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RESEARCH FINDINGS #40:
Uninsured All Year, 2013–2016: Estimates for Non-Elderly Adults by Selected Population Sub-groups and State Medicaid Expansion Status

January 2019

Jessica Vistnes, PhD and Patricia Keenan, PhD

Highlights

The percentage of non-elderly adults uninsured throughout the calendar year declined from 11.7 percent in 2015 (22.4 million adults) to 10.8 percent in 2016 (20.6 million adults).
In Medicaid expansion states, the calendar-year uninsured rate declined from 9.0 percent in 2015 to 8.2 percent in 2016, but there was no significant change in non-expansion states.
The calendar-year uninsured rate for non-elderly adults living in Medicaid expansion states in 2016 (8.2 percent) was lower than the rate for those living in non-expansions states (14.9 percent).
In 2016, there was no significant difference in non-elderly adults' uninsured rates by their perceived health status in Medicaid expansion states; but in non-expansion states and nationally, uninsured adults in fair or poor health had higher uninsured rates than those in good to excellent health.

Introduction

Using information from the Household Component of the Medical Expenditure Panel Survey (MEPS-HC), this Research Findings report examines changes in the percentage of non-elderly adults who were uninsured for the entire year (the "calendar-year uninsured rate") between 2015 and 2016 for non-elderly adults in various demographic groups, overall and by state Medicaid expansion status. This report also presents annual estimates for 2013–2016 of the percentage and number of non-elderly adults, ages 18–64, in the civilian noninstitutionalized population, who were uninsured for the entire calendar year and estimates of uninsured rates by demographic characteristics and Medicaid expansion status. Note that changes in states' expansion status over time are reflected in the estimates in this Report, which could account for some of the observed changes. The discussion in this Report focuses on the years 2015 and 2016; discussion of earlier years can be found in Findings Reports 35 and 36. All differences between estimates discussed in the text are statistically significant at the 0.05 level unless otherwise noted.

Findings

The calendar-year uninsured rate declined from 11.7 percent in 2015 (22.4 million adults) to 10.8 percent in 2016 (20.6 million adults) (figures 1 and 2). In Medicaid expansion states, the rate declined from 9.0 percent in 2015 to 8.2 percent in 2016, but there was no significant change in non-expansion states (figure 3). The uninsured rate for non-elderly adults living in Medicaid expansion states in 2016 (8.2 percent) was lower than the rate for those living in non-expansion states (14.9 percent).

The remainder of this Research Findings report examines changes in the calendar-year uninsured rate between 2015 and 2016 for non-elderly adults and 2016 differences across demographic groups, both nationally and by state Medicaid expansion status.

Sex
Between 2015 and 2016, uninsured rates declined by 0.9 percentage points for women but there was no significant change for men (figure 4). The pattern was similar in Medicaid expansion states, where uninsured rates declined significantly for women, from 7.2 percent in 2015 to 6.3 percent in 2016, but there was no significant change for men (figure 5). In non-expansion states, there were no significant changes in uninsured rates in 2016 for either men or women.

Uninsured rates for non-elderly men were higher than for women in 2016, both nationally and in Medicaid expansion and non-expansion states (figures 4 and 5). For example, 12.8 percent of men compared to 8.8 percent of women were uninsured at the national level in 2016. Uninsured rates for both men and women were significantly lower in Medicaid expansion states than non-expansion states in 2016.

Age
Between 2015 and 2016, uninsured rates declined by 1.4 percentage points for adults ages 18–35, but there were no significant changes for adults in other age groups (figure 6). In both Medicaid expansion and non-expansion states, there were no significant changes in uninsured rates for adults in any age group in this time period (figure 7).

Nationally and in non-expansion states, uninsured rates declined by age, with significant differences across each age category in 2016. In Medicaid expansion states, adults ages 55–64 had a lower uninsured rate (6.7 percent) than those in the youngest age category. There was no significant difference in uninsured rates between adults ages 18–35 (9.2 percent) and adults ages 36–54 (8.1 percent). Uninsured rates were lower in Medicaid expansion than non-expansion states for adults in each age category in 2016.

Race/ethnicity
From 2015 to 2016, there were no significant changes in uninsured rates in any race/ethnicity category, nationally or in non-expansion states.(figure 8). However, uninsured rates for black non-elderly adults living in Medicaid expansion states declined, from 10.1 percent in 2015 to 7.5 percent in 2016 (figure 9).

Uninsured rates were higher for Hispanic and black non-elderly adults than for white adults in 2016, nationally as well as in Medicaid expansion and non-expansion states, but there were no differences between rates for white and Asian adults.

Uninsured rates for white, black, and Hispanic adults were lower in Medicaid expansion states than non-expansion states in 2016. There were no significant differences between uninsured rates for Asian adults living in Medicaid expansion and non-expansion states in 2016.

Education
Between 2015 and 2016, uninsured rates for non-elderly adults with a high school diploma or GED and adults with some college education declined by 3.0 percentage points and 2.6 percentage points, respectively (figure 10). In Medicaid expansion states, uninsured rates declined for adults with a high school diploma or GED (by 2.3 percentage points) (figure 11). In non-expansion states, uninsured rates declined in 2016 for adults with a high school diploma or GED (by 3.6 percentage points) and adults with some college education (by 3.8 percentage points).

In 2016, adults with at least a college degree had lower uninsured rates than those with a lower level of educational attainment, nationally as well as in Medicaid expansion and non-expansion states. Nationally and in non-expansion states, the differences between uninsured rates for adults with a college degree and adults with a high school diploma or GED and adults with some college narrowed between 2015 and 2016.

Uninsured rates were significantly lower in states that expanded Medicaid than in non-expansion states for non-elderly adults in each education category in 2016 except for adults with some college education.

Health status
Nationally, uninsured rates for adults in good to excellent health declined from 11.1 percent in 2015 to 10.2 percent in 2016 (figure 12). In Medicaid expansion states, uninsured rates declined for adults in fair to poor health, falling from 10.1 percent in 2015 to 8.3 percent in 2016 (figure 13). However, there was no significant change in non-expansion states for adults in either health status category.

In Medicaid expansion states in 2016, there was no significant difference between uninsured rates for adults in good to excellent health and those in fair or poor health. However, in non-expansion states as well as nationally, adults in fair or poor health had higher uninsured rates than those in good to excellent health in 2016.

Uninsured rates in 2016 were significantly lower in states that expanded Medicaid than in non-expansion states for non-elderly adults in good to excellent health as well as those in fair to poor health. The uninsured rate for adults in fair or poor health in 2016 was 20.5 percent for non-elderly adults living in non-expansion states compared to 8.3 percent for those living in Medicaid expansion states.

Chronic conditions
Nationally, uninsured rates declined by 0.9 percentage points between 2015 and 2016 for adults with a diagnosed chronic condition(figure 14). However, there were no significant changes in uninsured rates in Medicaid expansion or non-expansion states in 2016 for either chronic condition group (figure 15).

Uninsured rates for adults with at least one diagnosed chronic condition were lower than for adults with no chronic conditions, nationally and in both state Medicaid expansion categories in 2016. Nationally, 7.8 percent of adults with at least one chronic condition were uninsured throughout 2016 compared to 14.0 percent of adults with no chronic conditions. Uninsured rates for those with and without a chronic condition were significantly lower in Medicaid expansion than non-expansion states in 2016.

Data Source

The estimates shown in this Research Findings report for 2013–2016 are drawn from analyses conducted by the MEPS staff from MEPS Full Year Consolidated Data Files HC-163, HC-171, HC-181, and HC-192. The 2013–2016 files are augmented with information on persons' state of residence.

Definitions

Sample
People who were between the ages of 18 and 64 throughout the calendar year and present in the MEPS-HC for the entire calendar year were included in the analyses. This restriction excludes individuals who were institutionalized, left the country, or died during the year and those who joined the household after January.

Age
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
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 race/ethnicity comparisons.

Education
Information on the highest level of schooling completed or the highest degree received by a person was asked in the first round in which the person was included in the MEPS-HC. The categories included in this Research Findings report include 12 or fewer years of school (no high school diploma), high school diploma or GED, some college, and a college degree or more. Note that the education questions in the MEPS-HC changed over this time period. These changes are described in the documentation for HC-192.

Health status
Information from three rounds of the MEPS-HC in each calendar year was used to classify individuals by perceived health status. In every round, the respondent was asked the following question to rate the health of every member of the family: "In general, compared to other people of (PERSON)'s age, would you say that (PERSON)'s health is excellent, very good, good, fair, or poor?" Individuals were classified as being in "fair/poor" health if they were reported to be in fair or poor health at any time during these three MEPS-HC rounds. Individuals were classified as being in "excellent/very good/good" health if they were reported to be in excellent, very good, or good health in each of these three rounds.

Chronic conditions
Adults who were reported as having one or more diagnosed chronic conditions were defined as those with: active asthma, arthritis, diabetes, emphysema, heart disease, high blood pressure, high cholesterol, bronchitis, or stroke. Active asthma was defined as adults who were ever told by a doctor or other health professional that they had asthma and who were reported to still have asthma or had an asthma attack in the past 12 months. Arthritis includes respondents with pain, aching, stiffness, or swelling around a joint in the past 12 months. Bronchitis includes respondents who were reported as having chronic bronchitis in the past 12 months. High blood pressure was defined as adults who were reported as being told on two or more occasions they had high blood pressure. Heart disease was created using four questions on whether the person was ever told she or he had: coronary heart disease, angina, a heart attack, or any other kind of heart condition or heart disease. Adults who had diabetes, emphysema, high cholesterol, and stroke were defined as adults who were reported as ever being told they had those conditions.

Medicaid expansion states
When analyzing 2013 and 2014 data, this Research Findings report 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, plus the three states that expanded during 2015: Alaska, Indiana, and Pennsylvania. In 2016, Louisiana and Montana were added to the 2015 list of Medicaid expansion states.

About MEPS-HC

The Medical Expenditure Panel Survey Household Component (MEPS-HC) collects nationally representative data on health care use, expenditures, sources of payment, and insurance coverage for the U.S. civilian noninstitutionalized population. The MEPS-HC is cosponsored by the Agency for Healthcare Research and Quality (AHRQ) and the National Center for Health Statistics (NCHS). More information about the MEPS-HC can be found on the MEPS Web site at https://meps.ahrq.gov/.

References

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. https://meps.ahrq.gov/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. https://meps.ahrq.gov/data_files/publications/mr22/mr22.shtml

Kaiser Family Foundation. Status of State Action on the Medicaid Expansion Decision. Kaiser Family Foundation, 2018. Accessed on September 13, 2018. https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

Vistnes, J. and Lipton, B. J. 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. https://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. https://meps.ahrq.gov/mepsweb/data_files/publications/rf36/rf36.shtml

Suggested Citation

Vistnes, J. and Keenan, P. The Uninsured in America, 2013–2016: Estimates for Non-Elderly Adults Uninsured Throughout Each Calendar Year, by Selected Population Sub-groups and State Medicaid Expansion Status. Research Findings #40. January 2019. Agency for Healthcare Research and Quality, Rockville, MD. https://meps.ahrq.gov/mepsweb/data_files/publications/rf40/rf40.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 report 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