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Small Business Employee Benefits and HR Blog

Health Insurance Exchange and Medicaid Eligibility, by U.S. County

The U.S. Census Bureau recently released a Small Area Health Insurance Estimates (SAHIE) report using data from 2011. The report outlines the uninsured population trends in the United States, how they have been affected by the Affordable Care Act (ACA) so far, and how they may be impacted by the ACA provisions going into effect in 2014.

According to the administration, one of the main goals of the ACA is to get more Americans insured under affordable health insurance policies that cover a broad range of benefits. This report shows where some of the problems lie, and estimates how many people may be eligible for financial aid as a part of the health reform law. This article outlines the key findings of this report. The main highlights include:

  • State-level uninsured rates for the population under age 65 ranged from 4.9% to 25.7%.
  • County-level uninsured rates for the population under age 65 ranged from 3.1% to 46.0%.
  • State-level uninsured rates for the population under age 65 declined in 19 states from 2010 to 2011, while they increased for only two. The other 29 states and the District of Columbia did not have a significant change.
  • Using this data, estimates of how many people will be eligible for Medicaid and premium tax subsidies can be made.

Working-Age Adults Have a Higher Percentage of Uninsured than Children

Across all states, the county-level median uninsured rate for people under 19 years old was 7.7%. This is lower than the median uninsured rate for working-age adults, aged 18-64 years old, which was 21.5%. As the maps below illustrate, in all states, there are more uninsured working-age adults than uninsured children. The percentage of uninsured adults by county ranges from 3.9% to 52.5%, while the percentage of uninsured children by county ranges from 1.3% to 32.2%. Additionally, in 2,216 out of 3,143 counties in the United States (or 70.5% of all counties), the percentage of uninsured children was less than 10%.

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Low Income Groups Had Higher Uninsured Rates

The maps below show how insurance coverage varies with income. Across all income levels, the percent of uninsured persons age 65 and under varies from 4.9% to 25.7% by county. But this percentage is related directly to income.

The SAHIE uses income to poverty ratios (IPR) as a measurement of income. The IPR is calculated in the same manner as the Federal Poverty Level (FPL), so for reference, these measurements are interchangeable, but for the purpose of keeping consistent with the SAHIE report, IPR will be used for this blog post. To read more about the FPL see: 2013 Federal Poverty Line (FPL) Guidelines.

Those aged 65 and under making less than or equal to 400% IPR had uninsured rates between 7.9% and 33.3%. Those making less than or equal to 250% IPR see a range of 9.4% to 38% uninsured. And of those making less than or equal to 138% IPR, 9.3% to 40% are uninsured.

The ACA allows states to expand Medicaid to cover families with incomes of 138% IPR or less, and authorizes tax credits to help pay for health coverage in the new health insurance exchanges for families with incomes between 138% and 400% IPR.

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From 2008-2009 Uninsured Increased, From 2010-2011 Uninsured Decreased

From 2008 to 2009, 32 states saw significant changes in their uninsured rates, the rest of the states had negligible changes that year. Of those 32 states, 29 of them saw their uninsured rates go up, and only 3 had their uninsured rates decrease.

This pattern saw a change from 2010-2011, during which time 21 states saw a significant change in the percent uninsured. That year, only 2 states saw an increase in uninsured population. 19 states had a significant decrease in their percent of uninsured.

As of 2011, four states had an uninsured rate of less than 10%. 35 states have an uninsured rate between 10% and 20%. And 12 states have an uninsured rate greater than 20%. Texas has the highest percent of uninsured population, with a percentage of 26% under age 65, and Massachusetts has the lowest, with just 5% uninsured under age 65.

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Estimating Medicaid Eligibility

The data from the SAHIE report provides estimates of IPRs 0-400% and 0-138%, which allows for further estimates of what portion of the population will be eligible for Medicaid and what portion will be eligible for discounts on their health insurance premium via tax subsidies under the Affordable Care Act (ACA). The 0-400% IPR group provides estimates of the uninsured population that may qualify for the tax subsidies or for Medicaid. The 0-138% IPR group provides estimates of the uninsured population that may qualify, in participating states, for Medicaid.

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Where does your state or county fall?

 The Comprehensive Guide to the Small Business HRA