AARP Public Policy Institute INSIGHT on the Issues Monitoring the Impact of Health Reform on Americans 50–64: Medicaid Expansion and Marketplace Implementation Increased Health Coverage Adam L. Weiss, Timothy A. Waidmann, and Kyle J. Caswell Urban Institute A survey conducted by the Urban Institute and AARP shows that the share of 50- to 64-year-olds without health insurance fell between December 2013 and March 2014. In states that expanded their Medicaid programs, a greater share of previously uninsured adults gained coverage, particularly among groups that have traditionally faced barriers to obtaining it. The survey also found that the newly insured differed in key ways from those who reported being insured for all of the past 12 months. On average, more were low income, and more reported that they had had trouble paying medical bills. This paper is part of a series that looks at the experience of 50- to 64-year-olds during the first open enrollment period of the Affordable Care Act (ACA). ACA Health Coverage Goals affordable for the 50- to 64-year-old Address Unique Needs of population through a number of changes Americans Ages 50–64 designed to expand coverage. Those changes include (a) guaranteeing that Health insurance access is a common individuals will have access to private concern for Americans ages 50 to 64, a insurance regardless of their medical population that has a high need for medi- history; (b) banning the use of health cal care but that has traditionally faced status in setting insurance rates; (c) lim- difficulties obtaining coverage. Those iting the amount that insurers can charge without coverage from an employer have older people relative to the amount they often faced barriers, including (a) limited can charge younger people; (d) extend- access to public insurance for poor adults ing the availability of Medicaid to poor, without children and (b) difficulty buying childless adults; and (e) subsidizing comprehensive coverage in the private the cost of private nongroup coverage health insurance market because of pre- bought through new health insurance existing conditions and cost. As a result, Marketplaces. coverage options for many Americans in that age bracket were limited to expen- This paper provides data on the effect of sive nongroup (individual) insurance, the ACA in the first few months of im- COBRA, high-risk pools, and plans that plementation (between December 2013 provided catastrophic coverage. and March 2014) and reports on changes in health insurance coverage among The Affordable Care Act (ACA) makes individuals ages 50 to 64. Data were col- health insurance more accessible and lected from the Urban Institute’s Health Monitoring the Impact of Health Reform on Americans 50–64: Medicaid Expansion and Marketplace Figure 1 Changes in the Uninsurance Rate for Select Groups among Adults 50–64 between December 2013 and March 2014 40.0% 40% 35% 32.7% 32.1% 30% 28.4% 24.9% 25% 22.0% 20% 15.2% 15% 12.7% 11.6% 10.3% 10% 5% 0 All adults Family income Unemployed Good, fair, Hispanic ages 50–64 at or below or poor health 138% of FPL Q4 2013 Q1 2014 Source: HRMS-AARP, quarter 4 2013 and quarter 1 2014. Note: FPL = federal poverty level. Estimated changes from quarter 4 2013 to quarter 1 2014 differ significantly from zero at at least the 5 percent level, using a two-tailed test. Reform Monitoring Survey. This analy- declines varied across different groups. sis compares the coverage type reported The following are some highlights (also by survey respondents in the fourth see figure 1): quarter of 2013 (largely December 2013) ■■ For individuals with family incomes with that reported by survey respondents in the first quarter of 2014 (largely dur- at or below the Medicaid expansion ing the first three weeks of March 2014). threshold of 138 percent of the More information about the Health federal poverty level (FPL), the share Reform Monitoring Survey is presented without insurance fell from 32.7 per­ in the box at the end of this paper. cent to 28.4 percent. (For those at or above 400 percent of poverty level, it Uninsurance Rates Fell among dropped from 2.2 percent to 1.4 per­ 50- to 64-Year-Olds in the First cent.) Months of 2014 ■■ The share of uninsured among the unemployed1 fell from 40.0 percent In December 2013, 11.6 percent of all to 32.1 percent. adults ages 50 to 64 reported being un- insured. Between December 2013 and ■■ Among individuals reporting March 2014, that rate fell to 10.3 per- worse health (“poor,” “fair,” or cent. Some groups within the 50–64 pop- “good” as opposed to “very good” ulation experienced more pronounced or “excellent”), the share of unin­ declines in the percentage without insur- sured fell from 15.2 percent to ance. Table 1 in the appendix shows how 12.7 percent. 2 Monitoring the Impact of Health Reform on Americans 50–64: Medicaid Expansion and Marketplace Figure 2 Changes in the Uninsurance Rate between December 2013 and March 2014 in Medicaid Expansion States 34.8% 35% 29.6% 30% 24.4% 25% 20.7% 20% 18.2% 15% 13.7% 11.8% 9.9% 7.7% 9.0% 10% 8.1% 5.4% 5% 0 All adults Family income Unemployed Good, fair, Had trouble White, ages 50–64 at or below or poor health paying medical non-Hispanic 138% of FPL bills in past 12 months December 2013 March 2014 Source: HRMS-AARP, quarter 4 2013 and quarter 1 2014. Note: FPL = federal poverty level. Estimated changes from quarter 4 2013 to quarter 1 2014 differ significantly from zero at at least the 5 percent level, using a two-tailed test. ■■ The share of Hispanics without Expansion States health insurance fell from 24.9 per­ The following are findings from states cent to 22.0 percent. that expanded Medicaid: State Medicaid Expansion ■■ Among all adults ages 50 to 64 Boosted Coverage Gains2 in Medicaid expansion states, the percentage of those without health Survey data show pronounced differ- insurance fell from 9.9 percent to ences between states that chose to ex- 7.7 percent, and the public coverage pand their Medicaid programs under the rate increased from 16.1 percent to ACA and those that did not (appendix 18.4 percent. tables 2 and 3). The percentage of un- ■■ Among individuals with family insured adults in Medicaid expansion incomes within the Medicaid states declined, while the percentage expansion threshold, the percentage with public coverage3 increased, espe- of uninsured fell from 29.6 percent to cially among groups that experience 20.7 percent, and the percentage of those with public coverage increased barriers to coverage (figures 2 and 3). from 54.1 percent to 64.4 percent. States that did not expand Medicaid There were no statistically significant showed more limited declines in the changes in the rates of uninsurance percentage of uninsured and no gains in and public insurance among 50- to public coverage. 64-year-olds with higher incomes. 3 Monitoring the Impact of Health Reform on Americans 50–64: Medicaid Expansion and Marketplace Figure 3 Changes in the Public Insurance Rate between December 2013 and March 2014 in Medicaid Expansion States 70% 64.4% 60% 54.1% 50% 38.2% 40% 32.6% 30% 18.4% 20% 16.1% 17.2% 16.1% 14.9% 14.1% 14.5% 12.0% 10% 0 All adults Family income Not working, Retired Didn’t have White, ages 50–64 at or below any reason trouble paying non-Hispanic 138% of FPL medical bills in past 12 months December 2013 March 2014 Source: HRMS-AARP, quarter 4 2013 and quarter 1 2014. Note: FPL = federal poverty level. Estimated changes from quarter 4 2013 to quarter 1 2014 differ significantly from zero at at least the 5 percent level, using a two-tailed test. Public insurance includes Medicaid, medical assistance, CHIP, any kind of state or other government-sponsored assistance plan based on income or disability, or Medicare. ■■ Among individuals who were paying medical bills in the past unemployed, the percentage of 12 months dropped from 18.2 per­ uninsured fell from 34.8 percent cent to 11.8 percent. Individuals to 24.4 percent. Among working who did not report problems paying individuals, the percentage of medical bills in the past 12 months uninsured declined from 8.1 percent experienced a smaller decline in the to 6.6 percent. The percentage of percentage without insurance. those groups with public coverage ■■ Among rose, but those increases were not white, non-Hispanic statistically significant. The increase individuals, the percentage of those in public coverage was significant without health insurance declined among nonworkers collectively and from 8.1 percent to 5.4 percent, and among retirees.. the percentage with public coverage rose from 12.0 to 14.5 percent. ■■ The percentage of individuals who were without insurance and who Nonexpansion States reported worse health (“poor,” “fair,” While the public insurance rate among or “good”) fell from 13.7 percent to adults with family incomes within the 9.0 percent. Medicaid threshold rose in expansion ■■ The uninsured rate among states, there was no statistically signifi- individuals who reported problems cant change in the public insurance rate 4 Monitoring the Impact of Health Reform on Americans 50–64: Medicaid Expansion and Marketplace Figure 4 Changes in the Public Insurance Rate between December 2013 and March 2014 among Adults 50–64 at or below 138% of FPL in Expansion vs. Nonexpansion States 70% 64.4% 60% 54.1% 48.5% 50% 46.8% 40% 30% 20% 10% 0 Expansion states Nonexpansion states December 2013 March 2014 Source: HRMS-AARP, quarter 4 2013 and quarter 1 2014. Note: FPL = federal povertly level. Estimated changes from quarter 4 2013 to quarter 1 2014 differ significantly from zero at at least the 5 percent level, using a two-tailed test. Estimated change in the nonexpansion states does not differ significantly. among the same group in states that did dividual’s health coverage for the past not expand Medicaid (figure 4). 12 months, thereby providing a longi- tudinal look at coverage during ACA Unlike expansion states, states that did implementation. not expand Medicaid did not experience a statistically significant change in the Those data reveal socioeconomic, percentage of all adults ages 50–64 who demographic, and health care charac- were uninsured.4 The significant changes teristics of the newly insured and con- in the share of uninsured adults observed tinuously insured. Respondents who in nonexpansion states occurred among reported being newly insured in March those with high family incomes, among 2014—that is, being uninsured for some Hispanics, and among those who did not period of time in the past 12 months have trouble paying medical bills. and immediately prior to obtaining Newly Insured Are More Likely to their current coverage—differed in key Be Lower Income, Unemployed ways from those who reported being insured for all of the past 12 months In addition to observing changes in (figure 5). Compared with those who coverage between the December 2013 were continuously insured, the newly and March 2014 survey samples, the insured, on average, have the following survey included questions about an in- characteristics: 5 Monitoring the Impact of Health Reform on Americans 50–64: Medicaid Expansion and Marketplace Figure 5 Characteristics of the Newly Insured and Continuously Insured in March 2014 100% 85.5% 80% 65.6% 60% 51.3% 44.4% 47.0% 42.6% 40.0% 40% 25.3% 24.6% 20% 14.6% 0 Family income Working Excellent or Had trouble paying Nonwhite less than 400% of FPL very good health medical bills in the or Hispanic past 12 months Newly insured Continuously insured Source: HRMS-AARP, quarter 4 2013 and quarter 1 2014. Note: FPL = federal poverty level. “Newly insured” respondents are those that reported being uninsured for some period of time in the past 12 months and immediately prior to their current coverage. “Continuously insured” respondents are those that reported being insured for the past 12 months. Percentages may not add up to 100 percent due to rounding. Estimates for the newly insured differ significanly from those for the continuously insured from zero at at least the 5 percent level, using a two-tailed test. ■■ Lower income. Of the newly compared with 47.0 percent of the insured, 41.7 percent reported continuously insured. family incomes that are less than or ■■ More likely to report trouble paying equal to 138 percent of the federal medical bills in the past 12 months. poverty level (FPL), and 85.5 per­ Of the newly insured, 42.6 percent cent reported family incomes less reported trouble, compared with 14.6 than 400 percent of FPL. Only percent of the continuously insured. 12.6 percent of the continuously ■■ More likely to be ethnic or racial insured reported family incomes less than 138 percent of FPL, and minorities. Of the newly insured, 44.4 percent reported family incomes 40.1 percent are nonwhite or less than 400 percent of FPL. Hispanic, compared with 24.6 percent of the continuously insured. ■■ More likely to be unemployed or out of the labor force. Of the newly More Research Is to Come about insured, 51.3 percent worked, Americans Ages 50–64 compared with 65.6 percent of the continuously insured. Analysis of HRMS-AARP survey data suggests that the ACA decreased the ■■ In worse health. Of the newly percentage of uninsured persons ages insured, 25.3 percent reported being 50–64 nationally. Moreover, it appears in excellent or very good health, that state Medicaid expansion had a big 6 Monitoring the Impact of Health Reform on Americans 50–64: Medicaid Expansion and Marketplace effect on decreasing the share of 50- to Most recent findings have continued to 64-year-olds without health insurance, show increases in coverage for the popu- particularly among groups that may have lation as a whole, suggesting that adults had difficulty accessing insurance before ages 50 to 64 have had a similar experi- the ACA was passed. Other provisions ence (Long et al. 2014; Clemans-Cope et of the ACA, such as limiting variation in al. 2014). Additional research is needed premiums for age and guaranteeing that to assess the effect of coverage on this people with preexisting health conditions group, including the incidence of financial have access to insurance, have likely hardship from high medical spending, ac- also had an effect on coverage among cess to health care, and health outcomes. older adults. This work is based on the Health Reform Monitoring Survey’s oversample of individuals ages 50 to 64, which is referred to as the HRMS-AARP and was from December 2013 and March 2014. The Health Reform Monitoring Survey is a quarterly Internet survey of individuals ages 18 to 64 that is designed to produce rapid feedback on ACA implementation before the federal government’s survey data are available (Long et al. 2013). It was developed by the Urban Institute (hrms.urban.org); fielded by GfK (www. gfk.com); and jointly funded by the Robert Wood Johnson Foundation (www.rwjf.org), the Ford Foundation (www.fordfound.org), and the Urban Institute (www.urban.org). AARP funded the 50- to 64-year-old oversample, which is designed to produce nationally representative statistics of individuals ages 50 to 64. The December 2013 survey includes approximately 8,200 respondents, most of whom completed the survey in the first three weeks of December 2013. The March 2014 survey includes approximately 8,759 respondents, the majority of whom completed the survey in the first three weeks of March 2014. Because most responses to the first quarter survey were collected in the first three weeks of March, those data may not capture all nongroup and Medicaid expansion coverage obtained in the first Marketplace open enrollment period. For more information on the survey instrument, go to http://hrms.urban.org/survey-instrument/index.html. References Clemans-Cope, Lisa, Michael Karpman, Adam Weiss, and Nathaniel Anderson. 2014. “Increase in Medicaid under the ACA Reduces Uninsurance, According to Early Estimates.” Policy Briefs Series about Health Reform Monitoring Survey. Washington, DC: Urban Institute. http://hrms.urban.org/briefs/ Increase-in-Medicaid-under-the-ACA-reduces-uninsurance.html. Long, Sharon K., Genevieve M. Kenney, Stephen Zuckerman, Dana E. Goin, Douglas Wissoker, Fredric Blavin, Linda J. Blumberg, Lisa Clemans-Cope, John Holahan, and Katherine Hempstead. 2013. “The Health Reform Monitoring Survey: Addressing Data Gaps to Provide Timely Insights into the Affordable Care Act.” Health Affairs 3 (1): 161–67. Long, Sharon K., Genevieve M. Kenney, Stephen Zuckerman, Douglas Wissoker, Adele Shartzer, Michael Karpman, and Nathaniel Anderson. 2014. “Quicktake: Number of Uninsured Adults Continues to Fall under the ACA: Down by 8.0 Million in June 2014.” Policy Briefs Series about Health Reform Monitoring Survey. Washington, DC: Urban Institute. http://hrms.urban.org/quicktakes/Number-of- Uninsured-Adults-Continues-to-Fall.html. 7 Monitoring the Impact of Health Reform on Americans 50–64: Medicaid Expansion and Marketplace Endnotes 1 “Unemployed” individuals reported that they either were looking for work or were temporarily laid off. 2 States that expanded Medicaid before April 1, 2014, are AZ, AR, CA, CO, CT, DE, DC, HI, IL, IA, KY, MD, MA, MN, NV, NJ, NM, NY, ND, OH, OR, RI, VT, WA, and WV. 3 Public coverage includes Medicaid, medical assistance, CHIP, Medicare, and any kind of state or other government-sponsored assistance plan that was based on income or disability. 4 Statistically significant at the 5 percent level, using a two-tailed test. 8 Monitoring the Impact of Health Reform on Americans 50–64: Medicaid Expansion and Marketplace Appendix Table 1 Percentage-Point Change in the Uninsurance Rate for Adults 50–64 between December 2013 and March 2014 Q4 2013 Q1 2014 Percentage- (percent) (percent) point change All adults ages 50–64 11.6 10.3 –1.3** Family income At or below 138% of FPL 32.7 28.4 –4.3* 139–399% of FPL 13.6 13.0 –0.6 400% of FPL or higher 2.2 1.4 –0.7* Work status Working 10.1 9.2 –0.9* Employed 8.0 7.2 –0.8 Self-employed 23.1 21.3 –1.8 Not working, any reason 14.2 12.4 –1.7* Retired 8.4 6.4 –1.9* Disabled 6.5 4.8 –1.6 Unemployed 40.0 32.1 –7.9** Other 20.2 21.5 1.3 Health Excellent or very good health 7.7 7.1 –0.6 Good, fair, or poor health 15.2 12.7 –2.5** Financial trouble in past 12 months Had trouble paying medical bills 20.4 19.0 –1.4 Didn’t have trouble paying medical bills 9.4 8.2 –1.2** Race or ethnicity White, non-Hispanic 9.5 8.0 –1.5** Nonwhite, non-Hispanic 12.5 13.1 0.6 Hispanic 24.9 22.0 –2.9* Source: HRMS-AARP, quarter 4 2013 and quarter 1 2014. Note: Estimated change is significantly different from zero, using a two-tailed test. Significance level: * = 5 percent, ** = 1 percent. 9 Monitoring the Impact of Health Reform on Americans 50–64: Medicaid Expansion and Marketplace Table 2 Percentage-Point Change in the Uninsurance Rate between December 2013 and March 2014, by State Medicaid Expansion Status Expansion states Nonexpansion states Q4 2013 Q1 2014 Percentage- Q4 2013 Q1 2014 Percentage- (percent) (percent) point change (percent) (percent) point change All adults ages 50–64 9.9 7.7 –2.2** 13.5 13.1 –0.4 Family income At or below 138% of FPL 29.6 20.7 –8.9** 35.4 34.8 –0.5 139–399% of FPL 13.1 11.4 –1.7 14.1 14.4 0.4 400% of FPL or higher 1.9 1.4 –0.5 2.5 1.5 –1.0* Work status Working 8.1 6.6 –1.5** 12.3 12.0 –0.3 Employed 6.3 5.0 –1.4** 9.8 9.6 –0.2 Self-employed 18.6 16.6 –2.0 28.5 26.3 –2.2 Not working, any reason 13.0 9.8 –3.2** 15.3 15.0 –0.3 Retired 6.1 4.6 –1.5** 10.8 8.4 –2.4 Disabled 7.3 2.7 –4.6* 5.8 6.5 0.7 Unemployed 34.8 24.4 –10.5** 47.4 42.4 –5.0 Other 17.2 17.9 0.7 23.2 25.2 2.0 Health Excellent or very good health 6.2 5.9 –0.3 9.5 8.7 –0.8 Good, fair, or poor health 13.7 9.0 –4.6** 16.7 16.2 –0.5 Financial trouble in past 12 months Had trouble paying medical bills 18.2 11.8 –6.4** 22.2 24.5 2.3 Didn’t have trouble paying medical bills 8.0 6.7 –1.3* 10.9 9.8 –1.1* Race/ethnicity White, non-Hispanic 8.1 5.4 –2.8** 10.9 10.7 –0.2 Nonwhite, non- Hispanic 10.8 10.0 –0.8 14.0 15.7 1.7 Hispanic 20.0 19.1 –0.9 31.0 25.8 –5.1* Source: HRMS-AARP, quarter 4 2013 and quarter 1 2014. Note: Estimated change is significantly different from zero, using a two-tailed test. Significance level: * = 5 percent, ** = 1 percent. 10 Monitoring the Impact of Health Reform on Americans 50–64: Medicaid Expansion and Marketplace Table 3 Percentage-Point Change in the Public Insurance Rate between December 2013 and March 2014, by State Medicaid Expansion Status Expansion states Nonexpansion states Q4 2013 Q1 2014 Percentage- Q4 2013 Q1 2014 Percentage- (percent) (percent) point change (percent) (percent) point change All adults ages 50–64 16.1 18.4 2.3** 18.0 17.4 –0.6 Family income At or below 138% of FPL 54.1 64.4 10.3* 48.5 46.8 –1.7 139–399% of FPL 16.2 18.5 2.3 15.6 16.4 0.8 400% of FPL or higher 4.3 3.7 –0.6 5.7 4.0 –1.6 Work status Working 6.5 7.5 1.1 4.4 4.7 0.3 Employed 6.0 7.0 1.0 4.3 4.4 0.1 Self-employed 9.5 11.0 1.5 5.2 6.8 1.6 Not working, any reason 32.6 38.2 5.6** 39.2 38.5 –0.7 Retired 14.9 17.2 2.4* 20.8 18.1 –2.6 Disabled 79.3 85.4 6.2* 80.6 81.8 1.2 Unemployed 16.8 22.3 5.5 6.4 10.4 4.0 Other 18.0 23.4 5.4* 21.1 12.8 –8.3* Health Excellent or very good health 7.6 8.8 1.2 8.1 7.2 –0.9 Good, fair, or poor health 24.5 26.8 2.3 26.3 24.6 –1.7 Financial trouble in past 12 months Had trouble paying medical bills 25.7 31.0 5.3 28.7 24.9 –3.8 Didn’t have trouble paying medical bills 14.1 16.1 2.0* 15.1 15.5 0.3 Race/ethnicity White, non-Hispanic 12.0 14.5 2.5* 13.1 13.0 –0.1 Nonwhite, non- Hispanic 21.4 23.5 2.1 30.7 30.3 –0.4 Hispanic 35.0 35.5 0.6 30.2 25.0 –5.2 Source: HRMS-AARP, quarter 4 2013 and quarter 1 2014. Note: Estimated change is significantly different from zero, using a two-tailed test. Significance level: * = 5 percent, ** = 1 percent. 11 Monitoring the Impact of Health Reform on Americans 50–64: Medicaid Expansion and Marketplace Table 4 Characteristics of the Continuously Insured and Newly Insured in March 2014 Insured for all of past 12 months Newly insured (percent) (percent) INSIGHT on the Issues Income (% in each category) At or below 138% of FPL 12.6 41.7** 139–399% of FPL 31.8 43.9* 400% of FPL or higher 55.6 14.5** Work status (% in each category) Working 65.6 51.3** Employed 58.0 41.3** Self-employed 7.5 9.9 Not working, any reason 34.4 48.7** Retired 14.1 8.7** Disabled 11.9 14.3 Unemployed 3.1 16.1** Other 5.3 9.6* Health (% in each category) Excellent or very good health 47.0 25.3** Good, fair, or poor health 52.8 73.7** Financial trouble in past 12 months (% in each category) Had trouble paying medical bills 14.6 42.6** Didn’t have trouble paying medical bills 85.0 57.3** Race/ethnicity (% in each category) White, non-Hispanic 75.4 59.9** Nonwhite, non-Hispanic 16.4 21.6 Hispanic 8.2 18.4 Source: HRMS-AARP, quarter 1 2014. Note: Among respondents, 43 indicated they were insured but did not indicate either the number of months out of the past 12 month that they were insured or whether they were uninsured immediately prior to having their current coverage. Estimated change is significantly different from zero, using a two-tailed test. Significance level: * = 5 percent, ** = 1 percent. Insight on the Issues 95, December 2015 Written by Adam L. Weiss, Timothy A. Waidmann, and Kyle J. Caswell AARP Public Policy Institute 601 E Street, NW, Washington, DC 20049 www.aarp.org/ppi 202-434-3890, ppi@aarp.org © 2015, AARP. Reprinting with permission only. AARP Public Policy Institute 12