Characteristics of Uninsured Low-Income Adults in States Expanding vs Not Expanding Medicaid

When the Supreme Court ruled that under the Patient Protection and Affordable Care Act, states could not be compelled to expand Medicaid,¹ it opened an unusual divide for public insurance coverage in the United States. Starting January 1, 2014, adults 19 to 64 years with family income up to 138% of the federal poverty line (133% plus a 5% income disregard) became eligible for Medicaid in 25 states and the District of Columbia (expansion states). In the remaining 25 states (nonexpansion states), while adults with incomes between 100% and 138% of the federal poverty line qualify for subsidized insurance coverage through the new marketplaces, those with income below the poverty line will not qualify and therefore are likely to remain uninsured. Previous estimates indicate that more uninsured adults who could have been made Medicaid eligible live in nonexpansion states (8.5 million) than in expansion states (6.6 million).²

We studied the characteristics of low-income (income no more than 138% of the poverty line) citizens aged 19 to 64 years in expansion and nonexpansion states before the 2014 expansion. We included noncitizens who have been in the United States at least 5 years since some may also be Medicaid eligible.³ We used data from the National Health Interview Survey, 2010–2012,⁴ the conduct of which was approved by the ethics review board of the National Center for Health Statistics. To describe possible health care needs of low-income adults in the 2 groups of states, we compared several measures of health status and the use of and access to health care reported by respondents to the National Health Interview Survey. Analyses were weighted to the civilian noninstitutionalized population, and SEs accounted for the complex design of the survey (Stata version 12; StataCorp LP). We used t tests (dichotomous variables) and the χ² test (categorical variables) to infer statistical significance of differences between groups.

Around 46.0% (95% CI, 44.6%–47.3%) of low-income adults were uninsured in nonexpansion states compared with 37.3% (95% CI, 36.0%–38.6%) in expansion states (P < .001) (Table 1). In nonexpansion states, the low-income uninsured were more likely to have delayed or not received health care in the past year due to cost than were the low-income uninsured in expansion states. The low-income uninsured in nonexpansion states were more likely to have had an emergency department visit in the past year (27.6%; 95% CI, 25.8%–29.4%) compared with those in expansion states (20.9%; 95% CI, 19.0%−22.8%; P < .001). The low-income uninsured in nonexpansion states were also more likely to smoke, to be in fair or poor health, and to have several health conditions (Table 2) than those in expansion states. For example, 22.4% (95% CI, 20.6%–24.2%) in nonexpansion states had diagnosed hypertension compared with 16.8% (95% CI, 15.1%–18.6%) in expansion states.

Table 1.

Low-Income Uninsured and Characteristics of the Low-Income Uninsured Aged 19 to 64 Years: NHIS, 2010 Through 2012^a

Characteristic	% (95% Cl)			P Value for Comparing States
	All	States
		Nonexpansion	Expansion
Uninsured	41.9 (40.9–42.8)	46.0 (44.6–47.3)	37.3 (36.0–38.6)	<.001
Characteristics of the uninsured
Male sex	52.6(51.9–53.3)	50.7 (49.8–51.7)	55.2 (54.2–56.2)	<.001
Race/ethnicityb
Non-Hispanic white	40.2 (38.6–41.8)	43.6 (41.3–45.8)	35.6 (33.4–37.8)	<.001
Non-Hispanic black	17.7 (16.6–18.8)	22.1 (20.5–23.7)	11.8 (10.5–13.1)	<.001
Hispanic	36.2 (34.5–37.9)	30.0 (27.5–31.9)	45.0 (42.6–47.5)	<.001
Non-Hispanic other race	5.9 (5.1–6.7)	4.6 (3.6–5.7)	7.6 (6.3–8.8)	<.001
Use of and access to health care services
Delayed care in the past year due to cost	31.9 (31.0–32.9)	32.8 (31.5–34.0)	30.8 (29.5–32.1)	.03
Did not get care in the past year due to cost	30.0 (29.6–32.1)	30.5 (29.2–31.7)	28.3 (26.8–29.8)	.03
Has a usual source of care other than an emergency department	54.2 (52.6–55.9)	53.7 (51.4–55.9)	55.0 (52.8–57.3)	.39
At least 1 physician visit in the past year	50.9 (49.4–52.4)	51.4(49.4–53.5)	50.2 (48.1–52.3)	.40
At least 1 emergency department visit in the past year	24.7 (23.4–26.1)	27.6 (25.8–29.4)	20.9 (19.0–22.8)	<.001

^aThe analysis sample is limited to adults with family income no more than 138% of the federal poverty line using the Census Bureau’s definition of family as all related persons in the household. The substance of the results is unchanged if we use a narrower definition of family that seeks to replicate the family unit that is more common for health insurance coverage. There are 42 102 observations in the analysis sample for the first row and 18 789 for subsequent rows through “Did not get care in the past year due to cost.” Subsequent rows have a sample size of 7785 adults since these variables come from the National Health Interview Survey (NHIS) sample adult file, where only 1 adult per household was surveyed. Some rows may have fewer observations due to missing values.

^bThe χ² test for equality of the race/ethnicity distribution between the 2 groups of states (expansion vs nonexpansion states) is χ² = 127, P < .001.

Table 2.

Measures of Health Status and Risk Factors Among the Low-Income Uninsured Aged 19 to 64 Years: NHIS, 2010 Through 2012^a

Characteristic	% (95% Cl)			P Value for Comparing States
	All	States
		Nonexpansion	Expansion
Fair or poor health status	17.4 (16.7–18.2)	18.7 (17.7–19.7)	15.7 (14.7–16.7)	<.001
Ever had any of the following health conditions
Hypertension	20.0 (18.8–21.3)	22.4 (20.6–24.2)	16.8 (15.1–18.6)	<.001
Heart condition	6.4 (5.7–7.2)	7.3 (6.3–8.2)	5.4 (4.4–6.3)	.008
Diabetes mellitus	5.7 (5.1–6.4)	6.1 (5.1–7.0)	5.2 (4.3–6.2)	.22
Cancer	2.5 (2.1–3.0)	3.1 (2.4–3.8)	1.8 (1.2–2.4)	.006
Stroke	1.6 (1.3–2.0)	2.0 (1.5–2.5)	1.1 (0.7–1.6)	.01
Emphysema	1.1 (0.9–1.4)	1.5 (1.1–1.9)	0.6 (0.3–0.8)	<.001
Any of the above	26.7 (25.3–28.2)	29.4 (27.4–31.4)	23.1 (21.0–25.2)	<.001
Risk factors
Smoker	32.5 (30.9–34.1)	36.5 (34.4–38.7)	27.1 (24.7–29.4)	<.001
Obese	35.2 (33.8–36.6)	35.8 (34.0–37.6)	34.4 (32.3–36.5)	.30

^aThe analysis sample is limited to adults with family income no more than 138% of the federal poverty line using the Census Bureau’s definition of family as all related persons in the household. The substance of the results is unchanged if we use a narrower definition of family that seeks to replicate the family unit that is more common for health insurance coverage. The sample size is 18 789 adults for “fair or poor health status.” Subsequent rows have a sample size of 7785 adults since these variables come from the National Health Interview Survey (NHIS) sample adult file, where only 1 adult per household was surveyed. Some rows may have fewer observations due to missing values. “Heart condition” refers to ever having had coronary heart disease, angina, myocardial infarction, or any other heart disease.

This analysis suggests that low-income adults in nonexpansion states could have more to gain from a Medicaid expansion than those in expansion states. However, these adults will not receive any direct benefit from the expansion unless their state decides to expand Medicaid. Although the expansion would be financed by the federal government from 2014 through2016,¹state policy makers are concerned about the costs when their contribution increases to 10% in years after 2016 if they choose to maintain the expansion. To the extent that the Medicaid expansion is successful at increasing health insurance coverage and access to care for low-income adults in expansion states, disparities between expansion and nonexpansion states in access to care and in the financial burden of paying for health care (for patients and providers providing charity care to uninsured patients) could widen in the coming years.