure Panel Survey - Household Component, 2013-2015

	Medicaid Expansion State			Non-Expansion State
Figure 8. Percentage of non-elderly adults, ages 18-64, who were uninsured for the entire calendar year, by race/ethnicity and state Medicaid expansion status: 2013-2015
	2013	2014	2015	2013	2014	2015
Hispanic	35.5%	26.7%	20.3%	44.6%	39.2%	35.8%
Non-Hispanic black	18.8%	13.3%	10.1%	22.7%	19.7%	16.4%
Non-Hispanic Asian	15.0%	8.8%	7.9%	24.1%	17.0%	11.5%
Non-Hispanic white	10.8%	6.6%	5.9%	16.2%	12.5%	10.0%
Source: Medical Expenditure Panel Survey - Household Component, 2013-2015

	2013	2014	2015
Figure 9. Percentage of non-elderly adults, ages 18-64, who were uninsured for the entire calendar year, by educational attainment: 2013-2015
No HS Diploma	37.4%	31.6%	27.7%
HS Diploma/GED	24.7%	19.7%	15.2%
Some College	17.9%	12.3%	9.5%
College Degree or more	6.3%	4.9%	4.0%
Source: Medical Expenditure Panel Survey - Household Component, 2013-2015

	Medicaid Expansion State			Non-Expansion State
Figure 10. Percentage of non-elderly adults ages 18-64, who were uninsured for the entire calendar year, by educational attainment and state Medicaid expansion status: 2013-2015
	2013	2014	2015	2013	2014	2015
No HS Diploma	33.5%	25.8%	21.0%	42.2%	38.6%	38.1%
HS Diploma/GED	21.8%	14.9%	11.4%	27.6%	24.3%	20.5%
Some College	16.1%	9.7%	7.5%	20.1%	15.4%	12.3%
College Degree or more	5.2%	4.3%	3.7%	7.8%	5.8%	4.7%
Source: Medical Expenditure Panel Survey - Household Component, 2013-2015

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RESEARCH FINDINGS #35: The Uninsured in America, 2013-2015: Estimates for Non-Elderly Adults Uninsured Throughout Each Calendar Year, by Selected Population Sub-groups and State Medicaid Expansion Status