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RESEARCH FINDINGS #36:
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
Highlights
- Uninsured adults in fair or poor health were more likely than those in good to excellent health to gain Medicaid coverage from 2013 to 2014 and from 2014 to 2015, while those in good to excellent health were more likely to gain other private/public coverage in those periods.
- From 2012 to 2013, insured adults in fair or poor health were more likely to lose insurance than those in good to excellent health (5.3 versus 2.9 percent). However, there was no statistically significant difference between health status groups in the likelihood of losing coverage in 2013-2014 or 2014-2015.
- From 2014 to 2015, the rate of losing coverage for those with at least one chronic condition (1.5 percent) was about half the rate for the 2012-2013 period (2.9 percent).
Introduction
Beginning in 2014, new sources of health insurance became available for uninsured individuals. These include premium tax credits for the purchase of private insurance for low- and middle-income individuals for insurance purchased through newly-established Marketplaces and, in participating states, expanded Medicaid eligibility for individuals 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.Using information from the Household Component of the Medical Expenditure Panel Survey (MEPS-HC), this Research Findings provides two sets of estimates of health insurance coverage for non-elderly adults, ages 18 to 64, in the U.S. civilian noninstitutionalized population. The first set includes the percentages of non-elderly adults who were uninsured for the entire calendar year for each year from 2013 to 2015. The second set includes transitions in coverage over the two years that MEPS respondents participate in the survey, comparing gains and losses in health insurance coverage in the periods from 2013 to 2014 and 2014 to 2015 to those in 2012 to 2013.1 This Findings presents both types of estimates separately for non-elderly adults in fair or poor health and those in excellent/very good/good health, as well as for those without and with at least 1 chronic condition. The calendar-year estimates are presented nationally, for all non-elderly adults, and for subgroups defined by state Medicaid expansion status.
The transition estimates include information on the percentage of uninsured adults who "gained" insurance and the percentage of insured adults who "lost" coverage in each two-year period. 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 who "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 to overall gains in coverage of three types of insurance—Marketplace coverage, Medicaid, and other private/public insurance. All differences between estimates discussed in the text are statistically significant at the 0.05 level, or better, unless otherwise noted.
Findings
Calendar-year estimatesHealth status, nationally
Nationally, the uninsured rate in 2013 was higher for non-elderly adults who were ever reported to be in fair or poor health during the year (23.8 percent) than for those who were reported to be in good to excellent health throughout the year (17.6 percent) (figure 1). The uninsured rates for adults in both health status categories declined in both 2014 and 2015. From 2013 to 2015, the uninsured rate for adults in fair or poor health declined by more than the uninsured rate for adults in good to excellent health (a 9.7 percentage point decline versus a 6.5 percentage point decline).
Health status, by State Medicaid Expansion Status
Uninsured rates were lower in Medicaid expansion states than non-expansion states in both health status categories in each year from 2013 to 2015. In both state categories, uninsured rates in 2013 were higher for non-elderly adults in fair or poor health than for those in good to excellent health. In the following two years, uninsured rates declined for adults in both health status categories regardless of whether they lived in a state that had expanded Medicaid. There were no significant differences in the percentage point declines by state expansion status for adults in either health status category. In Medicaid expansion states, the percentage point decline in the uninsured rate from 2013 to 2014 was greater for adults in fair or poor health than for adults in good to excellent health (8.1 percentage points versus 4.4 percentage points). Then, from 2014 to 2015, the uninsured rate for both health status groups each fell by an additional 2.2 percentage points.
Chronic conditions, nationally
In 2013, 22.6 percent of non-elderly adults without any chronic conditions2 were uninsured compared to 15.5 percent of those with at least 1 chronic condition. Uninsured rates declined for both groups in 2014 and 2015. From 2013 to 2015, the uninsured rate decreased from 22.6 to 14.9 percent among those with no chronic conditions and from 15.5 to 8.7 percent among those with at least 1 chronic condition (figure 3). The declines for those with and without chronic conditions were of similar magnitude (6.8 and 7.7 percentage points, respectively), so that there was no significant change in the percentage point gap in the uninsured rates for adults with and without chronic conditions between 2013 and 2015.
Chronic conditions by State Medicaid Expansion Status
In all years between 2013 and 2015, uninsured rates were higher for non-elderly adults with no chronic conditions than for adults with 1 or more chronic conditions in both Medicaid expansion and non-expansion states (figure 4). Furthermore, the differences in the uninsured rates for these groups in 2015 were similar to the differences in 2013 in both expansion and non-expansion states.
Transitions in coverage
Health status
Between 2012 and 2013, uninsured non-elderly adults in fair or poor health were more likely to gain some type of coverage than those in good to excellent health (22.3 percent versus 17.3 percent, p < 0.10) (figure 5). However, from 2013 to 2014 and from 2014 to 2015, there was no longer a significant difference in the rate of gaining coverage by health status. For adults in good to excellent health, the rate of gaining coverage was higher in both 2013–2014 (32.2 percent) and 2014–2015 (30.4) than in 2012–2013. For adults in fair or poor health, the rate of gaining coverage was higher in 2013–2014 (33.3 percent), but there was no significant difference in the rates between 2014–2015 and 2012–2013.
In all three two-year periods, uninsured non-elderly adults in fair or poor health were more likely to gain Medicaid coverage than those in good to excellent health. From 2012–2013 to 2013–2014, the rate of gaining Medicaid coverage for adults in fair or poor health increased from 7.9 to 17.8 percent (9.9 percentage points), while adults in good to excellent health had a smaller increase from 3.6 to 7.5 percent (3.9 percentage points). However, from 2013–2014 to 2014–2015, there was no significant change in the rate of gaining Medicaid coverage for adults in good to excellent health and the rate for adults in fair or poor health fell from 17.8 to 11.6 percent (6.2 percentage points). There were no significant differences by health status in the rates of gaining Marketplace coverage in either 2013–2014 or in 2014–2015.
While there was no significant difference by health status in the rate of gaining other private/public coverage in 2012–2013, in the two later periods non-elderly adults in good to excellent health were more likely than those in fair or poor health to gain other private/public coverage (18.7 percent versus 10.8 percent in 2013–2014 and 17.7 versus 9.1 percent in 2014–2015).
From 2012 to 2013, insured adults in fair or poor health were more likely to lose insurance than those in good to excellent health (5.3 versus 2.9 percent). The rate declined in the following period for adults in fair or poor health, from 5.3 percent in 2012–2013 to 2.7 percent in 2013–2014. At the same time, there was no significant change in the rate of losing coverage for adults in good to excellent health. As a result, in 2013–2014 there was no significant difference in the rate of losing coverage between the two groups.
From 2014 to 2015, there was no significant change in the rate of losing coverage for adults in fair or poor health compared to the 2013–2014 period, but the rate fell in these years for adults in good to excellent health (from 3.0 in 2013–2014 to 2.2 percent in 2014–2015, p < 0.10). From 2014 to 2015, as was the case from 2013 to 2014, there was no statistically significant difference by health status in the rate of losing coverage.
Chronic conditions
Uninsured non-elderly adults with at least 1 chronic condition were more likely to gain some type of coverage than their counterparts with no chronic conditions from 2012 to 2013 (21.2 versus 16.8 percent, p < 0.10) and 2013–2014 (38.4 versus 27.8 percent). However, in 2014–2015, there was no significant difference in the rates of gaining coverage across these groups (figure 6).
From 2012 to 2013, there was no statistically significant difference between the two groups in their rate of gaining Medicaid coverage. In the next period, the rate of gaining Medicaid coverage increased for both groups, but increased more for adults with at least 1 chronic condition. As a result, in 2013–2014, uninsured non-elderly adults with at least 1 chronic condition were more likely than those with no chronic conditions to gain Medicaid coverage (13.9 versus 7.2 percent). By 2014–2015, however, there was once again no significant difference in the two groups' rates of gaining Medicaid coverage.
With respect to gains of Marketplace coverage, adults with at least 1 chronic condition were more likely than those with no chronic conditions to enroll in newly available Marketplace coverage in both 2013–2014 (8.0 versus 3.8 percent) and 2014–2015 (8.3 versus 4.5 percent, p < 0.10).
From 2012–2013 to 2014–2015, the rate of losing coverage for those with at least 1 chronic condition fell by almost half, from 2.9 to 1.5 percent, but there was no significant change for those with no chronic conditions (figure 6). Adults with 1 or more chronic conditions had lower rates of losing coverage than those with no chronic conditions in all three two-year periods.
Data Source
The estimates shown in this Research Findings are drawn from analyses conducted by the MEPS staff from files HC-155, HC-171, and HC-174, augmented with information on the person's state of residence. 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
Population coveredPersons included in the estimates of transitions in coverage were in the survey for the entire two-year period and were ages 18–64 for the entire two years. 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. Persons included in the calendar-year estimates of uninsurance were in the survey for one calendar year and were ages 18–64 for the entire calendar year. This restriction excludes individuals who were institutionalized, left the country or died during the calendar year and those who joined the household after January of the calendar year.
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.
Health status
Information from three rounds of the MEPS-HC 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)' age, would you say that (PERSON)'s health is excellent, very good, good, fair, or poor?" Individuals were classified as being in fair or 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. For the calendar year estimates, individuals were classified using information on the three MEPS-HC rounds in the calendar year. For the transitions in coverage estimates, information from the person's first year in the MEPS-HC was used.
Chronic conditions
Information from the first year an individual was in the MEPS-HC was used to classify individuals according to the presence of chronic conditions for estimates of transitions in coverage. Information from the relevant calendar year was used for the calendar-year insurance estimates. 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 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 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.
State Medicaid Expansion Status
When analyzing 2013 and 2014 data, this 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. State Medicaid expansion status is based on individuals' state of residence in their second year in the survey.
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.shtmlCohen, 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
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://www.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://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 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.pdf
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
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://www.meps.ahrq.gov/mepsweb/data_files/publications/rf34/rf34.pdf
Suggested Citation
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.shtmlAHRQ 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
5600 Fishers Lane, Mailstop 07W41A
Rockville, MD 20857
1Note that the samples for the calendar-year estimates and the transitions in coverage estimates in this Research Findings differ because the transitions estimates use observations from one Panel in the MEPS-HC over a two-year period while the calendar-year estimates use observations from the combination of two Panels for one calendar year.
2These adults were not reported to have any of the chronic conditions considered in this Findings. See the definitions section for a list of chronic conditions.
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