The Center's work on 'Insurance Coverage' Issues


3 Reasons Why Oklahoma Decision Is Wrong About Health Subsidies

October 1, 2014 at 1:14 pm

A central piece of health reform authorizes the federal government to provide tax credits to help low- and moderate-income people buy coverage in the new health insurance marketplaces.  A federal district court judge in Oklahoma ruled yesterday that the law only authorizes the tax credits in states that have set up their own exchanges, not in states with a federally operated exchange.  (Other federal courts have split on the issue, which may eventually reach the Supreme Court.)  But this argument rests on a distorted reading of the law.  As I’ve explained:

  1. Section 1321 of health reform (the Affordable Care Act or ACA) says that if a state does not establish its own exchange or won’t be ready to operate its exchange in 2014, “the Secretary shall (directly or through agreement with a not-for-profit entity) establish and operate such Exchange within the State” (emphasis added).   In other words, the federal government will essentially “stand in the shoes” of a state that elects not to operate an exchange by establishing and operating the exchange on the state’s behalf.  That’s what the federal government has done in Oklahoma and other states that chose not to create their own exchange.
  2. Section 36B of the Internal Revenue Code, which section 1401 of the ACA added to the Code, specifically refers to federal exchanges in requiring all exchanges — state and federally operated — to report to the federal government on the amount of advance payments of premium credits that taxpayers receive.  That provision would make no sense if people buying coverage through a federally operated exchange weren’t eligible for credits.
  3. To help residents of states with state-run exchanges buy coverage but not residents of other states would clearly conflict with the ACA’s purpose, which is to ensure that all Americans have a path to affordable coverage, regardless of where they live.  As Chief Justice John Roberts noted in referring to the ACA’s Medicaid expansion, the exchanges are “an element of a comprehensive national plan to provide universal health insurance coverage.”

5 Takeaways From Last Week’s Figures on Poverty, Inequality, and Health Coverage

September 25, 2014 at 12:32 pm

Here are five key findings from our analyses (here and here) and blog posts on the new figures from the Census Bureau and Centers for Disease Control and Prevention (CDC).

  1. While poverty and median income improved last year for families with children,poverty rates reached record highs for childless families and individuals.  The poverty rate for individuals not living in families (people living alone or only with non-relatives) rose to 23.3 percent in 2013, the highest in over 30 years.  The poverty rate for childless families (childless couples, older couples or other families whose children have moved away or turned 18, and other relatives who live together), while much lower at 6.2 percent, was also the highest in over three decades.
  1. Income inequality remained historically high.  The share of the nation’s income going to the bottom fifth of households remained at 3.2 percent, tied for the lowest level on record with data back to 1967.  The ratio of the median income of the top fifth of households to that of the bottom fifth topped 12 to 1 for the first time on record, with data back to 1967.
  1. Austerity policies limited progress on jobs, income, and poverty.  Instead of responding to continued weak job growth by creating jobs (such as by expanding infrastructure investments), policymakers adopted various austerity policies that constrained consumer spending and employment growth.  Sequestration budget cuts, for example, lowered appropriations for most discretionary programs by 5 to 8 percent in 2013.  Policymakers also allowed a payroll tax holiday to expire after December 2012 and allowed tax cuts for very high-income individuals to expire (though the latter mattered less for consumer demand since high-income people’s spending is less sensitive to tax changes).  The Congressional Budget Office projected in early 2013 that these measures would reduce economic growth over the year by about 1½ percentage points and lower employment by more than 1 million jobs.
  1. The uninsured rate fell slightly last year and is falling further in 2014, as health reform’s major coverage expansions take effect.  The share of Americans without health coverage fell from 14.8 percent to 14.5 percent in 2013, according to Census’ American Community Survey.  And preliminary data from CDC — the first government survey data that reflect the early impact of the coverage expansions (the Medicaid expansion and subsidized marketplace coverage) — show that the number of uninsured fell by 3.8 million in the first quarter of 2014.
  1. The coverage gap between states that have expanded Medicaid and states that haven’t is widening.  In 2013,before the expansion took effect, some 14.1 percent of the people in the 27 expansion states (including Washington, D.C.) were uninsured, compared to 17.3 percent in the 24 non-expansion states.  Figures for the first part of 2014 show the gap is widening.  For example, CDC data show that 15.7 percent of non-elderly adults in expansion states were uninsured in the first quarter of 2014, compared to 21.5 percent for non-expansion states (see graph).

Census Data Show Improved Health Coverage in 2013

September 22, 2014 at 4:36 pm

We’ve posted our full analysis of the Census Bureau’s new data on health coverage, which show that the share and number of Americans with health insurance improved slightly last year.  (Because the results are for 2013, they don’t reflect the coverage gains in 2014 resulting from health reform’s major coverage provisions, which took effect on January 1 — namely, the Medicaid expansion and subsidized marketplace coverage.)

Census published data from both its Current Population Survey (CPS) and American Community Survey (ACS).  Although the CPS is the most widely used source of health coverage information, changes in its health coverage questions in 2013 — the result of a multi-year Census initiative to improve the reliability and accuracy of the survey’s health coverage estimates — mean the 2013 results can’t be compared to those for prior years.  Thus, for comparisons with earlier years, the ACS is the preferred data source this year.

The Census figures from the ACS show:

  • The share of Americans without health coverage fell slightly, from 14.8 percent in 2012 to 14.5 percent in 2013 (see chart).  The number of uninsured Americans also declined slightly, from 45.6 million in 2012 to 45.2 million in 2013.
  • The share of the population with private coverage remained stable at 65.0 percent in 2013 for the third consecutive year, while the share of the population with Medicaid or CHIP (Children’s Health Insurance Program) remained stable at 15.3 percent.
  • The share of the population enrolled in Medicare rose again in 2013 as another cohort of baby boomers aged into eligibility.
  • Some 14.1 percent of those living in states that have expanded Medicaid were uninsured in 2013, compared with 17.3 percent of residents of non-expansion states.  These results pre-date, and hence do not reflect, the coverage gains due to the Medicaid expansion.  This means that the coverage gap between expansion and non-expansion states will widen further in 2014.

 

Click here to read the full paper.

Coverage Gap Widening Between Medicaid Expansion States and Others

September 18, 2014 at 11:53 am

People in states that have adopted health reform’s Medicaid expansion had a lower uninsured rate in 2013 (before the expansion took effect) than people in non-expansion states — and non-expansion states are falling further behind in 2014, several recent government and independent surveys reveal.

Some 14.1 percent of the people in the 27 states (including Washington, D.C.) that have expanded Medicaid lacked health insurance in 2013, compared to 17.3 percent in the 24 non-expansion states, according to the Census Bureau’s American Community Survey (see chart).

Next year’s Census data, which will reflect the substantial coverage gains expected in expansion states in 2014 due to the expansion (which took effect January 1), should show a further widening of this coverage gap.

Results from several independent surveys — and this week from the Centers for Disease Control and Prevention (CDC), the first government survey data showing health reform’s early impacts — show that this is already happening.  For example, the Urban Institute’s Health Reform Monitoring Survey found that the uninsured rate for non-elderly adults in expansion states fell from 16.2 percent to 10.1 percent between the third quarter of 2013 and the second quarter of 2014, compared to a decline from 20.0 percent to 18.3 percent in non-expansion states.

Health reform’s Medicaid expansion creates a pathway to coverage for all non-elderly adults with incomes up to 138 percent of the poverty line, including, for the first time, low-income adults without children.  However, the 2012 Supreme Court decision upholding health reform made the expansion a state option.  States can opt in to the expansion at any time; the federal government will pick up all of the cost through 2016 and nearly all of the cost thereafter.

Census Data Show Continued Wide Disparities in Health Coverage

September 17, 2014 at 11:46 am

Certain groups of Americans continue to be uninsured at particularly high rates, the new Census Bureau data show.  African Americans and Hispanics, residents of the South and West, adults under age 35, and households with incomes under $50,000 had uninsured rates in 2013 well above the national average of 13.8 percent (see chart).  Hispanics’ 24.3 percent uninsured rate, for example, was nearly twice the national average.

These estimates, from the Current Population Survey (CPS), are the best source for comparing coverage rates among population groups in a single year but can’t be compared to CPS estimates from previous years because of changes to the CPS questions for 2013.  For health coverage trends over time, one should look instead to Census’ American Community Survey data, which we discussed yesterday.

Health reform’s major coverage expansions — the Medicaid expansion in many states to cover more low-income adults and the availability of subsidies for private marketplace coverage — will help reduce the disparities in health coverage among population groups.  But the expansions didn’t begin until 2014, so the new Census figures for 2013 don’t capture those coverage gains.  The Centers for Disease Control and Prevention released data yesterday covering the first quarter of 2014, and they show that the coverage gains in 2014 were greatest among some of the groups with the highest uninsured rates, including young adults, Latinos, and low-income households.