The Uninsured Low-Income Population in the United States

Many low-income adults in the United States live without health insurance. Most Americans receive health insurance through their employer as a fringe benefit; however, many people do not have access to such coverage either because they cannot afford the employee share of the cost or they are unemployed.

Since children who do not have health insurance coverage qualify for Medicaid and the Children’s Health Insurance Program, Adults with low incomes are particularly vulnerable to lack of coverage. Children who do not health insurance coverage qualify for Medicaid and the Children’s Health Insurance Program. Medicaid eligibility is severely limited for adults and, in most states, adults in homes with no dependent children are not covered through Medicaid.

Adults who do not have health insurance are more likely than those with such coverage to go without necessary medical care, including visiting a physician for treatment of chronic conditions such as diabetes or high blood pressure and filling prescriptions for recommended medications. They also are likely to miss recommended preventive services and are vulnerable to access barriers, as they have limited means to pay providers for necessary services.

In 2014, when additional provisions of the Patient Protection and Affordable Care Act (ACA) take effect, millions of low-income adults may become eligible for coverage via the expansion of Medicaid eligibility. Nationally, there are 21.5 million currently uninsured nonelderly adults who may meet the income and citizenship criteria to gain Medicaid eligibility. The number of individuals who may become eligible varies by state and depends on the income and age distribution in the state as well as the current scope of insurance coverage.

The Henry J. Kaiser Family Foundation’s Commission on Medicaid and the Uninsured recently released a report titled Characteristics of Uninsured Low-Income Adults. According to the report, most adults targeted by the expansion of Medicaid are in families with incomes below the federal poverty line ($10,830 for an individual and $14,570 for a family of 2). Most of those below the poverty line are below 50% of poverty (~$5400 for an individual or $7200 for a family of 2).

The remaining potentially eligible adults have incomes above the poverty line but below the new Medicaid threshold. Depending on whether their state implements the Medicaid expansion, they may be eligible for subsidies to help purchase insurance coverage through the new health insurance exchanges that will be in place in 2014.

The Medicaid expansion provision of the ACA has the potential to expand coverage among racial/ethnic minorities. Nationally, 47% of uninsured adults potentially eligible for Medicaid are white, 30% are Hispanic, and 17% are black.

Many of the adults in the group that may be eligible for Medicaid under the expansion are in working families; 52% are in a family with at least 1 part-time worker and approximately 25% are in a family with at least 1 full-time worker. According to the Kaiser report, these figures reflect the design of the expansion, which intends to reach those “left out of the employer-based system.” The figures also reflect the low incomes of those targeted by the expansion; a family of 2 with 1 adult engaged in full-time work at minimum wage would have earnings above the income level for the expansion, the report noted.

Finally, the report said that the majority (61%) of low-income adults potentially eligible for Medicaid after the expansion work in fields such as the service industry, agriculture, construction, wholesale or retail trade, and arts/entertainment/recreation. Workers in those industries are more likely to be uninsured than workers in other industries. Many companies in those fields are small and will be excluded from the ACA provision that firms with ≥50 employees pay a penalty if they do not provide employer-sponsored health coverage to workers. As a result, the report stated, “these workers may have limited options for accessing insurance coverage beyond their states’ Medicaid program.”

In summary, the authors of the report commented, “The Medicaid expansion under the ACA has the potential to extend coverage to millions of low-income adults who otherwise are unlikely to have an affordable coverage option. Many people in this target population have substantial health needs and currently face barriers to healthcare; expanding coverage would likely improve their ability to access needed services and, ultimately, their health.”