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State, County, and Local Estimates of the Uninsured Population: Prevalence and Key Demographic Features

Publication Date
Mar 11, 2021

State and Local Estimates of the Uninsured Population in the U.S. Using the Census Bureau’s 2019 American Community Survey

Methodological Description

March 12, 2021

In order to support state and local outreach efforts, ASPE has developed state and sub-state estimates of the number of uninsured, along with their demographic characteristics, who are likely to qualify for coverage through Qualified Health Plans (QHPs) in the Health Insurance Marketplace (“QHP-eligible uninsured”) using the most recent Census data available for this purpose.

To estimate the QHP-eligible uninsured population, we calculated the number of uninsured individuals ages 0-64 with family incomes (defined based on the health insurance unit [HIU], which consist of an adult, their spouse, and any dependent children) that would qualify them for QHP-eligibility in the 2019 American Community Survey (ACS). We present results at three levels of geography:

  1. State-level – for all 50 states and Washington DC
  2. Public Use Microdata Areas (PUMA) level – PUMAs are the most granular level of geography available in the ACS public use file. PUMAs are geographic areas within each state that contain no fewer than 100,000 people; they can consist of part of a single densely populated county, or can combine parts or all of multiple counties that are less densely populated. Detailed maps of PUMAs for each state are available at: https://www.census.gov/geographies/reference-maps/2010/geo/2010-pumas.html
  3. County-level – to create county level estimates, we used a PUMA-to-county crosswalk from the Missouri Census Data Center. PUMAs spanning multiple counties had their estimates apportioned across those counties based on overall 2010 Census populations. To the extent that the uninsured populations presented in these tables are distributed differently than the population as a whole, our estimates may overestimate or underestimate the true number of QHP eligible uninsured in a given county.

We adjusted the ACS weights for noncitizens based on the estimated probability that each individual is undocumented, in order to provide estimates of the uninsured population not including undocumented immigrants (who are not eligible for QHPs or Medicaid). The weight adjustment methodology is based on imputations of immigration legal status in ASPE’s TRIM3 microsimulation model.

Our estimates are less precise at the PUMA and county levels than at the state level and thus are subject to greater sampling error; accordingly, they should be used with caution for purposes that require precise estimates. Counts of uninsured populations have been rounded to the nearest 100. Cells based on fewer than three underlying observations have been censored and marked with double asterisks (**).

We define QHP-eligible uninsured adults (ages 19-64) as those who are uninsured and have incomes at or above the level that determines eligibility for Marketplace insurance affordability programs (generally HIU income greater than 138% of the federal poverty level [FPL] in Medicaid expansion states, and above 100% of FPL in non-expansion states). Adults in New York and Minnesota with incomes between 138 and 200% of FPL, which make them eligible for Basic Health Program (BHP) coverage, are included with the QHP-eligible population. Uninsured children (ages 0-18) in all states are defined as QHP-eligible based on HIU income greater than 250% of FPL to capture higher income eligibility limits in Medicaid or CHIP. The QHP-eligible group is further divided based on whether they are eligible for Advance Payments of the Premium Tax Credit (APTC), which is determined by whether their HIU income is above or below 400% of the FPL, the upper income for APTC eligibility prior to the implementation of the American Rescue Plan, which will remove this upper income limit for 2 years.

We also present estimates of the uninsured population with incomes too low to qualify for QHPs. In expansion states, this population is eligible for Medicaid. In non-expansion states, eligibility for Medicaid depends on specific income thresholds and categorical eligibility, and not all those included in these estimates will qualify.

These estimates are meant to be reflective of the approximate size of groups potentially eligible for enrollment in QHP plans, but they are not precise estimates of such populations. The approximations presented here may vary from other available estimates of the remaining uninsured due to differences in data sources and methodology. Since the 2019 Census American Community Survey was fielded, the COVID-19 pandemic has caused significant employment and health insurance status disruptions (as reflected in Census Household Pulse and unemployment filing data). Complete state and sub-state level 2020 or 2021 estimates of the uninsured are not yet available from the federal surveys that are the gold standard for estimates of the uninsured.

These results do not account for whether uninsured individuals have an affordable offer of employer coverage, which also affects eligibility for QHP enrollment. The results also do not account for detailed characteristics of legally present immigrants that may affect the programs for which they are eligible.

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