Utah Medicaid Gap Analysis February 2014 INTRODUCTION In 2010, the Patient Protection and Affordable Care Act (ACA) called for the expansion of Medicaid coverage to certain low income adults. In a 2012 US Supreme Court ruling the Medicaid expansion became an optional element of the new law. The result was that some individuals that do not qualify for Medicaid will be left without premium subsidies as well unless individual states elect to expand their Medicaid programs. These individuals who make too much to qualify for Medicaid but too little to qualify for insurance premium subsidies have been referred to as the Medicaid “gap”. Voices for Utah Children asked Notalys, LLC, an economic research and data intelligence firm, to estimate the number of individuals in the Medicaid gap in each legislative district in Utah. Notalys utilized population data from the American Community Survey (ACS) 5-year estimates compiled by the U.S. Census Bureau to arrive at these estimations. While several intricacies of the Medicaid eligibility and ACA subsidy rules cannot be exactly represented with existing and available data sources, Notalys has taken extreme care to represent the statistical ranges for each estimate and outline the possible limitations of this study. Main Findings The results of this analysis are a district by district estimate for the total number of people who are likely to be affected by the Medicaid gap if Medicaid is not expanded in the state of Utah. These numbers are presented in terms of the total count of individuals in the district who fall into the gap and in terms of the percentage of all adults 18-64 within the district who fall into the gap. The following sections provides some descriptive statistics as well as a list of the top ten and bottom ten districts in terms of percent of all adults. The top ten are districts that will be most affected, the bottom ten are districts that will be least affected by the gap. NOTALYS, LLC February 2014 Utah State House of Representatives House Descriptive Statistics Adjusted Uninsured Gap Total* Adjusted Uninsured Gap %** Mean 771 3.51% Median 616 2.86% Minimum 132 0.72% Maximum 3119 12.87% Notes: *The “adjusted uninsured gap total” is the estimated total number of people who are in the Medicaid gap income range and who are currently uninsured. **The “adjusted uninsured gap %” is the percentage of the total 18-64 adult population who is both uninsured and in the gap income range. Medicaid Gap Top 10 District (Percentage of Total Adult 18-64 Population) Top 10 Rank District Representative % in Gap 1 26 Angela Romero (D) 12.9% 2 23 Jennifer Seelig (D) 9.7% 3 33 Craig Hall (R) 7.4% 4 75 Don Ipson (R) 7.2% 5 10 Dixon Pitcher (R) 7.2% 6 64 Rebecca D. Lockhart (R) 6.8% 7 73 Michael Noel (R) 6.7% 8 4 Edward Redd (R) 6.6% 9 35 Mark A. Wheatley (D) 6.6% 10 9 Jeremy Peterson (R) 6.4% Notes: *The “adjusted uninsured gap %” is the percentage of the total 18-64 adult population who is both uninsured and in the gap income range. Medicaid Gap Bottom 10 District (Percentage of Total Adult 18-64 Population) Rank District Representative Adjusted Uninsured Gap %* 75 2 David Lifferth (R) 0.7% 74 18 Roger Barrus (R) 0.8% 73 27 Michael Kennedy (R) 0.9% 72 51 Gregory Hughes (R) 1.0% 71 15 Brad Wilson (R) 1.0% 70 41 Daniel McCay (R) 1.2% 69 36 Patrice Arent (D) 1.2% 68 52 John Knotwell (R) 1.3% 67 32 LaVar Christensen (R) 1.3% 66 66 Mike McKell (R) 1.3% Notes: *The “adjusted uninsured gap %” is the percentage of the total 18-64 adult population who is both uninsured and in the gap income range. NOTALYS, LLC February 2014 Utah State Senate Senate Descriptive Statistics Adjusted Uninsured Gap Total* Adjusted Uninsured Gap %** Mean 1995 3.52% Median 1945 3.53% Minimum 485 1.01% Maximum 4441 7.71% Notes: *The “adjusted uninsured gap total” is the estimated total number of people who are in the Medicaid gap income range and who are currently uninsured. **The “adjusted uninsured gap %” is the percentage of the total 18-64 adult population who is both uninsured and in the gap income range. Medicaid Gap Top 10 District (Percentage of Total Adult 18-64 Population) Top 10 Rank District Representative % in Gap 1 1 Luz Robles (D) 7.7% 2 2 Jim Dabakis (D) 6.6% 3 3 Gene Davis (D) 5.8% 4 15 Margaret Dayton (R) 5.4% 5 5 Karen Mayne (D) 5.3% 6 16 Curt Bramble (R) 5.1% 7 18 Stuart Reid (R) 5.0% 8 28 Evan Vickers (R) 4.9% 9 24 Ralph Okerlund (R) 4.5% 10 29 Stephen H. Urquhart (R) 4.5% Notes: *The “adjusted uninsured gap %” is the percentage of the total 18-64 adult population who is both uninsured and in the gap income range. Medicaid Gap Bottom 10 District (Percentage of Total Adult 18-64 Population) Rank District Senator Adjusted Uninsured Gap %* 29 13 Mark B. Madsen (R) 1.0% 28 11 Howard A. Stephenson (R) 1.0% 27 10 Aaron Osmond (R) 1.5% 26 22 J. Stuart Adams (R) 1.5% 25 9 Wayne L. Niederhauser (R) 1.6% 24 14 John L. Valentine (R) 1.8% 23 17 Peter C. Knudson (R) 2.0% 22 4 Patricia W. Jones (D) 2.0% 67 20 Scott K. Jenkins (R) 2.1% 66 21 Jerry W. Stevenson (R) 2.5% Notes: *The “adjusted uninsured gap %” is the percentage of the total 18-64 adult population who is both uninsured and in the gap income range. NOTALYS, LLC February 2014 METHODOLOGY Notalys estimated the total number of people within the gap income range as well as the total number of uninsured individuals in the gap income range for each of the legislative districts in both chambers of the Utah State Legislature (see results section). The following describes the steps taken to reach these estimates. For all steps the global population for this analysis is all adults ages 18 to 64 in the state of Utah for whom a poverty status is collected or imputed in the ACS. This population does slightly underestimate the total number of people living in the state. Specifically it does not include ineligible immigrants. The Kaiser adjustment in step 8 corrects for this function of the ACS data. For all estimates, uncertainty resulting from the ACS data collection methodology is carried through using ACS recommended margin of error calculations. Margins of error are reported at the 95% confidence level. Step 1 - Gathering Useful Data: The ACS provides data on the total number of adults, the number of families with and without children, the proportion of uninsured individuals for various income ranges, and the number of adults in each of many different income brackets as measured by the income ratio to the federal poverty line. Each of these numbers and their associated margins of error (MOEs) for each legislative district were accessed from the ACS web service. These variables sum to create the global population for this study shown as “All adults 18-64” in the full results section. Step 2 - Parental Status: Dividing the total number of adults between 18 and 65 into parents and non-parents is an essential step due to the differences in current program eligibility rules for these two populations. The ACS provides counts for the number of adults in two parent homes, single parent male household homes, and single parent female household homes. The number of parents in each legislative district is calculated using the following equation: Equation 1: ( ) ( ) ( ) Step 3 - Poverty Ratio Adjustment: The ACS reports counts of individuals at various income categories as a ratio of the federal poverty level (FPL). The lowest category accounts for those whose FPL ratio is less than .5, or 50% of FPL. Current Utah Medicaid rules allow for parents whose incomes are less than .45 of FPL to be eligible for coverage. Without correction our analysis would under report the number of people in the gap whose income we’re between .45 and .49 of FPL. To correct for this underestimation, we added 10% of the parents in the bottom FPL income ratio category (<.5) to the next highest category (.5 to .74) so they count in the gap. Step 4 - Statewide Proportions: Once the number of parents in each district is calculated and adjustments are made to account for eligibility rules, the entire data set is converted into proportions of the global population described above. This step allows us to impute the number of individuals in the gap in each legislative district. Step 5 - Overall Proportion: For each district, we multiply the proportion that are in poverty and the proportion that are adults (calculated in steps 1 through 4) to calculate the proportion of the global population in the gap. These results are the “Total Gap Population” in the full results section. Step 6 - Unadjusted Medicaid Gap Population: Once step 5 is completed for each legislative district, the resulting proportions are converted back into counts by multiplying the entire dataset by the global population. These results are represented in the results section as “Total Gap Population”. These values can be thought of as the total number of adults whose incomes would place them in the Medicaid gap for each district. This number does not account for insurance rates in the district. NOTALYS, LLC February 2014 Step 7 - Insurance Status Correction: To reduce the raw estimate to only include the uninsured population a correction factor representing the uninsured population in each district is applied to the estimates in step 6.