on medicaid a n d t h e uninsured July 2012 How will the Medicaid Expansion for Adults Impact Eligibility and Coverage? Key Findings in Brief Effective January 2014, the ACA establishes a new minimum Medicaid eligibility level of 138% FPL for adults who were not previously eligible for the program. The Supreme Court ruling maintains the Medicaid expansion for adults, but limits the Secretary s authority to enforce it. Medicaid eligibility for parents and other adults remains very limited in many states today. 33 states limit Medicaid eligibility to parents earning less than 100% FPL ($18,530 for a family of three in 2011), with 17 states limiting parent eligibility to less than half the poverty level. Only 9 states provide full Medicaid benefits to other adults. The Medicaid expansion for adults provides a new coverage pathway for millions of currently uninsured adults. The expansion would increase eligibility for parents in 40 states and in nearly every state for other adults. As of 2010, there were 41.2 million uninsured adults, and over half (52% or 21.6 million) had incomes below the new Medicaid eligibility limit of 138% FPL. If a state does not expand Medicaid, poor uninsured adults will be left out of coverage. Adults with incomes between 100% and 138% FPL will be eligible for subsidies to purchase coverage through new health insurance exchanges beginning in 2014, but those with incomes below 100% FPL will not be eligible to receive subsidies. As of 2010, there were over 16 million uninsured adults with incomes below the poverty level. Introduction Beginning in 2014, the Affordable Care Act (ACA) provides for the expansion of Medicaid eligibility to adults with incomes up to 138% FPL ($15,415 for an individual or $26,344 for a family of three in 2012), which would make millions of currently uninsured adults newly eligible for the program. The Supreme Court ruling maintains the Medicaid expansion, but limits the Secretary s authority to enforce it if a state does not implement the expansion, the Secretary can withhold federal ACA expansion funds, but not existing federal program funds. This change in enforcement authority may impact state decisions to implement the expansion. This brief provides an overview of current Medicaid eligibility for adults and data on uninsured adults to provide greater insight into the implications of the ACA Medicaid expansion on coverage for adults across states. Medicaid Eligibility for Low-Income Adults Prior to the ACA, to qualify for Medicaid, individuals had to meet financial eligibility criteria and belong to one of the following groups: children, parents, pregnant women, people with disabilities, and seniors. For each group, there is a federal core minimum eligibility level that states must cover as a condition of participating in Medicaid, and states have the option to expand eligibility to higher incomes. The minimum eligibility level for parents is set by reference to a state s 1996 welfare eligibility level, which varies across states, but is below 50% of the federal poverty level (FPL) in nearly all states. Historically, other non-disabled adults were excluded from Medicaid, regardless of their income, unless a state obtained a waiver to cover them. As such, currently, there is no federal minimum eligibility level for other non-disabled adults. / K CMUM U
Effective January 2014, the ACA establishes a new minimum Medicaid eligibility level of 138% FPL for adults who were not previously eligible for the program. This limit reflects an eligibility threshold of 133% FPL, with a five percentage points of FPL income disregard that raises the effective limit to 138% FPL. The ACA also provides states a new option, effective April 2010, to begin covering low-income adults to get an early start on the expansion. In addition, the ACA requires states to maintain eligibility levels for adults at levels as at least as high as those in place at the time the ACA was enacted until exchanges are certified as operational, expected in 2014. They also must maintain eligibility levels for children until 2019. Medicaid eligibility for parents and other adults remains very limited in in many states today. Nearly two-thirds of states (33) limit Medicaid eligibility for working parents to less than 100% FPL ($18,530 for a family of three in 2011), with 17 states limiting eligibility to less than half the federal poverty level (Figure 1, Tables 1 and 2). Eligibility for working parents ranges across states from 17% FPL in Arkansas and 24% FPL in Alabama and Indiana to over 200% FPL in the District of Columbia and Minnesota. Only 9 states provide full Medicaid benefits to other adults, and some of these states limit coverage to very low incomes and/or limit the number of adults that may enroll. (Figure 2, Tables 1 and 2). Figure 1 Medicaid Eligibility for Working Parents by Income, July 2012 CA AK OR WA NV ID AZ UT MT WY NM HI CO ND SD NE NOTE: The federal poverty line (FPL) for a family of three in 2011 is $18,530 per year. Several states also offer coverage with a benefit package that is more limited than Medicaid to parents at higher income levels through waiver or state-funded coverage. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012, with state updates. KS TX OK MN IA MO AR LA WI IL MS IN MI TN AL KY OH WV GA SC PA VT VA NC FL NY ME NH MA CT RI NJ DE MD DC < 50% FPL (17 states) 50% - 99% FPL (16 states) 100% FPL or Greater (18 states, including DC) Figure 2 Coverage of Low-Income Adults by Scope of Coverage, July 2012 WA OR* CA AK NV ID UT* AZ MT WY CO NM HI* ND SD NE KS TX OK No Coverage (25 states) More Limited than Medicaid (17 states) Medicaid Benefits (9 states, including DC) Closed denotes enrollment closed to new applicants NOTE: Map identifies the broadest scope of coverage in the state. HI, MN, & VT also offer waiver coverage that is more limited than Medicaid. OR and UT also offer premium assistance with open enrollment. The coverage in MO is limited to adults residing in the St. Louis area. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012, with state updates. MN IA WI MO AR LA IL MS MI IN TN AL KY OH WV GA SC PA VT* VA NC FL NY ME NH MA CT* RI NJ DE MD DC* Impact of the Medicaid Expansion on Eligibility and Coverage for Low-Income Adults The current gaps in Medicaid eligibility leave many low-income adults uninsured. Adults at or below 138% FPL have a very high uninsured rate, with 44% lacking coverage in 2010, a rate significantly higher than that for adults at higher incomes (Figure 3). Moreover, in contrast to children, for whom the availability of Medicaid and CHIP helped offset losses in employer-sponsored coverage during the recent economic recession, the number of uninsured low-income adults grew at a significant rate from 2007 to 2010. 400%+ 139-399% Under 139% Figure 3 Adults Health Insurance Coverage, by Family Poverty Level, 2010 26% Private Medicaid/Public Uninsured 67% 30% 91% 11% 44% 22% 3% 6% Number 68.6 M 69.2 M 48.9 M The federal poverty level for a family of three in 2010 was $18,310. Adults includes all individuals aged 19-64. Data may not total 100% due to rounding. SOURCE: KCMU/Urban Institute analysis of 2011 ASEC Supplement to the CPS. 2
The Medicaid expansion for adults provides a new coverage pathway for millions of currently uninsured adults. The Medicaid expansion for adults would increase eligibility for parents in 40 states (Figure 4) and in nearly every state for other adults. These eligibility increases would make millions of currently uninsured adults newly eligible for the program. As of 2010, there were 41.2 million uninsured adults, and over half (52% or 21.6 million) had incomes at or below the new Medicaid eligibility limit of 138% FPL (Figure 5). The share of uninsured adults with incomes below the Medicaid expansion income limit varies across states from nearly 60% in Michigan and Hawaii to about a third in Vermont and New Hampshire (Table 3). Figure 4 Changes in Parent Medicaid Eligibility Under the ACA Medicaid Expansion, as a Percent of the Federal Poverty Level Figure 5 Uninsured Adults By Income, 2010 133% Current Medicaid Limit ACA Expanson Minimum Limit 100% 50% <139% FPL (Medicaid) 52% 139% FPL+ 48% 0% AR AL IN LA TX VA KS WV MO ID OR MS UT PA GA NH NC WY SD OK MT NE FL KY ND MI WA AK IA NM NV OH SC HI AZ CA CO MD DE TN NOTE: The federal poverty line (FPL) for a family of three in 2011 is $18,530 per year. Eligibility levels shown are for full Medicaid coverage for working parents. Several states also offer coverage with a benefit package that is more limited than Medicaid to parents at higher income levels through waiver or state-funded coverage. Ten states (CT, L, ME, MA, MN, NJ, NY, RI, VT, WI) and DC already offer coverage to parents at or above 133% FPL. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012, with state updates. Total Uninsured Nonelderly Adults = 41.2 Million Adults includes all individuals aged 19-64. The federal poverty level for a family of three in 2010 was $18,210. SOURCE: KCMU/Urban Institute analysis of March 2011 Current Population Survey, Annual Social and Economic Supplement. If a state does not expand Medicaid, poor uninsured adults will be left out of coverage. If a state does not implement the Medicaid expansion for adults, those with incomes between 100% and 138% FPL will be eligible for subsidies to help purchase coverage through new health insurance exchanges beginning in 2014. However, those with incomes below the poverty level will not be eligible for these subsidies. In 2010, there were over 16 million uninsured adults with incomes below the poverty level. In the absence of a Medicaid expansion in their state, these adults will be left without an affordable coverage option and continue to face the health and financial consequences of being uninsured. Moreover, when the requirement for states to maintain eligibility for adults expires in 2014, states could reduce eligibility levels to federal minimums, which would increase the number of uninsured adults. In conclusion, Medicaid eligibility levels for adults remain very limited today, contributing to a high uninsured rate among low-income adults. The ACA Medicaid expansion for adults provides a new coverage pathway for millions of currently uninsured adults. However, if a state does not expand Medicaid, its poorest uninsured adults will be left without an affordable coverage option and continue to face the health and financial consequences of being uninsured. 3
Table 1 Medicaid Income Eligibility Limits for Adults as a Percent of the Federal Poverty Level, July 2012 (Based on a Family of Three for Parents and Based on an Individual for Other Adults) Parents Other Adults State Current Medicaid Limit More Limited Federal Waiver Coverage Federal Current Medicaid Limit Minimum Jobless Working to Higher Income Minimum Jobless Working Alabama 11% 11% 24% 0% Alaska 54% 76% 81% 0% Arizona 22% 100% 106% 0% 100% 110% Arkansas 2 13% 13% 17% Y 0% Y California 3 39% 100% 106% Y* 0% Y* Colorado 27% 100% 106% 0% 10%* 10%* Connecticut 4 56% 185% 191% 0% 56%* 72%* Delaware 22% 100% 119% 0% 100% 110% District of Columbia 27% 200% 206% 0% 200%* 211%* Florida 20% 20% 58% 0% Georgia 27% 27% 49% 0% Hawaii 5 100% 100% Y 0% 100% 100% Y Idaho 6 21% 21% 39% Y 0% Y Illinois 7 24% 133% 133% 0% More Limited Waiver Coverage to Higher Income Indiana 8 19% 19% 24% Y 0% Y Iowa 9 28% 28% 82% Y 0% Y Kansas 26% 26% 32% 0% Kentucky 59% 0% Louisiana 11% 11% 25% 0% Maine 10 36% 200% 200% 0% Y Maryland 11 24% 116% 116% 0% Y Massachusetts 12 37% 133% 133% Y 0% Y Michigan 13 32% 37% 63% 0% Y Minnesota 14 215% 215% Y 0% 75%* 75%* Y Mississippi 24% 24% 44% 0% Missouri 15 19% 19% 36% Y* 0% Y* Montana 28% 32% 55% 0% Nebraska 24% 46% 57% 0% Nevada 16 23% 25% 87% 0% New Hampshire 36% 39% 49% 0% New Jersey 17 200% 200% 27% (closed > 133%) (closed > 133%) 0% Y* New Mexico 18 25% 29% 85% Y 0% Y New York 19 46% 150% 150% 0% 100% 100% North Carolina 35% 35% 49% 0% North Dakota 28% 59% 0% Ohio 22% 90% 90% 0% Oklahoma 20 20% 37% 53% Y 0% Y Oregon 21 30% 31% 40% Y 0% Y Pennsylvania 26% 26% 46% 0% Rhode Island 22 36% 175% 181% 0% South Carolina 13% 50% 91% 0% South Dakota 33% 52% 52% 0% Tennessee 38% 69% 126% 0% Texas 12% 12% 26% 0% Utah 23 37% 38% 44% Y 0% Y Vermont 24 42% 185% 185% Y 0% 150% 150% Y Virginia 23% 25% 31% 0% Washington 25 35% 36% 73% Y* 0% Y* West Virginia 16% 16% 32% 0% Wisconsin 26 33% 200% 200% 0% Y Wyoming 23% 38% 51% 0% * Denotes coverage provided under an expansion that was implemented following enactment of the Affordable Care Act. "Closed" denotes that enrollment was closed to eligible adults at some point during 2011. Notes: Percentage of the federal poverty level calculated based on 2011 federal poverty levels, which are $18,530 for a family of three and $10,890 for an individual. Income limit thresholds for working parents and other adults are calculated with earnings disregards. Table does not include eligibility levels for fully state funded coverage programs. SOURCE: Based on a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured with the Georgetown University Center for Children and Families, 2012, with updates. 4
Table 2 Medicaid Income Eligibility Limits for Adults, July 2012 (Based on Percentage of the 2011 Federal Poverty Level for a Family of Three for Parents and for an Individual for Other Adults ) Parents State Current Medicaid Limit More Limited Federal Waiver Coverage Federal Current Medicaid Limit Minimum Jobless Working to Higher Income Minimum Jobless Working Alabama $2,038 $2,038 $4,447 $0 Alaska $12,506 $17,602 $18,760 $0 Arizona $4,077 $18,530 $19,642 $0 $10,890 $10,890 Arkansas 2 $2,409 $2,409 $3,150 Y $0 Y California 3 $7,227 $18,530 $19,642 Y* $0 Y* Colorado $5,003 $18,530 $19,642 $0 $1,089* $1,089* Connecticut 4 $10,377 $34,281 $35,392 $0 $6,098* $7841* Delaware $4,077 $18,530 $22,051 $0 $10,890 $11,979 District of Columbia $5,003 $37,060 $38,172 $0 $21,780* $22,978* Florida $3,706 $3,706 $10,747 $0 Georgia $5,003 $5,003 $9,080 $0 Hawaii 5 $8,741 $21,320 $21,320 Y $0 $12,540 $12,540 Y Idaho 6 $3,891 $3,891 $7,227 Y $0 Y Illinois 7 $4,447 $24,645 $24,645 $0 Other Adults More Limited Waiver Coverage to Higher Income Indiana 8 $3,521 $3,521 $4,447 Y $0 Y Iowa 9 $5,188 $5,188 $15,195 Y $0 Y Kansas $4,818 $4,818 $5,930 $0 Kentucky $6,300 $6,300 $10,933 $0 Louisiana $2,038 $2,038 $4,633 $0 Maine 10 $6,671 $37,060 $37,060 $0 Y Maryland 11 $4,447 $21,495 $21,495 $0 Y Massachusetts 12 $6,856 $24,645 $24,645 Y $0 Y Michigan 13 $5,930 $6,856 $11,674 $0 Y Minnesota 14 $6,300 $39,840 $39,840 Y $0 $8,168* $8,168* Y Mississippi $4,447 $4,447 $8,153 $0 Missouri 15 $3,521 $3,521 $6,671 Y* $0 Y* Montana $5,188 $5,930 $10,192 $0 Nebraska $4,447 $8,524 $10,562 $0 Nevada 16 $4,262 $4,633 $16,121 $0 New Hampshire $6,671 $7,227 $9,080 $0 New Jersey 17 $37,060 $37,060 $5,003 (closed >$24,645) (closed >$24,645) $0 Y* New Mexico 18 $4,633 $5,374 $15,751 Y $0 Y New York 19 $8,524 $27,795 $27,795 $0 $10,890 $10,890 North Carolina $6,486 $6,486 $9,080 $0 North Dakota $5,188 $6,300 $10,933 $0 Ohio $4,077 $16,677 $16,677 $0 Oklahoma 20 $3,706 $6,856 $9,821 Y $0 Y Oregon 21 $5,559 $5,744 $7,412 Y $0 Y Pennsylvania $4,818 $4,818 $8,524 $0 Rhode Island 22 $6,671 $32,428 $33,539 $0 South Carolina $2,409 $9,265 $16,862 $0 South Dakota $6,115 $9,636 $9,636 $0 Tennessee $7,041 $12,786 $23,348 $0 Texas $2,224 $2,224 $4,818 $0 Utah 23 $6,856 $7,041 $8,153 Y $0 Y Vermont 24 $7,783 $34,281 $34,281 Y $0 $16,335 $16,335 Y Virginia $4,262 $4,633 $5,744 $0 Washington 25 $6,486 $6,671 $13,527 Y* $0 Y* West Virginia $2,965 $2,965 $5,930 $0 Wisconsin 26 $6,115 $37,060 $37,060 $0 Y Wyoming $4,262 $7,041 $9,450 $0 * Denotes coverage provided under an expansion that was implemented following enactment of the Affordable Care Act. "Closed" denotes that enrollment was closed to eligible adults at some point during 2011. Notes: Percentage of the federal poverty level calculated based on 2011 federal poverty levels, which are $18,530 for a family of three and $10,890 for an individual. Income limit thresholds for working parents and other adults are calculated with earnings disregards. Table does not include eligibility levels for fully state funded coverage programs. SOURCE: Based on a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured with the Georgetown University Center for Children and Families, 2012, with updates. 5
Table 3 Number and Share of Uninsured Nonelderly Adults Below 139% FPL and 100% FPL by State, 2009 2010 Share of Share of Total Uninsured Uninsured Uninsured Uninsured Uninsured Nonelderly Nonelderly Nonelderly Nonelderly Nonelderly Adults Adults Adults Adults Adults <139% FPL <100% FPL <139% FPL <100% FPL United States* 41,160,162 21,560,100 52% 16,142,401 39% Alabama 630,161 367,861 58% 294,414 47% Alaska 95,777 47,146 49% 36,851 38% Arizona 957,800 537,390 56% 397,175 Arkansas 452,879 244,086 54% 173,170 38% California 5,918,725 3,181,547 54% 2,425,860 Colorado 571,641 268,848 47% 202,821 35% Connecticut 321,539 129,786 40% 100,205 31% Delaware 87,847 38,718 44% 29,425 33% District of Columbia 65,022 34,433 53% 28,869 44% Florida 3,171,607 1,602,787 51% 1,212,844 38% Georgia 1,607,041 902,357 56% 712,635 44% Hawaii 82,374 48,356 59% 40,377 49% Idaho 216,669 111,528 51% 85,011 39% Illinois 1,557,474 840,709 54% 638,511 Indiana 722,047 365,625 51% 290,767 40% Iowa 289,295 134,229 46% 95,053 33% Kansas 292,042 151,834 52% 111,940 38% Kentucky 568,364 329,945 58% 239,291 42% Louisiana 653,247 364,301 56% 291,669 45% Maine 111,662 44,139 40% 29,234 26% Maryland 621,241 294,332 47% 226,680 36% Massachusetts 266,709 119,343 45% 93,572 35% Michigan 1,121,444 646,086 58% 491,212 44% Minnesota 385,193 153,283 40% 112,295 29% Mississippi 448,615 263,822 59% 215,651 48% Missouri 713,373 367,943 52% 289,569 Montana 137,087 58,413 43% 44,587 33% Nebraska 173,498 75,068 43% 51,831 30% Nevada 434,415 223,693 51% 172,233 40% New Hampshire 116,761 42,204 36% 30,320 26% New Jersey 1,072,670 473,911 44% 368,205 New Mexico 337,558 176,079 52% 137,259 New York 2,362,672 1,058,878 45% 801,860 North Carolina 1,337,948 737,700 55% 559,369 42% North Dakota 61,401 28,443 46% 21,889 36% Ohio 1,304,409 694,254 53% 520,933 40% Oklahoma 511,866 251,029 49% 184,424 36% Oregon 529,430 284,083 54% 206,205 39% Pennsylvania 1,116,881 536,705 48% 400,884 36% Rhode Island 103,121 51,155 50% 41,127 40% South Carolina 682,712 362,865 53% 286,684 42% South Dakota 88,111 45,403 52% 34,360 39% Tennessee 808,442 465,747 58% 332,445 Texas 4,886,113 2,586,418 53% 1,893,893 39% Utah 280,564 124,818 44% 87,617 31% Vermont 52,053 17,498 13,473 26% Virginia 872,685 395,342 45% 296,247 Washington 786,074 364,991 46% 263,643 West Virginia 222,777 121,603 55% 90,642 Wisconsin 439,669 193,597 44% 146,725 33% Wyoming 73,300 28,259 39% 20,773 28% *US totals are for 2010 only. State data are from merged 2009 2010 data weighted to represent a single year. Source: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2010 and 2011 Current Population Survey (CPS: Annual Social and Economic Supplements). This publica on (#8338) is available on the Kaiser Family Founda on s website at www.kff.org.