MN HSR Conference, 2016, Elizabeth Lukanen

1. THE CHANGING DEMOGRAPHICS OF
THE UNINSURED IN MINNESOTA AND
THE NATION
Elizabeth Lukanen, MPH
State Health Access Data Assistance Center (SHADAC)
Minnesota Health Services Research Conference
March 1, 2016
St. Paul, MN

2. Outline
1. Study details
2. Coverage expansions and outreach under
the Affordable Care Act
3. Changes in uninsurance rates, 2013-2014
4. Changes in the characteristics of the
uninsured, 2013-2014
5. Conclusions and policy implications

3. Study Details
• Research question: Have insurance
coverage gains likely related to the Affordable
Care Act (ACA) changed the demographic
profile of the uninsured?
• Data source: 2013 and 2014 American
Community Survey Public Use Micro Data
Sample
• Approach: Descriptive statistics, year-over-
year testing for significance using t-test at
the 95% confidence interval
• Co-Author: Brett Fried, SHADAC
3

4. ACA COVERAGE EXPANSIONS AND
OUTREACH

5. Affordable Care Act Expanded Health
Insurance Coverage Options
• Optional Medicaid expansion for childless adults up
to 138% Federal Poverty Level (FPL, $16,104 in 2014)
• 32 states have currently expanded Medicaid, including
Minnesota
• Tax credits to purchase private coverage through the
health insurance Marketplace
• For families below 400% FPL ($46,680 for a family of 4 in
2014)
• Single, streamlined enrollment and application
assistance through the Marketplace
• 13 state-based (including Minnesota – MNsure), 11
Federally-supported or partnership and 27 states opted
to use the federal marketplace
• Expended the definition of “young adult” so that
children up to 25 could stay on their parents health
insurance plan

6. Financial Support for Outreach and
Enrollment
• Federal funding for outreach and assistance
during the first Open Enrollment Period (OEP)
exceeded $400 million
• Minnesota awarded more than $4.75 million in
outreach and enrollment grants in the first OEP
• Many states (including Minnesota) and the
federal government targeted groups with
historically high rates of uninsurance
• Young adults
• Racial and ethnic minorities
• Non- English speakers or limited English proficiency
• Immigrants and refugees
Source: “Survey of Health Insurance Marketplaces Assister Program” The Henry J. Kaiser Family Foundation, July 2014.

7. IMPACTS ON UNINSURED RATES, 2013-
2014

8. National Uninsured Rate Over Time, 2008-
2014
15% 15% 16% 15% 15% 15%
12%
8%
9% 9% 9% 8% 8%
6%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
2008 2009 2010 2011 2012 2013 2014
U.S. Minnesota
Source: SHADAC Analysis of the ACS.

9. Significant Declines Seen in all 50
States
Source: SHADAC Analysis of ACS.
Percentage Point Declines in State Uninsured Rates, 2013-2014

10. Uninsured Rates Declined for Most
Targeted Subpopulations
• Decline in every age category
• +5pp drop for young adults 19-25
• Decline in every racial/ethnic category
• Rates for Hispanics and Asians declined more than
4pp
• Rates for Blacks declined more than 4pp in MN and
3.5pp in the U.S.
• Decline in every income category
• +4pp declines for low income families (0-138 FPL
and 139 to 199% FPL)
• Declines in all category of workers, all education
levels and citizenship status categories

11. DID CHANGES IN RATES OF UNINSURANCE
IMPACT THE CHARACTERISTICS OF THE
UNINSURED?

12. Characteristics of Interest
• Age
• Sex
• Race/Ethnicity
• Marital status
• Employment status
• Industry
• Education
• Veteran status
• Disability status
• Citizenship status
• Language
• Receipt of public
assistance (e.g. food
stamps)
• Presence of internet in
the home
• Disability

13. Minnesota: Uninsured are now
More Likely to be Hispanic
16% 22%*
61%
58%
11% 10%
7% 5%3% 3%2% 2%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2013 2014
Characteristics of the Uninsured by Race/Ethnicity, 2013-
2014
Hispanic White Black Asian American Indian Multiple/other
Source: SHADAC analysis of the ACS. * significant at the 95% confidence interval.

14. Minnesota: Uninsured are now
More Likely to be Non-Citizens
16% 20%*
84% 80%*
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2013 2014
Characteristics of the Uninsured by Citizenship Status, 2013-2014
Non Citizen Citizen
Source: SHADAC analysis of the ACS. * significant at the 95% confidence interval.

15. Minnesota: Uninsured are now Less
Likely to be Children
19% 15%*
17%
16%
23%
25%
30% 33%
10% 11%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2013 2014
Characteristics of the Uninsured by Age, 2013-2014
0-17 18-25 26-44 45-54 55-64
Source: SHADAC analysis of the ACS. * significant at the 95% confidence interval.

16. U.S.: Uninsured are now More Likely, to be
Hispanic and Less Likely to be White /Asian
33% 35%*
44% 43%*
14% 14%
5% 5%*1% 1%2% 2%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2013 2014
Characteristics of the Uninsured by Race/Ethnicity, 2013-
2014
Hispanic White Black Asian American Indian Multiple/other
Source: SHADAC analysis of the ACS. * significant at the 95% confidence interval.

17. U.S.: Uninsured are now More
Likely to be Non-Citizens
22% 24%*
78% 76%*
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2013 2014
Characteristics of the Uninsured by Citizenship Status, 2013-2014
Non -Citizen Citizen
Source: SHADAC analysis of the ACS. * significant at the 95% confidence interval.

18. U.S.: Uninsured are now More Likely to
Work Full-Time, Less Likely to be Not
Working
10% 10%*
38% 39%*
16% 16%*
36% 35%*
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2013 2014
Characteristics of the Uninsured by Employment Status,
2013-2014
N/A (Under 16) Full-Time Part-Time Not Working
Source: SHADAC analysis of the ACS. * significant at the 95% confidence interval.

19. U.S.: Uninsured are now More Likely, to
Speak Spanish, Less Likely to Speak English
Only
1% 1%
56% 54%*
32% 34%*
5% 5%
4% 4%2% 2%
0%
20%
40%
60%
80%
100%
2013 2014
Characteristics of the Uninsured by Language Spoken in
the Home, 2013-2014
NA (Group Quarters) English only Spanish
Other Indo-European Asian Other
Source: SHADAC analysis of the ACS. * significant at the 95% confidence interval.

20. U.S.: Uninsured are now Less Likely to be
Very Low Income
55% 54%*
24% 24%
13% 13%
8% 8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2013 2014
Characteristics of the Uninsured by Income (% Federal
Poverty Level), 2013-2014
0-138% 139-250% 251-400% 400+
Source: SHADAC analysis of the ACS. * significant at the 95% confidence interval.

21. U.S.: Uninsured are now More Likely to Have
Less Education
25% 26%*
34% 35%*
30% 28%*
11% 11%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2013 2014
Characteristics of the Uninsured by Education, 2013-2014
Less than High School High school Graduate
Some college Bachelor's degree or higher
Source: SHADAC analysis of the ACS. * significant at the 95% confidence interval.

22. Conclusions
• Despite reductions in uninsurance, the
characteristics of the uninsured remains largely
unchanged
• Uninsured are now even more likely to have
characteristics of those with historically high rates of
uninsurance:
• Hispanics
• Non-citizens
• Spanish speakers
• Individuals with low educational attainment (in the U.S.)
• Declines in uninsurance did have some impact on
characteristics as the uninsured are now less likely
to be:
• Children
• Individuals who are not working
• Asian (in the U.S.)
• Very low income (in the U.S.)

23. Policy Implications
• Findings don’t signal a need for a radical shift
in approach to outreach and enrollment
• Outreach and enrollment efforts need to
continue to target Hispanics, Spanish
speakers and those with low education
• Policy action is needed to address individuals
whose citizenship status limits coverage
options (due to eligibility or fear)
• The Medicaid expansion is likely critical to
maintain shifts in the characteristics of the
uninsured related to income and age

24. www.shadac.org
@shadac
Elizabeth Lukanen
SHADAC Deputy Director
University of Minnesota Senior Fellow
elukanen@umn.edu
612.626.1537