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Estimates of Eligibility for ACA Coverage among the Uninsured in 2016

Data Note
  1. Kaiser Family Foundation. Key Facts about the Uninsured Population. (Washington, DC: Kaiser Family Foundation, September 2016). Available at: http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/

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  2. U.S. Department of Health and Human Services, Office of The Assistant Secretary for Planning and Evaluation, 2016 Poverty Guidelines. Available at: https://aspe.hhs.gov/poverty-guidelines

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  3. Kaiser Family Foundation State Health Facts Online. Medicaid/CHIP Upper Income Eligibility Limits for Children, 2000-2016. Available at: http://kff.org/medicaid/state-indicator/medicaidchip-upper-income-eligibility-limits-for-children/

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  4. U.S. Department of Health and Human Services, Office of The Assistant Secretary for Planning and Evaluation, 2014 Poverty Guidelines. Available at: https://aspe.hhs.gov/2015-poverty-guidelines

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  5. Tax credit eligibility in 2016 is based on 2015 poverty guidelines. In addition to the premium tax credits, the federal government also makes available cost-sharing subsidies to reduce what people with incomes between 100% and 250% of poverty have to pay out-of-pocket to access health services. The cost-sharing subsidies are also available on a sliding scale based on income.

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  6. Medicaid category also includes other public coverage, such as some state-funded programs for immigrants otherwise ineligible for Medicaid.

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  7. Includes individuals in Minnesota and New York who are eligible for coverage through the Basic Health Plan. See table notes for more detail.

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  8. Although we estimate that 5.3 million currently uninsured people would be eligible for tax credits if they purchased coverage through the exchanges, a separate analysis by ASPE estimates that an additional 2.5 million people already purchasing nongroup coverage off-exchange could be eligible for tax credits if they were to purchase through the exchange. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, About 2.5 Million People Who Currently Buy Coverage Off-Marketplace May Be Eligible for ACA Subsidies. Available at: https://aspe.hhs.gov/sites/default/files/pdf/208306/OffMarketplaceSubsidyeligible.pdf

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  9. Kaiser Family Foundation. Key Facts about the Uninsured Population. (Washington, DC: Kaiser Family Foundation, September 2016). Available at: http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/

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  10. Bianca DiJulio, Jamie Firth, and Mollyann Brodie. Kaiser Health Tracking Poll: December 2015, (Washington, D.C.: Kaiser Family Foundation, Dec 2015), Available at: http://kff.org/health-costs/poll-finding/kaiser-health-tracking-poll-december-2015/

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  11. Garfield, R. and K. Young. January 2015. Adults who Remained Uninsured at the End of 2014. (Washington, DC: Kaiser Family Foundation). Available at: http://kff.org/health-reform/issue-brief/adults-who-remained-uninsured-at-the-end-of-2014/

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  12. Ashley Kirzinger, Bianca DiJulio, Elise Sugarman, Bryan Wu, and Mollyann Brodie, A Final Look: California's Previously Uninsured after the ACA's Third Open Enrollment Period (Washington, D.C. : Kaiser Family Foundation, April 2016), Available at: http://kff.org/report-section/a-final-look-californias-previously-uninsured-after-the-acas-third-open-enrollment-period-section-3-the-remaining-uninsured/

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  13. Artiga, S. February 2013. Immigration Reform and Access to Health Coverage: Key Issues to Consider. (Washington, DC: Kaiser Family Foundation). Available at: http://kff.org/uninsured/issue-brief/immigration-reform-and-access-to-health-coverage-key-issues-to-consider/

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  14. State Health Access Data Assistance Center. 2013. “State Estimates of the Low-income Uninsured Not Eligible for the ACA Medicaid Expansion.” Issue Brief #35. Minneapolis, MN: University of Minnesota. Available at: http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf404825

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  15. Van Hook, J., Bachmeier, J., Coffman, D., and Harel, O. 2015. “Can We Spin Straw into Gold? An Evaluation of Immigrant Legal Status Imputation Approaches.” Demography. 52(1):329-54.

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  16. Based on state-reported eligibility levels as of January 1, 2016. Eligibility levels are updated to reflect state implementation of the Medicaid expansion as of September 2016 and 2016 Federal Poverty Levels, but may not reflect other eligibility policy changes since January 2016. The Kaiser Family Foundation State Health Facts. Data Source: Kaiser Commission on Medicaid and the Uninsured with the Georgetown University Center for Children and Families. Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost-Sharing Policies as of January 2016: Findings from a 50-State Survey, (Washington, DC: Kaiser Family Foundation, January 21, 2016), Available at: http://kff.org/medicaid/report/medicaid-and-chip-eligibility-enrollment-renewal-and-cost-sharing-policies-as-of-january-2016-findings-from-a-50-state-survey/

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  17. Non-MAGI pathways for nonelderly adults include disability-related pathways, such as SSI beneficiary; Qualified Severely Impaired Individuals; Working Disabled; and Medically Needy. We are unable to assess disability status in the CPS sufficiently to model eligibility under these pathways. However, previous research indicates high current participation rates among individuals with disabilities (largely due to the automatic link between SSI and Medicaid in most states, see Kenney GM, V Lynch, J Haley, and M Huntress. “Variation in Medicaid Eligibility and Participation among Adults: Implications for the Affordable Care Act.” Inquiry. 49:231-53 (Fall 2012)), indicating that there may be a small number of eligible uninsured individuals in this group. Further, many of these pathways (with the exception of SSI, which automatically links an individual to Medicaid in most states) are optional for states, and eligibility in states not implementing the ACA expansion is limited. For example, the median income eligibility level for coverage through the Medically Needy pathway is 36% of poverty in states that are not expanding Medicaid. (See: Molly O'Malley Watts, Watts Health Policy; Elizabeth Cornachione and MaryBeth Musumeci, Kaiser Family Foundation, Medicaid Financial Eligibility for Seniors and People with Disabilities in 2015, (Washington, DC, Kaiser Family Foundation, February 2016), Available at: http://kff.org/medicaid/report/medicaid-financial-eligibility-for-seniors-and-people-with-disabilities-in-2015/

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Appendix A: Household Construction
  1. Medicaid eligibility in 2016 is based on 2016 poverty guidelines, available at: U.S. Department of Health and Human Services, Office of The Assistant Secretary for Planning and Evaluation, Poverty Guidelines. https://aspe.hhs.gov/poverty-guidelines. Tax credit eligibility in 2016 is based on 2015 poverty guidelines, available at: U.S. Department of Health and Human Services, Office of The Assistant Secretary for Planning and Evaluation, 2015 Poverty Guidelines. http://aspe.hhs.gov/2015-poverty-guidelines.

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  2. See Internal Revenue Service, Publication 501, Table 1.2015: Filing Requirements Chart for Most Taxpayers. Available at: https://www.irs.gov/publications/p501/ar02.html#en_US_2015_publink1000270109

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  3. See Internal Revenue Service, Publication 501, Qualifying Relative. Available at: https://www.irs.gov/publications/p501/ar02.html#en_US_2015_publink1000220939

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  4. A detailed explanation of Medicaid and Marketplace income counting rules can be found in Center on Budget and Policy Priorities webinar available at: http://www.healthreformbeyondthebasics.org/wp-content/uploads/2013/08/Income-Definitions-Webinar-Aug-28.pdf

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  5. A detailed explanation of Medicaid and Marketplace HIU size calculations can be found in the Center on Budget and Policy Priorities webinar available at http://www.healthreformbeyondthebasics.org/wp-content/uploads/2013/08/Household-Definitions-Webinar-7Aug13.pdf

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  6. This is the same underlying data as the 2016 Health Insurance Marketplace Calculator. Available at: http://kff.org/interactive/subsidy-calculator/ For a more detailed examination of plans available in the Health Insurance Marketplaces in 2016, see Kaiser Family Foundation, Analysis of 2016 Premium Changes and Insurer Participation in the Affordable Care Act’s Health Insurance Marketplaces. Available at: http://kff.org/health-reform/issue-brief/analysis-of-2016-premium-changes-and-insurer-participation-in-the-affordable-care-acts-health-insurance-marketplaces/

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  7. See Bureau of Labor Statistics, CPI Inflation Calculator. Available at: http://www.bls.gov/data/inflation_calculator.htm

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  8. See Internal Revenue Service, Publication 501, Table 1.2015: Filing Requirements Chart for Most Taxpayers. Available at: https://www.irs.gov/publications/p501/ar02.html#en_US_2015_publink1000270109

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  9. See Internal Revenue Service, Publication 501, Qualifying Relative. Available at: https://www.irs.gov/publications/p501/ar02.html#en_US_2015_publink1000220939

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Appendix B: Immigration Status Imputation
  1. State Health Access Data Assistance Center. 2013. “State Estimates of the Low-income Uninsured Not Eligible for the ACA Medicaid Expansion.” Issue Brief #35. Minneapolis, MN: University of Minnesota. Available at: http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf404825

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  2. Van Hook, J., Bachmeier, J., Coffman, D., and Harel, O. 2015. “Can We Spin Straw into Gold? An Evaluation of Immigrant Legal Status Imputation Approaches” Demography. 52(1):329-54.

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  3. DHS updates these estimates periodically. We use the estimates applicable to the year for the data sets to which we apply the regression model. The most recent estimates are: N Rytina, B Baker. Estimates of the Unauthorized Immigrant Population Residing in the United States. (Department of Homeland Security, Office of Immigration Statistics), March 2013. Available at: http://www.dhs.gov/publication/estimates-unauthorized-immigrant-population-residing-united-states-january-2012.  Since an update of this document has not occurred for the most recent years of data, 2012 estimates were inflated for 2013, 2014, and 2015 using non-citizen population growth in the 2012, 2013, and 2014 American Community Survey subtracted by counts of legal permanent residents, asylees, and refugees also published by DHS-OIS. This inflation technique was developed from conversations with DHS-OIS researchers, and subsequently distributed using age and state-stratified population proportions also furnished by DHS-OIS researchers.

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  4. Indicators that imply legal status include: (i) respondent entered the US prior to 1980, or (ii) respondent is enrolled in any of the following public programs: Medicare, military health insurance, public assistance, Supplemental Security Income, or Social Security Income.

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  5. The first three listed independent variables are excluded when using the regression model to analyze the SIPP Core Data because they are not included in Core SIPP files.

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  6. For more information, see SHADAC 2013, footnote 6. The table created for this function contains estimates of the undocumented across 2007-2015. Only five large states were included in the strata due to low sample size within some of the age categories by state relative to the calculated population targets.

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  7. For more detail, see documentation available at: National Health Interview Survey. 2015 Imputed Income Files. October 3, 2016. Available at: http://www.cdc.gov/nchs/nhis/nhis_2015_data_release.htm

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  8. As an example of this, we found that approximately half of undocumented children in the state of Texas did not have health insurance during calendar year 2013. Our undocumented uninsured model for all post-2014 calculations now incorporates the assumption that about half of undocumented children in Texas should be sampled from the insured population and the other half should be sampled from the uninsured population, thereby holding the uninsured rate constant. Prior to implementing this new sampling dimension, we found unrealistic drops in the uninsured rate of the undocumented population that we largely attributed to our prediction model's inability to discern this group from legally-present non-citizens, many of whom are eligible for assistance under the ACA's coverage expansions. Although a few states have implemented programs that allow for coverage of the undocumented population, these programs are state-funded and relatively small in scale compared to the nationwide coverage expansions accompanying the ACA.

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Appendix C: Imputation of Offer of Employer-Sponsored Insurance
  1. Survey of Income and Program Participation. 2008 Panel Topical Module List. Available at: http://www.census.gov/programs-surveys/sipp/tech-documentation/topical-modules/topical-modules-2008.html

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  2. Abramowitz J., O'Hara B. 2016 "New Estimates of Offer and Take-Up of Employer-Sponsored Insurance" Med Care Res Rev. pii: 1077558716654630.

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  3. CPS ASEC Research Files. Offer and Take-up of Employer Sponsored Insurance. Available at: http://www.census.gov/data/datasets/time-series/demo/health-insurance/cps-asec-research-files.html

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  4. [4] Following the advice of researchers at the US Census Bureau, we re-coded the offer status of certain workers. Workers who reported not holding an offer of ESI and also reported the reason for not being offered as "plan too expensive" were re-coded to be workers holding an offer of ESI. Workers who reported holding an offer of ESI who also reported that they did not take-up that offer because they had either not worked at the employer long enough to be covered or were not allowed in the plan due to contract or temporary work were re-coded to be workers not holding an offer of ESI. We confirmed that our calculations precisely matched CPS-ASEC 2015 statistics published by researchers at the US Census Bureau. See Majority of Workers Take Health Insurance Offered by Their Employers. US Census Bureau. Available at: http://blogs.census.gov/2016/06/16/majority-of-workers-take-health-insurance-offered-by-their-employers/

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  5. For example, anyone who did not work during 2015 who then held an offer of ESI in early 2016 would appear incongruous in our eligibility model. In the other direction, workers covered by health insurance through their own employer in 2015 who lost their offer of ESI during the early months of 2016 (perhaps due to a job change) would also appear incongruous due to the discrepancy across the two time periods.

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  6. As described in note 4, we re-coded the offer status of certain workers.

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  7. For an explanation of affordability, see: Kaiser Family Foundation. Employer Responsibility Under the Affordable Care Act. October 2015. Available at: http://kff.org/infographic/employer-responsibility-under-the-affordable-care-act/

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Appendix D: Uninsured Calibration
  1. Barnett, Jessica C. and Marina S. Vornovitsky, Current Population Reports, P60-257(RV), Health Insurance Coverage in the United States: 2015, U.S. Government Printing Office, Washington, DC, 2016. Available at: http://www.census.gov/content/dam/Census/library/publications/2016/demo/p60-257.pdf.

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  2. Cohen RA, Martinez ME, Zammitti EP. Health insurance coverage: Early release of estimates from the National Health Interview Survey, 2015. National Center for Health Statistics. May 2016. Available from: http://www.cdc.gov/nchs/nhis/releases.htm.

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  3. Cohen RA, Martinez ME, Zammitti EP. Health insurance coverage: Early release of estimates from the National Health Interview Survey, January – March 2016. National Center for Health Statistics. September 2016. Available from: http://www.cdc.gov/nchs/nhis/releases.htm.

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  4. The CPS-ASEC 2016 also contains health insurance coverage information for the interview month (February, March, or April) in early 2016, but these statistics diverge from the NHIS first quarter 2016 estimates. The complete point-in-time health insurance coverage information collected as part of the re-designed CPS-ASEC has not yet been released by the US Census Bureau, so we have chosen to rely on the NHIS quarterly early release estimates which have provided stable estimates of health insurance coverage like the NHIS annual and CPS annual estimates.

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  5. Kaiser Family Foundation/Health Research & Education Trust. 2016 Employer Health Benefits Survey. Section Three: Employee Coverage, Eligibility, and Participation. Available at: http://kff.org/report-section/ehbs-2016-section-three-employee-coverage-eligibility-and-participation/

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  6. U.S. Census Bureau (2016). Number of People by Type of Health Insurance Coverage by Selected Demographic Characteristics: 2014 and 2015. Available at: http://www2.census.gov/programs-surveys/demo/tables/p60/257/tableA5.pdf

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  7. U. S. Census Bureau. (2016). 2016 Current Population Survey’s Annual Social and Economic Supplement User Note. Available at: http://www.census.gov/topics/income-poverty/guidance/2016-usernote.html

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