Who Are the Newly Insured as of Early March 2014?
Adele Shartzer, Sharon K. Long, and Stephen Zuckerman
May 22, 2014 - Urban Institute
In May 2014, the US Department of Health and Human Services (HHS)
announced that enrollment in health plans through the health insurance
Marketplaces had exceeded 8 million people, with 5.4 million people
signing up through the federal Marketplace and another 2.6 million
enrolling through state-based Marketplaces. Estimates suggest that another
5 million people purchased Affordable Care Act (ACA)-compliant plans
outside the Marketplaces (HHS 2014). The Centers for Medicare and Medicaid
Services (CMS) report that total Medicaid and CHIP enrollment increased by
an estimated 4.8 million people between October 2013 and March 2014
relative to the July–September 2013 period (CMS 2014). Although some of
these individuals may already have had coverage, data from multiple
sources suggest that the uninsured rate declined rapidly in early 2014
(Carman and Eibner 2014).1
For example, Long and colleagues report a 2.7 percentage-point drop in
uninsurance between September 2013 and early March 2014, representing a
gain in coverage for about 5.4 million people.2
Knowledge about the characteristics of these newly insured individuals
provides an early assessment of how well the different components of the
ACA are working at expanding coverage as of early March. Further,
information on the health needs and health care experiences of newly
insured individuals is important for understanding their likely health
care demands as they gain coverage, along with their potential effect on
the risk pools in private and public insurance programs.
What We Did
This brief draws on data collected in the March 2014 wave of the Health
Reform Monitoring Survey (HRMS). We examine the demographic
characteristics and health status of the newly insured, whom we define as
those who have gained coverage within the past 12 months and were
uninsured just before enrolling in their current coverage. We compare them
to those who already had coverage for the whole previous 12-month period
(whom we refer to as the gfull-year insuredh), and provide some
information on those who are uninsured at the time of the March 2014
survey (the gremaining uninsuredh).3
It is important to note several things about these data. First, the
newly insured group includes those who gained Medicaid or CHIP as well as
those who gained private coverage through an employer or the
Marketplaces.4
Second, because 80 percent of the March 2014 HRMS sample had completed the
survey by March 6, these estimates do not capture the characteristics of
adults who enrolled in a Marketplace plan during the enrollment surge in
late March and early April, which increased enrollment by about 3.8
million (HHS 2014). Our definition of gnewly insuredh restricts the
population to those with coverage changes within the previous 12 months
(i.e., since March 2013), and so we miss any previously uninsured people
who gained coverage under ACA changes that occurred before 2013 (such as
the ability to keep dependents on a parentfs health plan until age 26 and
early state Medicaid expansions). Finally, small sample sizes for some
subgroups within the newly insured population limit the analyses that are
possible with a single quarter of data. We plan to provide more in-depth
analyses of the uninsured in the future by pooling multiple quarters of
the HRMS.
What We Found
Most of the newly insured adults are in the income groups targeted
by the ACAfs Medicaid expansion and the health insurance
Marketplaces. Nearly half of the newly insured
adults (49.4 percent) have family incomes at or below 138 percent of the
federal poverty level (FPL), the income group targeted by the Medicaid
expansion (figure 1). Another 40.1 percent have family income between 139
and 399 percent of FPL, the income group that could be eligible for
subsidized coverage through the Marketplace. Only 10.5 percent of the
newly insured adults have family income at or above 400 percent of
FPL.
Consistent with the strong gain in coverage among the population
targeted by the Medicaid expansion, the majority of the newly insured
adults (56.2 percent) are in the states that expanded Medicaid under the
ACA. Despite the gain in coverage for low-income adults, however, the
majority of the remaining uninsured are also in this low-income group in
both the Medicaid expansion states and in the nonexpanding states, at 58.7
percent with family income at or below 138 percent of FPL in the Medicaid
expansion states and 68.9 percent in the nonexpanding states (data not
shown).
The newly insured adults tend to be younger than adults who had
coverage for the full year (50.4 percent versus 33.0 percent under age
35); however, they are more likely to report fair or poor health than
full-year insured adults (17.4 percent versus 11.8 percent).5
While 81.8 percent of the newly insured are in good, very good, or
excellent health, about 1 in 5 newly insured adults is in fair or poor
health. The newly insured adults are also more likely than adults who had
coverage for the full year to report days with poor physical and mental
health, a measure of health-related quality of life (figure 2). However,
when we focus on the population targeted by the Medicaid expansion (family
income at or below 138 percent of FPL), we find that newly insured
low-income adults are less likely than the full-year insured adults in
that income range to be in fair or poor health (figure 3). However, among
adults with family incomes above 138 percent of FPL, we find the newly
insured are more likely than the full-year insured to be in fair or poor
health and to report having days in poor physical or mental health (figure
4). Thus, while the newly insured overall may have higher health care
needs than all adults with full-year coverage, that is not the case among
adults within the target populations for the Medicaid expansion.
The newly insured adults often lack a strong connection to the
health care system; more than a third (35.7 percent) did not have a usual
source of care at the time of the survey. Further, almost half (47.9
percent) reported that it has been a year or more since their last routine
checkup. These levels are much higher than those reported for full-year
insured adults, at 18.9 percent without a usual source of care and 30.8
percent without a routine checkup in the previous year (figure 5).
What It Means
As the first open enrollment period in the health insurance
Marketplaces began its last month, data from the March HRMS suggests that
many of those who gained coverage were within the ACA target populations
for the Medicaid expansion and Marketplace subsidies. Nearly half of the
newly insured have family income below 138 percent of FPL, the income
range targeted by the Medicaid expansion in the 24 states (plus the
District of Columbia) that implemented a coverage expansion by April 1,
2014.6
Another 40 percent have family income in the range that could qualify them
for subsidized coverage through the Marketplace. Thus, both of the key
components of the ACA that were implemented in early 2014 played a role in
expanding coverage.
Nonetheless a large share of the adults who remained uninsured in March
(64.7 percent) also fall within the target population for the Medicaid
expansion. While the gains in coverage for low-income adults have been
impressive for the states that expanded Medicaid, the high share of the
remaining uninsured with family income at or below 138 percent of FPL in
those states highlights the continued need for outreach to enroll more of
the adults who are eligible under the Medicaid expansion. This should be
the priority group for state outreach and education efforts for most of
2014, because most higher-income adults cannot enroll through the
Marketplace until the next open enrollment period in November.7
In states that had not expanded Medicaid, there are few coverage options
for the remaining uninsured with low family incomes.
Expanded insurance coverage under the ACA is just the first step toward
improved access to and use of health care, with the long-term goal of
improving health status. The findings here highlight challenges faced by
the newly insured and the health plans and providers that serve them.
Although most of the newly insured are in good or better health, roughly 1
in 5 are in fair or poor health, and more than half report poor health
days due to either physical or mental health issues. Yet, even with these
high levels of health care needs, only about a third of the newly insured
have a usual source of care and only about half had a routine checkup in
the past year. Helping the newly insured form connections with primary
care providers and obtain the care that they need in the appropriate
settings is the next step in moving from coverage to care. Making that
transition may be difficult as the newly insured, particularly the newly
insured who have not had health insurance before, may need help learning
how to access care through their coverage (Decker et al. 2012; Taubman et
al. 2014).
References
Carman, K., and C. Eibner. 2014. Changes in Health Insurance
Enrollment since 2013. Santa Monica, CA: RAND.
Centers for Medicare and Medicaid Services. 2014. Medicaid &
CHIP: March 2014 Monthly Applications, Eligibility Determinations, and
Enrollment Report. Washington, DC: US Department of Health and Human
Services.
Decker, S. L., J. A. Doshi, A. E. Knaup, and D. Polsky. 2012. gHealth
Service Use among the Previously Uninsured: Is Subsidized Health Insurance
Enough?h Health Economics 21(10): 1155–68.
Taubman, S., H. Allen, B. Wright, K. Baicker, and A. Finkelstein. 2014.
gMedicaid Increases Emergency Department Use: Evidence from Oregonfs
Health Insurance Experiment.h Science 343(6168): 263–268.
US Department of Health and Human Services (HHS). 2014. Enrollment
in the Health Insurance Marketplace Totals over 8 Million People.
Washington, DC: HHS.
About the Series
This brief is part of a series drawing on the Health Reform Monitoring
Survey (HRMS), a quarterly survey of the nonelderly population that is
exploring the value of cutting-edge Internet-based survey methods to
monitor the Affordable Care Act (ACA) before data from federal government
surveys are available. The briefs provide information on health insurance
coverage, access to and use of health care, health care affordability, and
self-reported health status, as well as timely data on important
implementation issues under the ACA. Funding for the core HRMS is provided
by the Robert Wood Johnson Foundation, the Ford Foundation, and the Urban
Institute.
For more information on the HRMS and for other briefs in this series,
visit http://hrms.urban.org/index.html.
About the Authors
Adele Shartzer is a research associate, Sharon Long is a senior fellow,
and Stephen Zuckerman is a senior fellow and codirector in the Urban
Institutefs Health Policy Center.
The authors gratefully acknowledge the suggestions and assistance of
Dana Goin, Michael Karpman and Katherine Hempstead.
Note
1 See also
gUS Uninsured Rate Drops to 13.4%,h Gallup, May 5,
2014.
2 Long,
Sharon K., Genevieve M. Kenney, Stephen Zuckerman, Douglas Wissoker, Dana
Goin, Katherine Hempstead, Michael Karpman, and Nathaniel Anderson. gEarly
Estimates Indicate Rapid Increase in Health Insurance Coverage under the
ACA: A Promising Start.h Washington, DC: Urban Institute, 2014.
3 In this
brief, comparisons between the newly insured, full-year insured, and
remaining uninsured are not adjusted for age, gender, or other demographic
characteristics. Among the newly insured, 32.3 percent were insured none
of the previous 12 months, 31.9 percent were insured 1–5 months, and 33.5
percent were insured 6–11 months.
4 By
definition, the newly insured excludes those who had coverage before
enrolling in Medicaid or health plans through Marketplaces.
5 April
2014 estimates from HHS find that 28 percent of enrollees in health plans
through the Marketplace were under age 35; our definition of newly insured
differs from the population in the HHS report in important ways that could
contribute to the different age distributions. For example, we include in
the newly insured adults with Medicaid and ESI, and the HHS estimates
include those who may have had coverage prior to enrolling in health plans
through the Marketplace.
6 Two
states elected to expand Medicaid coverage but had not implemented the
expansion as of April 1, 2014.
7 Special
enrollment periods in Marketplace health plans are possible if an
individual experiences a qualifying life event, such as a move to another
state or a change in income or family size.
© 2013 Urban Institute