Health Insurance Coverage in 2013: Gains in Public Coverage Continue to Offset Loss of Private Insurance Laura Skopec, John Holahan, and Megan McGrath Since the Great Recession peaked in 2010, the economic picture has steadily improved, and in 2013, GDP increased relative to 2012 and the unemployment rate fell but remained fairly high at 7.4 percent. In addition, the uninsured rate decreased slightly (0.1 percentage point) in 2013, continuing the trend from 2011 and 2012. Despite these improvements, rates of coverage through employer sponsored insurance have declined since 2010, though more slowly in recent years than at the height of the recession. Gains in coverage since 2010 have been largely due to increases in coverage through public programs such as Medicaid and the Children’s Health Insurance Program (CHIP). Population changes also affected insurance coverage patterns between 2008 and 2013. The only income group with net population growth between 2008 and 2013 was families at or below 138 percent of poverty, which grew by 17.6 million. In contrast, the population with family incomes above 400 percent of poverty shrank by 8.3 million. There were also fewer workers in 2013 (138.0 million) than in 2008 (140.4 million), with a low point of 133.1 million workers in 2010. In addition, national population growth between 2008 and 2013 was concentrated in the South and West, which gained 4.3 million and 1.9 million people, respectively. These regions tend to have lower rates of employer coverage and lower Medicaid eligibility thresholds for adults. It is important to understand the effect of these population shifts and economic forces on coverage to assess the impact of the ACA. Many of the health insurance coverage expansions in the ACA went into effect on January 1, 2014, making 2013 the final baseline year against which to measure coverage changes under the ACA. Though 2013 is not a perfect baseline (several smaller coverage expansions under the ACA went into effect in 2010, including allowing dependents to stay on their parents’ plan until age 26, and a handful of states fully or partially expanded eligibility for their Medicaid programs in 2010 or 2011), understanding trends in coverage during the recession and recovery will help disentangle the effects of the ACA on health insurance coverage from demographic and economic factors. In this brief, we examine coverage patterns for the nonelderly population from 2008 through 2013 using data from the American Community Survey. While prior research on this topic has frequently relied on the Census Bureau’s March Supplement to the Current Population Survey (CPS), long planned improvements to the insurance questions for that survey resulted in a break in trend between the 2013 CPS and the 2014 CPS, which collected data on coverage in 2012 and 2013, respectively. Therefore, in order to examine trends from 2008 to 2013, we focused our analysis on the American Community Survey. The economy has steadily improved since the Great Recession peaked in 2010, but recovery in employment and household income has lagged behind GDP growth. While real GDP recovered to its 2007 high by 2011, the unemployment rate declined but remained high through 2013 (7.4 percent), and median household income continued to decline through 2012. The recession accelerated the long-standing decline in employer-sponsored health insurance (ESI),1 and through 2013 most of the recovery in the uninsured rate was due to increased enrollment in public insurance, primarily Medicaid and the Children’s Health Insurance Program (CHIP). For adults, coverage through Medicare and military healthcare programs also increased slightly between 2010 and 2013, though not as substantially as Medicaid and CHIP coverage. With the exception of young adults ages 19 to 25, who are able to remain on their parents’ health plan until age 26 under the Affordable Care Act (ACA), ESI coverage rates for adults and children continued to decrease between 2010 and 2013. These declines in ESI coverage are partly attributable to changes in population characteristics among the nonelderly, including an increase in the number of low-income families, population growth in low-ESI regions, and workforce growth in low-ESI industries. This brief uses data from the American Community Survey (ACS), an annual survey conducted by the Census Bureau and designed to be representative at the national and state level. The public microdata sample for the ACS contains 1.9 million observations annually, making it by far the largest of the federal surveys. The ACS contains data on income, health insurance, demographics, work status, and industry sufficient to allow analyses of the differences in insurance coverage patterns across various populations. In addition, the very large sample size allows for state-level trend analyses (not included here). Prior issue briefs in this series used the Current Population Survey Annual Social and Economic Supplement (CPS) to describe trends in health insurance coverage.2 However, long planned improvements to the insurance questions for that survey resulted in a break in trend between the 2013 CPS and the 2014 CPS, which collected data on coverage in 2012 and 2013, respectively.3 This brief therefore focuses on trends from 2008 to 2013 using the ACS. While the ACS has a significantly larger sample size than the CPS, it also has a few disadvantages. First, the income information in the CPS is much more detailed than that collected in the ACS, and income data from the CPS is therefore the source of official estimates of poverty in the United States.4 Second, the ACS does not collect data on employer size, so this brief does not present trends in ESI coverage by firm size. This analysis uses the ACS iPUMS files created by the Minnesota Population Center, which have consistent variable definitions over time and include constructed variables on family relationships and income that are used to create Health Insurance Units (HIU)5 and calculate HIU income as a percent of the FPL.6 In addition, the Urban Institute has developed a series of logical coverage edits to the ACS designed to correct for known inaccuracies in survey-based estimates of health insurance coverage.7 In particular, the ACS over-represents private non-group coverage relative to other surveys and under-represents Medicaid and CHIP coverage among children relative to administrative data.8 These logical coverage edits reassign coverage types for respondents when other information collected in the ACS, such as receipt of Supplemental Nutrition Assistant Program (SNAP) or other public assistance, implies that a respondent’s coverage has likely been misclassified.9 Health Insurance Coverage in 2013: Gains in Public Coverage Continue to Offset Loss of Private Insurance 2 Finally, all individuals reporting multiple health insurance types have been assigned to a single primary insurance type using a hierarchy, which further corrects for over-reporting of private non-group coverage. The hierarchy used for all analyses in this brief is as follows: employer-sponsored insurance, Medicaid or CHIP, military health care or Medicare, private non-group insurance, or uninsured. Most economic indicators suggest continued recovery since Figure 1 the peak of the recession in 2009 and 2010. Real GDP fell Real GDP, 2000-2013 from $14.9 trillion in 2007 to $14.4 trillion in 2009 but In trillions of chained 2009 dollars recovered starting in 2010 to hit $15.7 trillion in 2013 (Figure 1). The unemployment rate increased from 4.6 percent in 2007 to peak at 9.6 percent in 2010, falling back $15.0 $15.4 $15.7 $14.6 $14.9 $14.8 $14.4 $14.8 to 7.4 percent in 2013 (Figure 2). The most recent data $13.8 $14.2 $13.3 $12.9 (February 2015) suggest that the unemployment rate has $12.6 $12.7 now recovered to 2008 levels (5.6 percent).10 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Real median household income and real per capita income SOURCE: Bureau of Economic Analysis. “Current-dollar and ‘real’ GDP.” February 27, 2015. Available at: http://www.bea.gov/national/index.htm#gdp. also fell between 2008 and 2010 and have shown less recovery than other economic indicators. Median household income continued to fall between 2010 and 2012 and increased only $180 between 2012 and 2013, not a statistically significant change. Similarly, real per capita income remains more than $1,500 below its 2006 peak (Figure 3). Figure 2 Figure 3 National unemployment rate, 2000-2013 Real median household income and per capita income, 2000-2013 Real median household income in 2013 CPI-U-RS adjusted dollars Per capita money income in 2013 CPI-U-RS adjusted dollars $56,800 $55,562 $56,436 $54,913 $54,865 $54,674 $55,278 $55,689 $54,432 $54,059 $52,646 $51,842 $51,759 $51,939 9.3% 9.6% 8.9% 8.1% 7.4% 5.8% 6.0% 5.5% 5.8% $30,228 $30,067 $29,515 $29,481 $29,421 $29,874 $30,446 $30,114 $29,173 $28,812 $28,374 $28,538 $28,692 $28,829 4.7% 5.1% 4.6% 4.6% 4.0% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 SOURCES: US Census Bureau. “Table H-6, Regions—All Races by Median and Mean Income: 1975 to 2013.” Available at: http://www.census.gov/hhes/www/income/data/historical/household/2013/h06AR.xls; and US Census Bureau. “Table P-1. CPS SOURCE: Bureau of Labor Statistics. “Labor Force Statistics from the Current Population Survey.” March 19, 2015. Available at: Population and PER Capita Money Income, All Races: 1967 to 2013.” Available at: http://data.bls.gov/timeseries/LNU04000000?years_option=all_years&periods_option=specific_periods&periods=Annual+Data http://www.census.gov/hhes/www/income/data/historical/people/2013/p01AR.xls. Health Insurance Coverage in 2013: Gains in Public Coverage Continue to Offset Loss of Private Insurance 3 As the economy continued to improve between 2012 and 2013, the uninsured rate fell by 0.1 percentage point and the number of uninsured Americans fell by 200,000 (Figure 4). The decrease in the uninsured rate was entirely among nonelderly adults and was primarily due to increases in public coverage. From 2012 to 2013, the ESI coverage rate declined 0.3 percentage points, leading to 300,000 fewer people with ESI, while Medicaid and Children’s Health Insurance Program (CHIP) coverage increased by 0.2 percentage points, or 700,000 people. The reduction in ESI and increase in Medicaid and CHIP coverage rates were more prominent among children than nonelderly adults. In addition, nearly all of the reduction in the number of uninsured was among non-Hispanic whites below 138 percent of the FPL (data not shown). Finally, private non-group coverage increased by 0.1 percentage points among nonelderly adults, all of which was due to an increase of non-group coverage among young adults (young adult data not shown). The additional 200,000 young adults with non-group coverage may reflect young adults staying on their parents’ non-group plan until age 26 or, potentially, misreporting of October through December 2013 enrollment in the Marketplaces for 2014.11 Because the changes in insurance coverage from 2012 to 2013 were small overall, the remainder of this brief will focus on trends in insurance coverage from 2008 to 2013. Figure 4 Percent point changes in health insurance coverage among the nonelderly (ages 0-64) by age group, 2012-2013 Employer Medicaid and State Private Nongroup Uninsured All non-elderly Non-elderly adults Children 0.4%* 0.2%* 0.2%* 0.1%* 0.1%* 0.1% 0.0% -0.1%# -0.2%* -0.2%* -0.3%* -0.5%* Change in 0.8 million* 0.9 million* -0.1 million* Population Change in -0.2 million -0.2 million 0.0 million uninsured NOTES: * Change is statistically significant at the 5% level # Change is statistically significant at the 10% level. Coverage through CHAMPUS and Medicare are not shown because coverage rates for those coverage types among the nonelderly change little year-to-year. SOURCE: Urban Institute Analysis of the 2012 and 2013 American Community Survey Health Insurance Coverage in 2013: Gains in Public Coverage Continue to Offset Loss of Private Insurance 4 Figure 5 shows the changes in health insurance coverage that occurred during the recession and recovery for the nonelderly population (under age 65). The Great Recession began in December 2007 and ended in June 2009, making 2010 the first full year since 2007 in which GDP did not decline.12 Therefore, 2010 is used as the break point between the recession and recovery throughout this brief. From 2008 to 2010, the ESI coverage rate fell from 61.0 percent to 57.1 percent. At the end of this period, 8.2 million fewer nonelderly adults and children had ESI coverage. In addition, 500,000 fewer people had private non-group coverage at the end of this period. Some of these coverage losses were offset by gains in public coverage. The Medicaid coverage rate increased from 15.3 percent to 18.2 percent during this period, resulting in 8.1 million additional people with Medicaid coverage. In addition, military (CHAMPUS) and Medicare coverage increased by 0.3 percent (data not shown).13 In total, the uninsured rate grew from 16.8 percent to 17.9 percent, meaning 3.5 million more people were uninsured in 2010 than in 2008. Between 2010 and 2013, as the economy began to improve, the uninsured rate began to fall. In 2013, the uninsured rate had fallen to 16.9 percent, still slightly above the level of 2008. Most of the gains in insurance coverage during the economic recovery came from public coverage sources. Between 2010 and 2013, there was a 1.1 percentage point increase in Medicaid and CHIP coverage,14 resulting in 3.5 million additional people covered by the Medicaid program. While this increase in Medicaid coverage may reflect, in part, the early Medicaid expansions undertaken in 2010 and 2011 by four states (California, Connecticut, the District of Columbia, and Minnesota), those early expansions alone did not affect a large enough population to account for the entire increase in Medicaid coverage.15 From 2010 to 2013, ESI coverage declined another 0.5 percentage points, from 57.1 percent to 56.6 percent. Figure 5 Percentage point changes in health insurance coverage among the nonelderly, 2008-2013 Employer Medicaid and State Private Nongroup Uninsured 2008-2010 2010-2013 2.9%* 1.1% 1.1%* 0.0% -0.2% -0.5%* -0.9% -3.9%* Change in 3.7 million* 2.7 million* Population Change in 3.5 million* -2.0 million* uninsured NOTES: * Change is statistically significant at the 5% level # Change is statistically significant at the 10% level. Coverage through CHAMPUS and Medicare are not shown because coverage rates for those coverage types among the nonelderly change little year-to-year. SOURCE: Urban Institute Analysis of the 2008-2013 American Community Survey Health Insurance Coverage in 2013: Gains in Public Coverage Continue to Offset Loss of Private Insurance 5 Between 2008 and 2010, the entirety of the net increase in the number of uninsured Figure 6 was due to loss in coverage among those Percentage point changes in health insurance coverage with family incomes below 138 percent of among the nonelderly by income, 2008-2010 the FPL (Figure 6). Increases in Medicaid Employer Medicaid and State Private Nongroup Uninsured All non-elderly <138 FPL 138-400 FPL 400+ FPL coverage made up for much of the loss of ESI in this income group, and the 2.9%* 2.0%* uninsured rate among this group increased 1.1%* 0.8%* 0.3%* 0.3%* 0.0% 0.0% by only 0.3 percentage points. However, -0.1%* -0.2%* -0.3%* -0.3%* -0.3%* the size of the population with income -0.9%* below 138 percent of the FPL swelled by -2.1%* 14.3 million, leading to 4.7 million more -3.9%* Change in 3.7 million* 14.3 million* -2.5 million* -8.0 million* Population low-income Americans uninsured. In Change in 3.5 million* 4.7 million* -0.7 million* -0.6 million* uninsured contrast, both the income group between NOTES: * Change is statistically significant at the 5% level 138 to 400 percent FPL and the income Coverage through CHAMPUS and Medicare are not shown because coverage rates for those coverage types among the nonelderly change little year-to-year. group above 400 percent FPL shrank SOURCE: Urban Institute Analysis of the 2008 and 2010 American Community Survey between 2008 and 2010, and there were 1.3 million fewer uninsured Americans in these income groups in 2010 than in 2008. As shown in Figure 7, the uninsured rate for those with family incomes below 138 percent of the FPL declined as the economy improved between 2010 and 2013, leading to 1.6 million fewer uninsured Americans in this income group. Only those with incomes below 138 percent of the FPL showed a net gain in ESI coverage between 2010 and 2013, though the ESI coverage rate for that group remained low at 20.8 percent (compared to 18.9 percent in 2010). ESI coverage declined from 64.6 percent to 63.8 percent for those with incomes between 138 and 400 percent of the FPL, and from 88.1 percent to 87.2 percent for those with incomes above 400 percent of the FPL between 2010 and Figure 7 2013. The loss of ESI was offset by gains in Percentage point changes in health insurance coverage Medicaid among the middle income group, among the nonelderly by income, 2010-2013 and the uninsured rate fell 0.5 percentage Employer Medicaid and State Private Nongroup Uninsured points for that group. The highest income All non-elderly <138 FPL 138-400 FPL 400+ FPL group showed a 0.3 percent increase in the uninsured rate, meaning an additional 1.1%* 1.9%* 1.1%* 1.0%* 200,000 people with incomes above 400 0.0% 0.1% 0.2%* 0.3%* 0.3%* -0.2%* percent of the FPL were uninsured. Overall, -0.5%* -0.9%* -0.8%* -0.5%* -0.9%* there were 2 million fewer uninsured -2.9%* Americans in 2013 than in 2010 due to Change in 2.7 million* 3.3 million* -0.3 million* -0.3 million* increases in Medicaid coverage among Population Change in -2.0 million* -1.6 million* -0.6 million* 0.2 million* those with incomes below 400 percent of uninsured the FPL and increases in ESI among those NOTES: * Change is statistically significant at the 5% level Coverage through CHAMPUS and Medicare are not shown because coverage rates for those coverage types among the nonelderly change little year-to-year. with incomes below 138 percent of the FPL, SOURCE: Urban Institute Analysis of the 2010 and 2013 American Community Survey who had the largest ESI losses during the Great Recession. Health Insurance Coverage in 2013: Gains in Public Coverage Continue to Offset Loss of Private Insurance 6 The health insurance coverage patterns for children, young adults, and adults differ from 2008 to 2013. The uninsured rate for nonelderly adults was more than double that for children throughout this period, in part because Medicaid and CHIP have higher income eligibility limits for children. In addition, the ACA provision allowing young adults to stay on their parents’ plan until the age of 26 led to significant gains in ESI coverage among this population beginning in 2010 that were not shared by older adults.16 Given these different policy contexts, we examined coverage changes from 2008 to 2013 separately for each of these age groups. Figure 8 From 2008 to 2010, there was a 3.9 Percentage point changes in health insurance coverage among nonelderly adults by income, 2008-2010 percentage point decrease in the ESI Employer Medicaid and State Private Nongroup Uninsured coverage rate for nonelderly adults and a All nonelderly adults <138 FPL 138-400 FPL 400+ FPL 1.7 percentage point increase in Medicaid and other state coverage (Figure 8). In 2.0%* 1.7%* 1.5%* total, the uninsured rate for nonelderly 1.0%* 0.6%* 0.0% 0.1% 0.1% 0.1%* adults increased by 2.0 percentage points, -0.2%* -0.1%* -0.2%* -0.3%* -1.2%* and 4.4 million more nonelderly adults -2.2%* were uninsured. All of the increase in the -3.9%* number of uninsured was among adults in Change in Population 3.5 million* 9.9 million* -0.6 million* -5.7 million* Change in 4.4 million* 4.9 million* -0.1 million* -0.4 million* families with income at or below 138 uninsured percent of the FPL (4.9 million). The NOTES: * Change is statistically significant at the 5% level Coverage through CHAMPUS and Medicare are not shown because coverage rates for those coverage types among the nonelderly number of nonelderly adults in families change little year-to-year. SOURCE: Urban Institute Analysis of the 2008 and 2010 American Community Survey with incomes above 400 percent of the FPL shrank significantly, by 5.7 million, and Figure 9 this group saw a small decrease in the Percentage point changes in health insurance coverage among nonelderly adults by income, 2010-2013 uninsured rate of 0.3 percentage points Employer Medicaid and State Private Nongroup Uninsured between 2008 and 2010. All nonelderly adults <138 FPL 138-400 FPL 400+ FPL Between 2010 and 2013, the overall ESI 3.0%* coverage rate for nonelderly adults was 0.9%* 1.2%* 0.4%* 0.0% 0.1% 0.1%* 0.3%* 0.3%* nearly stable, and the uninsured rate -0.1% -0.1% -0.4%* -0.7%* declined by 1 percentage point in part due -1.0%* -0.8%* to increases in public coverage. However, -4.0%* there was significant variation by income Change in 3.4 million* 3.5 million* 0.2 million* -0.3 million* Population group. Nonelderly adults below 138 Change in uninsured -1.1 million* -0.9 million* -0.4 million* 0.2 million* percent of the FPL saw a 3.0 percentage NOTES: * Change is statistically significant at the 5% level Coverage through CHAMPUS and Medicare are not shown because coverage rates for those coverage types among the nonelderly point gain in ESI coverage and a 1.2 change little year-to-year. SOURCE: Urban Institute Analysis of the 2010 and 2013 American Community Survey percentage point gain in Medicaid and CHIP coverage, leading to a 4.0 percentage point reduction in the uninsured rate for that income group. In contrast, ESI coverage for those with incomes above 400 percent of the FPL continued to decline, leading to a 0.3 percentage point increase in the uninsured rate for that group. Health Insurance Coverage in 2013: Gains in Public Coverage Continue to Offset Loss of Private Insurance 7 Beginning in September 2010, the ACA Figure 10 required most health plans to allow Percentage point changes in health insurance coverage children to stay on their parents’ plan as a among nonelderly adults by age, 2008-2010 dependent until age 26. Between 2008 and Employer Medicaid and State Private Nongroup Uninsured 2010, this age group lost ESI coverage at a All adults 19-25 26-45 46-64 rate similar to the rest of the adult population (Figure 10). However, the trend 1.7%* 2.0%* 2.1%* 1.8%* 1.9%* 2.4%* 1.4%* 1.9%* for young adults diverged significantly 0.0% -0.2%* -0.2%* -0.2%* from other nonelderly adults from 2010 to 2013 (Figure 11). While other age groups -3.9%* -4.2%* -4.3%* -3.4%* continued to lose ESI coverage, albeit more Change in 3.5 million* 0.7 million* -0.8 million* 3.6 million* slowly than between 2008 and 2010, young Population Change in 4.4 million* 0.7 million* 1.7 million* 1.9 million* uninsured adults had large gains in ESI coverage. NOTES: * Change is statistically significant at the 5% level Between 2010 and 2013, 2.6 million young Coverage through CHAMPUS and Medicare are not shown because coverage rates for those coverage types among the nonelderly change little year-to-year. adults gained ESI coverage, a 6.7 SOURCE: Urban Institute Analysis of the 2008 and 2010 American Community Survey percentage point increase in the ESI coverage rate (Figure 11). Young adults did not gain Medicaid and CHIP coverage as quickly as other age groups in this time period. These gains for young adults created a Figure 11 near-stabilization of ESI coverage rates Percentage point changes in health insurance coverage between 2010 and 2013 for all nonelderly among nonelderly adults by age, 2010-2013 adults. For other adult groups, however, Employer Medicaid and State Private Nongroup Uninsured ESI coverage losses continued, resulting in All adults 19-25 26-45 46-64 6.7%* 700,000 adults ages 26 to 64 losing ESI coverage between 2010 and 2013. 0.9%* 1.0%* 1.0%* Similarly, nearly all of the decrease in the 0.0% 0.1% 0.0% 0.0% 0.5%* -0.1% uninsured rate and number uninsured seen -1.0%* -0.3%* -1.0%* -0.3%* -1.8%* among nonelderly adults between 2010 and 2013 was among young adults. While -6.7%* Change in 3.4 million* 1.1 million* 0.7 million* 1.6 million* the ACA policy had the intended effect of Population Change in -1.1 million* -1.7 million* -0.1 million* 0.6 million* decreasing the uninsured rate among uninsured young adults, it masked a continued trend NOTES: * Change is statistically significant at the 5% level Coverage through CHAMPUS and Medicare are not shown because coverage rates for those coverage types among the nonelderly change little year-to-year. of loss in ESI coverage among other age SOURCE: Urban Institute Analysis of the 2010 and 2013 American Community Survey groups. Health Insurance Coverage in 2013: Gains in Public Coverage Continue to Offset Loss of Private Insurance 8 The pattern of coverage for children under age 19 is different from that of adults, primarily due to greater access to Medicaid and CHIP coverage. During the recession, children were more likely to lose access to ESI than adults. Between 2008 and 2010, the ESI coverage rate for children fell 4.2 percentage points, from 54.7 percent to 50.5 percent (Figure 12). Most of Figure 12 this loss of ESI was among low-income Percentage point changes in health insurance coverage children and was more than made up for by among children, 2008-2013 increases in Medicaid and CHIP coverage. Employer Medicaid and State Private Nongroup Uninsured 2008-2010 2010-2013 The Medicaid and CHIP coverage rate for 5.8%* children increased from 31.7 percent to 2.4%* 37.5 percent in this time period, meaning 4.6 million additional children were 0.0% -0.5%* covered in those programs, 4.5 million of -1.2%* -1.5%* -1.0%* whom had family incomes below 138 -4.2%* percent of the FPL. Overall, the uninsured Change in 0.2 million* -0.7 million* rate for children actually declined during Population Change in -1.0 million* -0.8 million* uninsured the recession, from 9.2 percent to 8.0 NOTES: * Change is statistically significant at the 5% level percent, and 1 million fewer children were Coverage through CHAMPUS and Medicare are not shown because coverage rates for those coverage types among the nonelderly change little year-to-year. uninsured in 2010 than in 2008. SOURCE: Urban Institute Analysis of the 2008-2013 American Community Survey The economic recovery from 2010 to 2013 showed a similar pattern for children (Figure 12). The ESI coverage rate among children continued to fall, from 50.5 percent in 2010 to 49.1 percent in 2013. This continued reduction in ESI coverage was spread across all income groups. However, this loss of ESI coverage was more than made up for by continued gains in Medicaid and CHIP coverage, which increased from 37.5 percent in 2010 to 39.8 percent in 2013. Overall, 800,000 fewer children were uninsured in 2013 than in 2010, 700,000 of whom had with family incomes below 138 percent of the FPL. The uninsured rate for children with family incomes above 400 percent of the FPL increased 0.3 percentage points between 2010 and 2013, largely due to losses of ESI coverage in that income group Figure 13 (data not shown). Trend in the uninsured rate among children, 2008-2013 The increases in Medicaid and CHIP Family income at or below 138% FPL Family income 138-400% FPL Family income 400% FPL and above coverage rates for children seen during the 13.8% Great Recession and recovery have reduced 11.3% the disparity in the uninsured rate among 9.3% children by income (Figure 13). In 2008, 8.9% 9.7% children in families with income of less 8.2% 7.7% 7.8% than 138 percent of the FPL had an uninsured rate of 13.8 percent, versus 2.6 2.6% 2.1% 2.1% 2.4% percent for those in families with incomes above 400 percent of the FPL. By 2013, the uninsured rate for low-income children was 2008 2010 2012 2013 down to 8.9 percent, compared to 2.4 SOURCE: Urban Institute Analysis of the 2008-2013 American Community Survey percent for higher-income children. Health Insurance Coverage in 2013: Gains in Public Coverage Continue to Offset Loss of Private Insurance 9 There are two important demographic trends in the United States that affect health insurance coverage among the nonelderly. First, racial and ethnic minority populations have grown. Between 2008 and 2013, the non- Hispanic White population shrank by 5.4 million people, while the Hispanic population grew by 6.4 million people. The non-Hispanic Black population also grew by 1.5 million people during this time period, and other racial and ethnic groups also grew by 3.8 million people.17 Hispanics and non-Hispanic Blacks have lower rates of ESI and higher uninsured rates than non-Hispanic Whites, so increases in the size of these populations tend to increase the uninsured rate and the number of uninsured. Second, the US population has shifted geographically. The Northeast and Midwest saw almost no population growth between 2008 and 2013, while the South and West grew by 4.3 million people and 1.9 million people, respectively. On average, the South and West have lower ESI coverage rates and higher uninsured rates than the Northeast and Midwest. In addition, states that have not expanded Medicaid under the ACA are concentrated in these regions, which will exacerbate the regional disparities in uninsured rates in 2014. Between 2008 and 2010, non-Hispanic Blacks and Hispanics had more substantial reductions in ESI coverage than non-Hispanic Whites (Figure 14). Figure 14 While some of this disparity was made up Percentage point changes in health insurance coverage by by increases in public coverage, overall 2.3 race and ethnicity, 2008-2010 of the 3.5 million people who lost coverage Employer Medicaid and State Private Nongroup Uninsured between 2008 and 2010 were people of White, non-Hispanic Black, non-Hispanic Hispanic Other, non-Hispanic color. The increases in the uninsured rate 4.0%* 4.0%* were concentrated among low-income 2.0%* 2.2%* 0.9%* 1.0%* people of all racial and ethnic groups. Non- 0.7%* 0.2% Hispanic Whites over 400 percent of the -0.2%* -0.2%* -0.1%* -0.1% FPL fared best during the recession, -3.0%* -2.9%* experiencing an increase in the ESI -5.1%* -4.2%* coverage rate and 400,000 fewer Change in Population -3.0 million* 1.0 million* 3.7 million* 2.1 million* Change in 1.1 million* 0.5 million* 1.3 million* 0.5 million* uninsured (data not shown). uninsured NOTES: * Change is statistically significant at the 5% level Coverage through CHAMPUS and Medicare are not shown because coverage rates for those coverage types among the nonelderly change little year-to-year. SOURCE: Urban Institute Analysis of the 2008 and 2010 American Community Survey Health Insurance Coverage in 2013: Gains in Public Coverage Continue to Offset Loss of Private Insurance 10 As the economy recovered between 2010 Figure 15 and 2013, the uninsured rate fell for all Percentage point changes in health insurance coverage by racial and ethnic groups, largely due to race and ethnicity, 2010-2013 increases in public coverage (Figure 15). Employer Medicaid and State Private Nongroup Uninsured White, non-Hispanic Black, non-Hispanic Hispanic Other, non-Hispanic Hispanics saw the largest percentage point decrease in the uninsured rate, from 32.2 1.6%* percent in 2010 to 29.7 percent in 2013. 0.8%* 0.0% 0.9%* 0.1% 0.7%* 0.1%* 0.3% 0.8%* This is due to increases in both public -0.4%* -0.2% -0.1% -0.7%* -1.0%* coverage and ESI coverage among the -1.2%* -2.6%* Hispanic population. Change in -2.3 million* 0.5 million* 2.7 million* 1.8 million* Between 2008 and 2013, the gap in the Population Change in -1.4 million* -0.2 million* -0.4 million* 0.0 million* uninsured uninsured rate between non-Hispanic NOTES: * Change is statistically significant at the 5% level #Change is statistically significant at the 10% level whites and Hispanics narrowed, from 19.6 Coverage through CHAMPUS and Medicare are not shown because coverage rates for those coverage types among the nonelderly change little year-to-year. percentage points in 2008 to 17.1 SOURCE: Urban Institute Analysis of the 2010 and 2013 American Community Survey percentage points in 2013 (Figure 16). Most Figure 16 of this narrowing was due to increases in Trends in the uninsured rate by race and ethnicity, 2008- the Medicaid coverage rate for Hispanics, 2013 from 24.2 percent in 2008 to 29.8 percent White, non-Hispanic Black, non-Hispanic Hispanic Other, non-Hispanic in 2013, a gain of 4.4 million Hispanic Medicaid enrollees (Figures 14 and 15). Despite these gains, the uninsured rate for 32.0% 32.2% 30.2% 29.7% Hispanics remained more than double that for non-Hispanic Whites in 2013. The gap 18.7% 19.7% 18.7% 18.7% in the uninsured rate between non- 17.9% 17.1% 17.2% 16.7% Hispanic Whites and non-Hispanic Blacks 12.4% 13.3% 12.8% 12.6% remained virtually unchanged, narrowing by only 0.2 percentage points. 2008 2010 2012 2013 SOURCE: Urban Institute Analysis of the 2008-2013 American Community Survey Health Insurance Coverage in 2013: Gains in Public Coverage Continue to Offset Loss of Private Insurance 11 The effects of the recession and recovery on Figure 17 health insurance coverage were not Percentage point changes in health insurance coverage by consistent across the country, as shown in region, 2008-2010 Figures 17 and 18. Between 2008 and 2010, Employer Medicaid and State Private Nongroup Uninsured Northeast Midwest South West the Midwest saw the largest losses of ESI coverage, from 66.3 percent to 61.9 3.1%* 3.0%* 2.7%* 2.8%* percent, and the largest increase in the 1.3%* 1.1%* 0.8%* 0.9%* uninsured rate, from 12.9 percent to 14.2 0.0% percent (Figure 17). The Northeast fared -0.2%* -0.3%* -0.4%* the best in the early years of the recession, with only 400,000 additional uninsured. -3.7%* -3.6%* -4.5%* -3.9%* Change in 0.2 million* 0.1 million* 2.5 million* 0.9 million* This was due, in part, to slightly larger Population Change in 0.4 million* 0.8 million* 1.6 million* 0.7 million* uninsured percentage point gains in Medicaid coverage in the Northeast, which NOTES: * Change is statistically significant at the 5% level Coverage through CHAMPUS and Medicare are not shown because coverage rates for those coverage types among the nonelderly change little year-to-year. traditionally has higher income thresholds SOURCE: Urban Institute Analysis of the 2008 and 2010 American Community Survey for adults and children than the South or West. During the recovery, the Northeast saw the Figure 18 largest continued reduction in ESI Percentage point changes in health insurance coverage by coverage, resulting in approximately region, 2010-2013 500,000 fewer Northeast residents with Employer Medicaid and State Private Nongroup Uninsured ESI in 2013 than in 2010 (Figure 18). The Northeast Midwest South West South and West saw the largest percentage point decreases in the uninsured rate (1.1 1.2%* 1.0%* 1.2%* 1.1%* percent), largely due to gains in public 0.1% 0.1%# 0.0% coverage. In addition, population shifts -1.0%* -0.5%* -0.4%# -0.9%* -0.3%* -0.1% -0.1% -1.1%* -1.1%* between regions continued between 2010 and 2013, with the Midwest experiencing a Change in 0.0 million* -0.2 million* 1.9 million* 1.0 million* net population loss, the Northeast Population Change in -0.2 million* -0.6 million* -0.7 million* -0.5 million* experiencing no net change in population, uninsured and the South and West each increasing in NOTES: * Change is statistically significant at the 5% level Coverage through CHAMPUS and Medicare are not shown because coverage rates for those coverage types among the nonelderly population by a million or more people. change little year-to-year. SOURCE: Urban Institute Analysis of the 2010 and 2013 American Community Survey The effect of the recovery between 2010 and 2013 on insurance coverage also differed substantially by state (see Appendix A, Table 7 for uninsured rates by state). Overall, the uninsured rate declined in 39 states and increased in 12 states between 2010 and 2013. Oregon had largest percentage point decrease in the uninsured rate (2.3 percentage points), while Alaska had the highest percentage point increase (1.2 percentage points). In all but 4 states, the Medicaid and CHIP coverage rate increased between 2010 and 2013. Montana had the largest percentage point increase in Medicaid coverage (3.7 percentage points), and Alaska had the largest decline (1.8 percentage points). Finally, ESI coverage rates increased in 17 states and declined in 34 states. Wyoming had the largest increase in ESI at 3.2 percentage points, and Connecticut had the largest decline at 3.3 percentage points. Health Insurance Coverage in 2013: Gains in Public Coverage Continue to Offset Loss of Private Insurance 12 Between 2008 and 2010, the total number Figure 19 of workers aged 18 to 64 declined from Percentage point changes in health insurance coverage 140.4 million to 133.1 million. . Overall, among workers, by industry, 2008-2010 between 2008 and 2010, workers Employer Medicaid and State Private Nongroup Uninsured experienced a decline in ESI coverage from Non-elderly adult workers High ESI industries Low ESI industries 72.4 percent to 70.8 percent, which 1.3%* translates to a loss of ESI coverage for 7.5 0.9%* 0.8%* 0.6%* million workers (Figure 19). This ESI loss 0.3%* 0.0% 0.3%* was partially mitigated by increases in -0.1%* -0.1%# Medicaid coverage for low-income workers, -0.8%* -1.6%* but overall the uninsured rate for workers -2.0%* rose 0.9 percentage points. More workers Change in -7.3 million* -2.9 million* -4.4 million* Population Change in 0.0 million -0.1 million 0.1 million in “low ESI” industries lost ESI than those uninsured in “high ESI” industries (4.6 million and NOTES: * Change is statistically significant at the 5% level # Change is statistically significant at the 10% level. Coverage through CHAMPUS and Medicare are not shown because coverage rates for those coverage types among the nonelderly 2.8 million, respectively).18 From 2008 to change little year-to-year. SOURCE: Urban Institute Analysis of the 2008 and 2010 American Community Survey 2010, the low ESI industries saw a larger decline in the number of workers than high ESI industries (4.4 million and 2.9 million, respectively). Because of the decline in the number of workers, the total number of uninsured workers was flat between 2008 and 2010 despite an increase in the uninsured rate. Between 2010 and 2013, the number of workers recovered from 133.1 million to 138.0 million. This increase was concentrated in low ESI industries, which grew by 4.2 million workers between 2010 and 2013. The rate of ESI coverage among all workers also continued to decline between 2010 and 2013, dropping from 70.8 percent to 70.2 percent in that time period (Figure 20). The decline in the ESI coverage rate Figure 20 was more substantial for high ESI Percentage point changes in health insurance coverage industries, where the ESI coverage rate fell among workers, by industry, 2010-2013 Employer Medicaid and State Private Nongroup Uninsured by 0.8 percentage points. Workers in high Non-elderly adult workers High ESI industries Low ESI industries ESI industries saw an increase in the uninsured rate between 2010 and 2013, and 200,000 more were uninsured. 0.6%* 0.1% # 0.3%* 0.1%* 0.2%* 0.7%* 0.0% Workers in low ESI industries, conversely, # -0.2%* -0.2% had a 0.6 percentage point reduction in the -0.6%* -0.8%* -0.6%* uninsured rate between 2010 and 2013 due to increases in Medicaid coverage. Change in 4.8 million* 0.7 million* 4.2 million* Population However, because of the population growth Change in 0.6 million 0.2 million 0.4 million uninsured in low ESI industries, there were 400,000 NOTES: * Change is statistically significant at the 5% level # Change is statistically significant at the 10% level. more workers in low ESI industries without Coverage through CHAMPUS and Medicare are not shown because coverage rates for those coverage types among the nonelderly change little year-to-year. SOURCE: Urban Institute Analysis of the 2010 and 2013 American Community Survey health insurance in 2013 than in 2010. Health Insurance Coverage in 2013: Gains in Public Coverage Continue to Offset Loss of Private Insurance 13 The coverage provisions of the ACA that went into effect on January 1, 2014 were primarily designed to increase health insurance coverage among low-to middle-income adults. These provisions include both the establishment of Health Insurance Marketplaces to provide subsidized private non-group health insurance and, in 28 states and the District of Columbia, an expansion of Medicaid eligibility to adults up to 138 percent of the FPL. The 2013 American Community Survey does not capture these expansions, though it does capture early expansions of Medicaid by four states and the expansion of dependent coverage to young adults. Despite capturing some of the early coverage expansions under the ACA, the 2013 ACS serves as a final, albeit imperfect, baseline against which to measure the coverage shifts resulting from the major coverage expansions in the ACA. In addition, the 2013 ACS provides the opportunity to clarify trends in coverage during the economic recovery that preceded the major ACA coverage expansions. The Great Recession led to a significant increase in the uninsured rate and accelerated the decline in ESI coverage, particularly among those with incomes below 138 percent of the FPL. Since 2010, the recovery has steadily improved uninsured rates, but ESI coverage has continued to decline, albeit at a slower rate, for children and adults aged 26 and older. Adults aged 19 to 25 experienced significant growth in ESI from 2010 to 2013 due to the ACA policy allowing young adults to continue receiving insurance through their parents’ plan until age 26. In addition, most of the growth in employment between 2010 and 2013 was in low ESI industries, and the average ESI coverage rate in those industries was 20 percentage points below that for high ESI industries in 2013 (63.2 percent and 83.2 percent, respectively). The increases in the uninsured rate during the Great Recession occurred mostly among low-income families, and the reductions in the uninsured rate during the recovery have primarily been through growth in Medicaid and CHIP. Coverage for children, in particular, was stabilized by growth in Medicaid and CHIP enrollment that offset losses in ESI coverage. While adult enrollment in Medicaid grew by 2.6 percentage points between 2008 and 2013, the effect was less pronounced than the 8.1 percentage point growth for children, likely due to lower eligibility levels for adults than for children. As the ACA is fully implemented, ESI will remain the largest source of insurance coverage for Americans. However, much of the growth in coverage under the ACA is expected to come from Medicaid enrollment and increases in private non-group health insurance coverage purchased through the Health Insurance Marketplaces. It is therefore important to continue to track trends in ESI coverage alongside coverage gains in Medicaid and private non-group health insurance under the ACA to fully understand the effects of the ACA on health insurance coverage. This issue brief was prepared by Laura Skopec, John Holahan, and Megan McGrath of the Urban Institute Health Insurance Coverage in 2013: Gains in Public Coverage Continue to Offset Loss of Private Insurance 14 261.4 265.1 3.7 267.8 2.7a Employer 61.0% 57.1% -3.9% -8.2 56.6% -0.5%* 0.3 Medicaid and State 15.3% 18.2% 2.9% 8.1 19.3% 1.1%* 3.5a CHAMPUS/Medicare 2.4% 2.6% 0.3% 0.8 2.8% 0.2%* 0.6a Private Non-group 4.5% 4.2% -0.2% -0.5 4.3% 0.0% 0.2b Uninsured 16.8% 17.9% 1.1% 3.5 16.9% -0.9%* -2.0a Employer 21.0% 18.9% -2.1% 1.2 20.8% 1.9%* 2.3a Medicaid and State 41.6% 43.6% 2.0% 7.7 44.7% 1.1%* 2.4a CHAMPUS/Medicare 3.0% 2.9% -0.1% 0.4 3.1% 0.2%* 0.2a Private Non-group 3.3% 3.2% -0.1% 0.4 3.0% -0.2%* -0.1a Uninsured 31.0% 31.4% 0.3% 4.7 28.4% -2.9%* -1.6a 99.6 97.1 -2.5 96.7 -0.3 Employer 65.5% 64.6% -0.9% -2.5 63.8% -0.8%* -1.0a Medicaid and State 9.3% 10.1% 0.8% 0.6 11.1% 1.0%* 0.9a CHAMPUS/Medicare 2.6% 3.0% 0.4% 0.3 3.3% 0.3%* 0.3a Private Non-group 4.7% 4.6% 0.0% -0.2 4.7% 0.1% 0.1 Uninsured 17.9% 17.6% -0.3% -0.7 17.1% -0.5%* -0.6a 90.2 82.2 -8 81.9 -0.3 Employer 87.9% 88.1% 0.3% -6.8 87.2% -0.9%* -1.0a Medicaid and State 1.2% 1.2% 0.0% -0.1 1.4% 0.2%* 0.2a CHAMPUS/Medicare 1.6% 1.9% 0.3%* 0.1 2.0% 0.1%* 0.1a Private Non-group 5.2% 4.9% -0.3%* -0.7 5.1% 0.3%* 0.2a Uninsured 4.2% 4.0% -0.3% -0.6 4.3% 0.3%* 0.2a Source: Analysis of the Urban Institute's Health Policy Center's American Community Survey (ACS) Medicaid/CHIP Simulation Model based on data from the Integrated Public Use Microdata Series (IPUMS) from 2010 and 2013. Note: Excludes persons aged 65 and older and those in the Armed Forces. Estimates reflect an adjustment for the misreporting of coverage on the ACS. * Indicates change in percent of people is statistically significant (at the 95% confidence level). # Indicates change in percent of people is statistically significant (at the 90% confidence level) a Indicates change in numbers of people is statistically significant (at the 95% confidence level). b Indicates change in numbers of people is statistically significant (at the 90% confidence level). Health Insurance Coverage in 2013: Gains in Public Coverage Continue to Offset Loss of Private Insurance 15 183.0 186.5 3.5a 189.9 3.4a Employer 63.7% 59.9% -3.9%* -5.0a 59.7% -0.1% 1.8a Medicaid and State 8.3% 10.1% 1.7%* 3.5a 10.9% 0.9%* 2.0a CHAMPUS/Medicare 2.7% 3.0% 0.3%* 0.7a 3.3% 0.3%* 0.6a Private Non-group 5.2% 5.0% -0.2%* -0.1b 5.0% 0.0% 0.1a Uninsured 20.0% 22.0% 2.0%* 4.4a 21.0% -1.0%* -1.1a 45.0 54.9 9.9a 58.3 3.5a Employer 23.6% 21.5% -2.2%* 1.1a 24.5% 3.0%* 2.5a Medicaid and State 26.4% 27.4% 1.0%* 3.2a 28.6% 1.2%* 1.6a CHAMPUS/Medicare 4.1% 3.9% -0.2%* 0.3a 4.1% 0.2%* 0.3a Private Non-group 4.5% 4.4% -0.1%* 0.4a 4.1% -0.4%* -0.1a Uninsured 41.3% 42.8% 1.5%* 4.9a 38.7% -4.0%* -0.9a 68.6 68.0 -0.6a 68.2 0.2 Employer 65.8% 64.7% -1.2%* -1.2a 64.6% -0.1% 0.1 Medicaid and State 4.2% 4.7% 0.6%* 0.4a 5.1% 0.4%* 0.3a CHAMPUS/Medicare 2.8% 3.3% 0.5%* 0.3a 3.7% 0.3%* 0.2a Private Non-group 5.6% 5.6% 0.0% 0.0 5.6% 0.1% 0.1 Uninsured 21.6% 21.7% 0.1% -0.1 21.0% -0.7%* -0.4a 69.3 63.6 -5.7a 63.4 -0.3 Employer 87.7% 87.8% 0.1% -4.9a 87.0% -0.8%* -0.8a Medicaid and State 0.7% 0.8% 0.1%* 0.0 0.9% 0.1%* 0.1a CHAMPUS/Medicare 1.6% 1.9% 0.3%* 0.1a 2.0% 0.1%* 0.1a Private Non-group 5.2% 5.0% -0.2%* -0.5a 5.3% 0.3%* 0.2a Uninsured 4.8% 4.5% -0.3%* -0.4a 4.8% 0.3%* 0.2a Source: Analysis of the Urban Institute's Health Policy Center's American Community Survey (ACS) Medicaid/CHIP Simulation Model based on data from the Integrated Public Use Microdata Series (IPUMS) from 2010 and 2013. Note: Excludes persons aged 65 and older and those in the Armed Forces. Estimates reflect an adjustment for the misreporting of coverage on the ACS. * Indicates change in percent of people is statistically significant (at the 95% confidence level). # Indicates change in percent of people is statistically significant (at the 90% confidence level) a Indicates change in numbers of people is statistically significant (at the 95% confidence level). b Indicates change in numbers of people is statistically significant (at the 90% confidence level). Health Insurance Coverage in 2013: Gains in Public Coverage Continue to Offset Loss of Private Insurance 16 183.0 186.5 3.5a 189.9 3.4a Employer 63.7% 59.9% -3.9% -5.0a 59.7% -0.1% 1.8a Medicaid and State 8.3% 10.1% 1.7% 3.5a 10.9% 0.9%* 2.0a CHAMPUS/Medicare 2.7% 3.0% 0.3% 0.7a 3.3% 0.3%* 0.6a Private Non-group 5.2% 5.0% -0.2% -0.1b 5.0% 0.0% 0.1a Uninsured 20.0% 22.0% 2.0% 4.4a 21.0% -1.0%* -1.1a 28.9 29.6 0.7a 30.7 1.1a Employer 50.5% 46.2% -4.2% -0.9a 53.0% 6.7%* 2.6a Medicaid and State 9.8% 12.0% 2.1% 0.7a 12.1% 0.1% 0.2a CHAMPUS/Medicare 1.6% 1.9% 0.3%* 0.1a 2.0% 0.1%* 0.1a Private Non-group 7.7% 7.7% 0.0% 0.1b 7.5% -0.3%* 0.0 Uninsured 30.4% 32.2% 1.8% 0.7a 25.5% -6.7%* -1.7a 81.4 80.6 -0.8a 81.3 0.7a Employer 64.1% 59.8% -4.3% -4.0a 58.7% -1.0%* -0.4a Medicaid and State 8.5% 10.4% 1.9% 1.5a 11.4% 1.0%* 0.9a CHAMPUS/Medicare 1.5% 1.7% 0.2% 0.2a 2.0% 0.3%* 0.2a Private Non-group 3.8% 3.6% -0.2%* -0.2a 3.6% 0.0% 0.0 Uninsured 22.1% 24.5% 2.4% 1.7a 24.2% -0.3%* -0.1 72.7 76.3 3.6a 78.0 1.6a Employer 68.6% 65.2% -3.4% -0.1 63.4% -1.8%* -0.3a Medicaid and State 7.6% 9.0% 1.4%* 1.3a 10.0% 1.0%* 0.9a CHAMPUS/Medicare 4.4% 4.8% 0.4%* 0.4a 5.1% 0.3%* 0.3a Private Non-group 5.7% 5.5% -0.2%* 0.0 5.5% 0.0% 0.1a Uninsured 13.6% 15.5% 1.9% 1.9a 16.0% 0.5%* 0.6a Source: Analysis of the Urban Institute's Health Policy Center's American Community Survey (ACS) Medicaid/CHIP Simulation Model based on data from the Integrated Public Use Microdata Series (IPUMS) from 2010 and 2013. Note: Excludes persons aged 65 and older and those in the Armed Forces. Estimates reflect an adjustment for the misreporting of coverage on the ACS. * Indicates change in percent of people is statistically significant (at the 95% confidence level). # Indicates change in percent of people is statistically significant (at the 90% confidence level) a Indicates change in numbers of people is statistically significant (at the 95% confidence level). b Indicates change in numbers of people is statistically significant (at the 90% confidence level). Health Insurance Coverage in 2013: Gains in Public Coverage Continue to Offset Loss of Private Insurance 17 78.4 78.6 0.2a 77.9 -0.7a Employer 54.7% 50.5% -4.2% -3.2a 49.1% -1.5%* -1.5a Medicaid and State 31.7% 37.5% 5.8% 4.6a 39.8% 2.4%* 1.6a CHAMPUS/Medicare 1.6% 1.7% 0.1% 0.1b 1.8% 0.1%* 0.0b Private Non-group 2.8% 2.3% -0.5% 0.0a 2.4% 0.0% 0.0 Uninsured 9.2% 8.0% -1.2% -1.0a 7.0% -1.0%* -0.8a 26.6 31.0 4.4a 30.8 -0.2 Employer 16.6% 14.3% -2.2% 0.0 13.7% -0.6%* -0.2a Medicaid and State 67.3% 72.3% 5.0% 4.5a 75.4% 3.1%* 0.8a CHAMPUS/Medicare 1.1% 1.1% 0.1%# 0.1a 1.1% -0.1% 0.0 Private Non-group 1.3% 1.0% -0.3% 0.0a 0.9% -0.1%* 0.0a Uninsured 13.8% 11.3% -2.5% -0.2a 8.9% -2.3%* -0.7a 30.9 29.1 -1.9a 28.5 -0.5a Employer 64.7% 64.5% -0.2% -1.3a 61.9% -2.6%* -1.1a Medicaid and State 20.6% 22.7% 2.0% 0.2a 25.3% 2.7%* 0.6a CHAMPUS/Medicare 2.2% 2.3% 0.0% 0.0 2.5% 0.3%* 0.1a Private Non-group 2.7% 2.4% -0.3%* 0.0a 2.4% 0.1% 0.0 Uninsured 9.7% 8.2% -1.5% -0.6a 7.8% -0.4%* -0.2a 20.9 18.6 -2.3a 18.6 0.0 Employer 88.4% 89.2% 0.7% -1.9a 88.0% -1.2%* -0.2b Medicaid and State 2.6% 2.5% 0.0% -0.1a 3.2% 0.6%* 0.1a CHAMPUS/Medicare 1.5% 1.8% 0.3%* 0.0 1.8% 0.0% 0.0 Private Non-group 4.9% 4.4% -0.5%* 0.0a 4.7% 0.2%* 0.0a Uninsured 2.6% 2.1% -0.5% -0.1a 2.4% 0.3%* 0.1a Source: Analysis of the Urban Institute's Health Policy Center's American Community Survey (ACS) Medicaid/CHIP Simulation Model based on data from the Integrated Public Use Microdata Series (IPUMS) from 2010 and 2013. Note: Excludes persons aged 65 and older and those in the Armed Forces. Estimates reflect an adjustment for the misreporting of coverage on the ACS. * Indicates change in percent of people is statistically significant (at the 95% confidence level). # Indicates change in percent of people is statistically significant (at the 90% confidence level) a Indicates change in numbers of people is statistically significant (at the 95% confidence level). b Indicates change in numbers of people is statistically significant (at the 90% confidence level). Health Insurance Coverage in 2013: Gains in Public Coverage Continue to Offset Loss of Private Insurance 18 165.9 162.9 -3.0a 160.5 -2.3a Employer 69.0% 66.0% -3.0% -7.0a 65.5% -0.4% * -2.3a Medicaid and State 10.6% 12.6% 2.0% 3.0a 13.4% 0.8%* 1.0a CHAMPUS/Medicare 2.5% 2.8% 0.3% 0.4a 3.1% 0.3%* 0.4a Private Non-group 5.5% 5.3% -0.2% -0.5a 5.3% 0.0% -0.1 Uninsured 12.4% 13.3% 0.9% 1.1a 12.6% -0.7%* -1.4a 32.4 33.4 1.0a 33.9 0.5a Employer 49.0% 43.9% -5.1% -1.2a 43.7% -0.2% 0.2b Medicaid and State 27.4% 31.4% 4.0% 1.6a 32.3% 0.9%* 0.5a CHAMPUS/Medicare 2.9% 3.3% 0.4%* 0.2a 3.5% 0.2%* 0.1a Private Non-group 1.9% 1.7% -0.2% -0.1a 1.7% 0.1% 0.0a Uninsured 18.7% 19.7% 1.0% 0.5a 18.7% -1.0%* -0.2a 43.6 47.3 3.7a 50.0 2.7a Employer 40.4% 36.2% -4.2% -0.5a 36.9% 0.7%* 1.3a Medicaid and State 24.2% 28.2% 4.0% 2.8a 29.8% 1.6%* 1.6a CHAMPUS/Medicare 1.5% 1.6% 0.1% 0.1a 1.7% 0.1%* 0.1a Private Non-group 2.0% 1.8% -0.1%* 0.0 2.0% 0.1%* 0.1a Uninsured 32.0% 32.2% 0.2% 1.3a 29.7% -2.6%* -0.4a 19.5 21.6 2.1a 23.4 1.8a Employer 59.2% 56.2% -2.9% 0.6a 56.5% 0.3% 1.1a Medicaid and State 16.0% 18.2% 2.2%* 0.8a 19.0% 0.8%* 0.5a CHAMPUS/Medicare 2.2% 2.3% 0.1% 0.1a 2.4% 0.1%# 0.1a Private Non-group 5.5% 5.4% -0.1% 0.1a 5.3% -0.1% 0.1a Uninsured 17.2% 17.9% 0.7% 0.5a 16.7% -1.2%* 0.0 Source: Analysis of the Urban Institute's Health Policy Center's American Community Survey (ACS) Medicaid/CHIP Simulation Model based on data from the Integrated Public Use Microdata Series (IPUMS) from 2010 and 2013. Note: Excludes persons aged 65 and older and those in the Armed Forces. Estimates reflect an adjustment for the misreporting of coverage on the ACS. * Indicates change in percent of people is statistically significant (at the 95% confidence level). # Indicates change in percent of people is statistically significant (at the 90% confidence level) a Indicates change in numbers of people is statistically significant (at the 95% confidence level). b Indicates change in numbers of people is statistically significant (at the 90% confidence level). Health Insurance Coverage in 2013: Gains in Public Coverage Continue to Offset Loss of Private Insurance 19 46.9 47.1 0.2 a 47.1 0.0a Employer 66.9% 63.2% -3.7% -1.6a 62.2% -1.0% * -0.5a Medicaid and State 16.2% 19.3% 3.1% 1.5a 20.5% 1.2%* 0.6a CHAMPUS/Medicare 1.4% 1.5% 0.1% 0.0a 1.7% 0.2%* 0.1a Private Non-group 3.9% 3.7% -0.2% 0.0a 3.8% 0.1% 0.0 Uninsured 11.6% 12.3% 0.8% 0.4a 11.9% -0.5%* -0.2a 57.2 57.3 0.1a 57.2 -0.2a Employer 66.3% 61.9% -4.5% -2.5a 61.5% -0.4%# -0.3a Medicaid and State 14.7% 17.7% 3.0% 1.7a 18.7% 1.0%* 0.5a CHAMPUS/Medicare 1.7% 1.9% 0.2%* 0.1a 2.1% 0.2%* 0.1a Private Non-group 4.3% 4.3% 0.0% 0.0 4.4% 0.1%# 0.1 Uninsured 12.9% 14.2% 1.3% 0.8a 13.3% -0.9%* -0.6a 95.6 98.1 2.5a 100.0 1.9a Employer 57.1% 53.3% -3.9% -2.4a 52.9% -0.3%* 0.7a Medicaid and State 15.2% 17.9% 2.7% 3.0a 19.1% 1.2%* 1.5a CHAMPUS/Medicare 3.3% 3.6% 0.3% 0.4a 3.9% 0.2%* 0.3a Private Non-group 4.2% 4.0% -0.3%* -0.1a 3.9% 0.0% 0.1 Uninsured 20.2% 21.3% 1.1% 1.6a 20.2% -1.1%* -0.7a 61.7 62.6 0.9a 63.6 1.0a Employer 57.7% 54.1% -3.6% -1.7a 54.0% -0.1% 0.5a Medicaid and State 15.5% 18.4% 2.8%* 1.9a 19.5% 1.1%* 0.9a CHAMPUS/Medicare 2.3% 2.5% 0.3%* 0.2a 2.7% 0.2%* 0.1a Private Non-group 5.5% 5.1% -0.4%* -0.2a 5.0% -0.1% 0.0 Uninsured 19.1% 20.0% 0.9% 0.7a 18.9% -1.1%* -0.5a Source: Analysis of the Urban Institute's Health Policy Center's American Community Survey (ACS) Medicaid/CHIP Simulation Model based on data from the Integrated Public Use Microdata Series (IPUMS) from 2010 and 2013. Note: Excludes persons aged 65 and older and those in the Armed Forces. Estimates reflect an adjustment for the misreporting of coverage on the ACS. * Indicates change in percent of people is statistically significant (at the 95% confidence level). # Indicates change in percent of people is statistically significant (at the 90% confidence level) a Indicates change in numbers of people is statistically significant (at the 95% confidence level). b Indicates change in numbers of people is statistically significant (at the 90% confidence level). Health Insurance Coverage in 2013: Gains in Public Coverage Continue to Offset Loss of Private Insurance 20 47.3 17.9% 45.4 16.9% -0.9% -2.0a Alabama 0.7 17.3% 0.7 16.4% -0.8% 0.0a Alaska 0.1 19.3% 0.1 20.5% 1.2% 0.0 Arizona 1.1 19.7% 1.1 20.6% 0.9% 0.1a Arkansas 0.5 20.2% 0.5 19.0% -1.2% 0.0b California 6.8 21.0% 6.5 19.7% -1.3% -0.3a Colorado 0.8 18.0% 0.7 16.1% -1.9% -0.1a Connecticut 0.3 10.5% 0.3 11.0% 0.5% 0.0 Delaware 0.1 11.8% 0.1 11.8% 0.0% 0.0 DC 0.0 9.1% 0.0 7.7% -1.3% 0.0 Florida 3.9 25.7% 3.9 24.6% -1.1% -0.1b Georgia 1.9 22.0% 1.8 21.2% -0.8% 0.0 Hawaii 0.1 8.9% 0.1 8.6% -0.3% 0.0 Idaho 0.3 20.7% 0.3 18.9% -1.8% 0.0b Illinois 1.8 15.8% 1.6 14.5% -1.3% -0.2a Indiana 0.9 16.9% 0.9 16.1% -0.8% 0.0a Iowa 0.3 11.0% 0.3 10.5% -0.4% 0.0 Kansas 0.4 15.8% 0.4 14.6% -1.3% 0.0a Kentucky 0.7 17.7% 0.6 17.0% -0.7% 0.0 Louisiana 0.8 20.3% 0.8 19.4% -1.0% 0.0b Maine 0.1 12.8% 0.1 13.6% 0.8% 0.0 Maryland 0.7 13.0% 0.6 11.8% -1.2% -0.1a Massachusetts 0.3 5.4% 0.3 4.8% -0.6% 0.0a Michigan 1.2 14.6% 1.1 13.2% -1.4% -0.1a Minnesota 0.5 10.3% 0.5 9.7% -0.5% 0.0 Mississippi 0.5 20.8% 0.5 19.7% -1.1% 0.0a Missouri 0.8 15.4% 0.8 15.4% 0.1% 0.0 Montana 0.2 20.3% 0.2 20.0% -0.3% 0.0 Nebraska 0.2 13.8% 0.2 12.4% -1.4% 0.0a Nevada 0.6 25.5% 0.6 23.5% -2.0% 0.0a New Hampshire 0.1 12.6% 0.1 12.6% 0.0% 0.0 New Jersey 1.1 15.2% 1.2 15.5% 0.3% 0.0 New Mexico 0.4 23.1% 0.4 22.5% -0.6% 0.0 New York 2.3 13.8% 2.1 12.7% -1.1% -0.2a North Carolina 1.6 19.4% 1.5 18.4% -1.0% -0.1a North Dakota 0.1 11.9% 0.1 12.3% 0.3% 0.0 Ohio 1.4 14.1% 1.3 12.9% -1.3% -0.1a Oklahoma 0.7 21.9% 0.7 20.3% -1.5% 0.0a Oregon 0.7 20.1% 0.6 17.8% -2.3% -0.1a Pennsylvania 1.3 12.2% 1.2 11.7% -0.5% -0.1a Rhode Island 0.1 14.1% 0.1 14.1% 0.0% 0.0 South Carolina 0.8 20.4% 0.7 18.6% -1.8% -0.1a South Dakota 0.1 14.0% 0.1 14.7% 0.6% 0.0 Tennessee 0.9 16.7% 0.9 16.4% -0.3% 0.0 Texas 5.8 26.3% 5.7 24.5% -1.7% -0.2a Utah 0.4 17.1% 0.4 14.9% -2.2% 0.0a Health Insurance Coverage in 2013: Gains in Public Coverage Continue to Offset Loss of Private Insurance 21 Vermont 0.0 9.4% 0.0 8.3% -1.1% 0.0 Virginia 1.0 14.6% 1.0 14.3% -0.3% 0.0 Washington 0.9 16.3% 1.0 16.5% 0.2% 0.0 West Virginia 0.3 17.3% 0.2 16.3% -0.9% 0.0b Wisconsin 0.5 11.2% 0.5 10.8% -0.4% 0.0 Wyoming 0.1 16.7% 0.1 15.2% -1.6% 0.0 Source: Analysis of the Urban Institute's Health Policy Center's American Community Survey (ACS) Medicaid/CHIP Simulation Model based on data from the Integrated Public Use Microdata Series (IPUMS) from 2010 and 2013. Note: Excludes persons aged 65 and older and those in the Armed Forces. Estimates reflect an adjustment for the misreporting of coverage on the ACS. * Indicates change in percent of people is statistically significant (at the 95% confidence level). # Indicates change in percent of people is statistically significant (at the 90% confidence level) a Indicates change in numbers of people is statistically significant (at the 95% confidence level). b Indicates change in numbers of people is statistically significant (at the 90% confidence level). Health Insurance Coverage in 2013: Gains in Public Coverage Continue to Offset Loss of Private Insurance 22 140.4 133.1 -7.3a 138.0 4.8a Employer 72.4% 70.8% -1.6% -7.5a 70.2% -0.6% * 2.6a Medicaid and State 4.3% 4.9% 0.6% 0.5a 5.5% 0.6%* 1.1a CHAMPUS/Medicare 1.3% 1.5% 0.1% 0.1a 1.6% 0.2%* 0.3a Private Non-group 4.8% 4.7% -0.1% -0.4a 4.8% 0.1%# 0.3a Uninsured 17.2% 18.1% 0.9% 0.0 17.9% -0.2%* 0.6a a a 50.2 47.3 -2.9 48.0 0.7 Employer 84.9% 84.1% -0.8% -2.8a 83.2% -0.8%* 0.2 Medicaid and State 2.2% 2.5% 0.3% 0.1a 2.8% 0.3%* 0.2a CHAMPUS/Medicare 1.2% 1.5% 0.3% 0.1a 1.7% 0.2%* 0.1a Private Non-group 3.1% 3.1% 0.0% -0.1a 3.2% 0.1%* 0.1a Uninsured 8.6% 8.9% 0.3% -0.1a 9.1% 0.2%* 0.2a 90.2 85.8 -4.4a 90.0 4.2a Employer 65.5% 63.5% -2.0% -4.6a 63.2% -0.2%# 2.4a Medicaid and State 5.4% 6.2% 0.8% 0.5a 6.9% 0.7%* 0.9a CHAMPUS/Medicare 1.5% 1.5% 0.0% 0.0b 1.6% 0.1%* 0.2a Private Non-group 5.7% 5.6% -0.1% -0.3a 5.6% 0.0% 0.2a Uninsured 22.0% 23.2% 1.3% 0.1 22.6% -0.6%* 0.4a Source: Analysis of the Urban Institute's Health Policy Center's American Community Survey (ACS) Medicaid/CHIP Simulation Model based on data from the Integrated Public Use Microdata Series (IPUMS) from 2010 and 2013. Note: Excludes persons aged 65 and older and those in the Armed Forces. Estimates reflect an adjustment for the misreporting of coverage on the ACS. * Indicates change in percent of people is statistically significant (at the 95% confidence level). # Indicates change in percent of people is statistically significant (at the 90% confidence level) a Indicates change in numbers of people is statistically significant (at the 95% confidence level). b Indicates change in numbers of people is statistically significant (at the 90% confidence level). Health Insurance Coverage in 2013: Gains in Public Coverage Continue to Offset Loss of Private Insurance 23 1Blavin, F., Holahan, J., Kenney, G., and Chen, V. 2013. A Decade of Coverage Losses: Implications for the Affordable Care Act. The Urban Institute. Available at: http://www.urban.org/UploadedPDF/412514-Implications-for-the-Affordable-Care-Act.pdf. 2Holahan, J. and McGrath, M. 2014. As the Economy Improves, the Number of Uninsured is Falling but not because of a Rebound in Employer Sponsored Insurance. Kaiser Family Foundation. Available at: http://kff.org/uninsured/issue-brief/as-the-economy- improves-the-number-of-uninsured-is-falling-but-not-because-of-a-rebound-in-employer-sponsored-insurance/ ; Holahan, J. and McGrath, M. 2013. Reversing the Trend? Understanding the Recent Increase in Health Insurance Coverage among the Nonelderly Population. Kaiser Family Foundation. Available at: http://kff.org/uninsured/issue-brief/reversing-the-trend-understanding-the- recent-increase-in-health-insurance-coverage-among-the-nonelderly-population/; and Holahan, J. and Chen, V. 2011. Changes in Health Insurance Coverage in the Great Recession, 2007-2010. Kaiser Family Foundation. Available at: http://kff.org/medicaid/issue- brief/changes-in-health-insurance-coverage-in-the/. 3 O’Hara, B. and Medalia, C. 2014. CPS and ACS Health Insurance Estimates: Consistent Trends from 2009-2012. SEHSD Working Paper 2014-29. Available at: https://www.census.gov/hhes/www/hlthins/data/incpovhlth/2013/CPS_ACS_Trends.pdf 4United States Census Bureau. Fact Sheet – Differences Between CPS ASEC and ACS. Available at: https://www.census.gov/hhes/www/poverty/about/datasources/factsheet.html. 5The HIU is a unit of analysis for determining family income that more accurately reflects eligibility for public assistance than does analysis at the household level. The HIU includes members of a family who can be covered under one health insurance policy, such as the policyholder, spouse, children under age 19, and full-time students under age 23. The household, by contrast, may include other relatives or unrelated individuals. 6Steven Ruggles, J. Trent Alexander, Katie Genadek, Ronald Goeken, Matthew B. Schroeder, and Matthew Sobek. Integrated Public Use Microdata Series: Version 5.0 [Machine-readable database]. Minneapolis: University of Minnesota, 2010. Further information on the creation of the ACS iPUMS files is available at: www.ipums.org. 7 For further details, see Lynch, V. Kenney, G.M., Haley, J., and Resnick, D. 2011. Improving the Validity of the Medicaid/CHIP Estimates on the American Community Survey: The Role of Logical Coverage Edits. Report to the U.S. Census Bureau. Available at: http://www.census.gov/hhes/www/hlthins/publications/Improving%20the%20 Validity%20of%20the%20Medicaid- CHIP%20Estimates%20on%20the%20ACS.pdf 8Ibid and Haley, J.M., Lynch, V., and Kenney, G.M. 2014. The Urban Institute Health Policy Center’s Medicaid/CHIP Eligibility Simulation Model. The Urban Institute. Available at: http://www.urban.org/publications/413069. 9 Ibid 10 Bureau of Labor Statistics. “Labor Force Statistics from the Current Population Survey.” March 19, 2015. Available at: http://data.bls.gov/timeseries/LNS14000000. The public use file of the American Community Survey does not include a postmark or interview date, so it is not possible to 11 determine whether the 200,000 additional young adults with private non-group coverage enrolled before or after October 2013. 12While 2007 may provide a better pre-recession measure, the ACS did not begin asking about health insurance until the 2008 survey year. Official recession dates from National Bureau of Economic Research. 13 Given the relative stability of and limited eligibility for military and Medicare coverage among the nonelderly population, this coverage is not shown throughout this brief. 14 This coverage type includes Medicaid, CHIP, and other state coverage programs for those with low incomes or a disability. Sommers, B.D, Kenney, G.M., and Epstein, A.M. 2014. “New Evidence on the Affordable Care Act: Coverage Impacts of Early 15 Medicaid Expanions.” Health Affairs 33(1): 78-87. 16 Sommers, B.D., Buchmueller, T., Decker, S.L., Carey, C., and Kronick, R. 2013. The Affordable Care Act Has Led to Significant Gains in Health Insurance and Access to Care for Young Adults. Health Affairs 32(1): 165-174. 17 The other group includes Asians, Pacific Islanders, American Indians, Alaska Natives, and anyone reporting two or more races. 18High ESI industries are those with ESI coverage rates of more than 80 percent in 2012 and consist primarily of finance, manufacturing, information and communications firms. Low ESI industries had ESI coverage rates of less than 80 percent in 2012 and consist primarily of agriculture, construction, and wholesale and retail trade. The Henry J. Kaiser Family Foundation Headquarters: 2400 Sand Hill Road, Menlo Park, CA 94025 | Phone 650-854-9400 Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 | Phone 202-347-5270 www.kff.org | Email Alerts: kff.org/email | facebook.com/KaiserFamilyFoundation | twitter.com/KaiserFamFound Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.