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Nearly 80% of Uninsured Population in Super Tuesday States Are Eligible for Assistance

Summary

New Avalere analysis finds that 76% of uninsured individuals lawfully present in the 14 Super Tuesday states are currently eligible for Medicaid, the Children’s Health Insurance Program (CHIP), or exchange plan subsidies.

Background

In 2020, an estimated 30M individuals remain uninsured nationally, including 13M in states with Super Tuesday primaries. While some of the uninsured in these states may be a result of decisions not to expand Medicaid or individuals choosing not to buy insurance, more than three-quarters are eligible for help affording their coverage.

Many Democratic candidate proposals would expand public programs, such as a public option or single payer. Based on Avalere’s analysis, reforms that target the affordability and availability of current insurance options may be able to reduce the number of uninsured without fundamental changes to existing programs.

“Democratic presidential candidates are proposing a range of policies with a wide spectrum of potential impacts on the uninsured,” said Chris Sloan, associate principal at Avalere. “The data underscore that even if programs exist to provide access to insurance, there is no guarantee that eligible people will enroll. People may still find coverage unaffordable or decide insurance is not worth the cost.”

Figure 1. Composition of Lawfully Present Uninsured, Super Tuesday States, 2020
Figure 1. Composition of Lawfully Present Uninsured, Super Tuesday States, 2020

Uninsured Eligibility Group Detail

In Super Tuesday states, the uninsured rate ranges from 3% in VT to 18% in TX. Coverage for the uninsured population—including those who are eligible for Medicaid, CHIP, or an Affordable Care Act (ACA) exchange market subsidy, or in the Medicaid coverage gap in non-expansion states—could be increased today through higher enrollment of eligible people in existing programs.

  • Currently Eligible for Medicaid or CHIP: In addition to low-income children, pregnant women, and elderly individuals, adults earning up to 138% of the federal poverty limit (FPL) may also be eligible for Medicaid in the 9 Super Tuesday states that have expanded under the ACA. In Super Tuesday states, those eligible for Medicaid and CHIP range from 18% of uninsured in TX to 80% in VT. Barriers to Medicaid enrollment for the eligible uninsured population may include a lack of education on how to enroll or other access limitations (e.g., geography, transportation, internet access).
  • Currently Eligible for Subsidized ACA Exchange Coverage: Individuals earning between 138% and 400% FPL in Medicaid expansion states and between 100% and 400% in non-expansion states may be eligible for subsidized coverage in ACA exchange plans. With current subsidies, individuals earning 300% FPL may still have to pay up to 9.78% of their income, or $3,744 per year, for the second-lowest cost silver plan—and 16% to 62% of the uninsured population are eligible for subsidized ACA coverage in VT and CA, respectively.
  • Living in Non-Medicaid Expansion State and Income Below 100% FPL, Ineligible for Subsidized Coverage: To date, 5 of the Super Tuesday states have not expanded Medicaid. As a result, individuals living in non-expansion states with incomes below 100% FPL may be ineligible for subsidized coverage—making up 3% to 18% of the uninsured population in NC and AL, respectively.
  • Income Above 400% FPL, Ineligible for Subsidized Coverage: Individuals earning more than 400% of the FPL who are not eligible for exchange subsidies or Medicaid make up 7% of the uninsured in TN to 28% in VA. Lack of enrollment in this group may result from affordability issues (both monthly premiums and out-of-pocket costs) and behavioral determinants (e.g., “young invincibles”).

“The data provide a roadmap for candidates and policymakers looking to design targeted reforms,” said Elizabeth Carpenter, head of advisory services at Avalere. “Providing additional incentives for states to expand Medicaid, optimizing exchange subsidies to make coverage affordable for higher-income individuals, and enhancing Medicaid outreach and enrollment efforts, could move the needle on the uninsured.”

Table 1. Percent of Lawfully Present Uninsured Population by Coverage Eligibility Group, Super Tuesday States, 2020
State Percent Uninsured Eligible for Medicaid or CHIP Living in Non-Medicaid Expansion State and Income Below 100% FPL, Ineligible for Subsidized Coverage Eligible for Subsidized ACA Exchange Coverage Income Above 400% FPL, Ineligible for Subsidized Coverage
AL* 11% 15% 18% 53% 14%
AR 8% 57% 0% 33% 10%
CA 7% 22% 0% 62% 16%
CO 7% 23% 0% 56% 21%
MA 2% 26% 0% 50% 24%
ME 8% 52% 0% 34% 13%
MN 4% 46% 0% 41% 12%
NC* 11% 27% 3% 49% 21%
OK* 11% 18% 15% 53% 14%
TN* 10% 24% 8% 62% 7%
TX* 18% 18% 14% 53% 14%
UT 8% 31% 0% 51% 18%
VA 7% 24% 0% 48% 28%
VT 3% 80% 0% 16% 5%

Note: Avalere analysis does not account for individuals not lawfully present in the US, including non-citizens who are ineligible for marketplace subsidies and for most Medicaid benefits. States marked with an asterisk did not participate in the Medicaid expansion.

Methodology

To conduct the analysis, Avalere estimated the number of uninsured by state using the American Community Survey 2017 1-year sample and health insurance coverage in the United States in 2020 from the proprietary Avalere All-Payer Enrollment Model. To determine the total number and growth rate of the uninsured from 2017 to 2020, Avalere used the Congressional Budget Office reports on Federal Subsidies for Health Insurance Coverage for People Under Age 65: 2018 to 2028 and 2019 to 2029. Avalere analyzed eligibility for Medicaid and CHIP using state-reported Medicaid expansion decisions, as well as pre-ACA expansion Medicaid eligibility levels as a percent of FPL, including eligibility for Temporary Assistance for Needy Families. Avalere also determined eligibility for subsidized ACA exchange plan coverage using state-reported income levels to qualify for premium tax credits or cost sharing reductions. The analysis excludes children from eligibility for subsidized ACA exchange plan coverage and assumes eligibility for Medicaid or CHIP as the primary potential payer.

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