Who Are the Remaining Uninsured Adult Kansans?

Key Points

• • Despite gains in insurance coverage since 2009 for nonelderly Kansas adults age 19-64, 201,275 remain uninsured.
  • Most uninsured nonelderly Kansas adults in 2017 were working (73.4 percent), had completed high school or higher (77.1 percent) and were U.S. citizens (81.7 percent).
  • Among nonelderly Kansas adults in 2017, those with less than a high school education were 4.6 times more likely to be uninsured than were those who attended college.
  • In Kansas, low-wage full-time workers are no more likely to have insurance than the unemployed. This raises important questions about the often-cited assumption that obtaining low-wage employment — even if it is full-time year-round — is a good way to get insurance coverage.
  • In 2017, one in four (25.2 percent) uninsured nonelderly Kansas adults were not eligible for Medicaid and made too little to qualify for marketplace financial assistance, falling into the so-called “coverage gap.”

Introduction

Despite gains in insurance coverage since 2009 for nonelderly Kansas adults age 19-64, many remain uninsured. Based on the latest estimates from the U.S. Census Bureau, 201,275 (11.9 percent) nonelderly Kansas adults were uninsured in 2017.

Using data from the 2017 American Community Survey conducted by the U.S. Census Bureau, this issue brief builds on information presented in the 2019 Annual Insurance Update to describe in detail those nonelderly Kansas adults who remain uninsured, including their employment, educational attainment and citizenship status.

Socioeconomic status (SES) and citizenship status could be associated with the lack of coverage. Common measures of SES include income, employment and education, and people with low SES are more likely to face obstacles obtaining insurance. Obstacles could include lack of employment, employment in a job that does not provide insurance coverage, affordability of premiums or out of pocket costs, or a lack of understanding how insurance coverage works. Lack of citizenship or lawful immigrant status further restrict coverage options.

Share of Uninsured by Category

Most uninsured nonelderly Kansas adults were working, had completed high school or higher and were U.S. citizens (Figure 2). However, the distribution varied across income levels.

Employment

Almost three-quarters (73.4 percent) of all uninsured nonelderly Kansas adults were working at least part-time (Figure 2). However, only three in 10 (29.7 percent) uninsured parents with family income <38 percent FPL were working. More than half (61.4 percent) of uninsured parents with family income 38-<100 percent FPL or uninsured childless adults with family income <100 percent FPL were working, while 85.5 percent of uninsured nonelderly adults with family income >400 percent FPL were working.

Education

Approximately three-quarters (77.1 percent) of all uninsured nonelderly Kansas adults had at least a high school education (Figure 2). For uninsured parents with family income <38 percent FPL, 72.7 percent had completed high school or some college and above, as had 85.5 percent of uninsured nonelderly adults with income >400 percent FPL.

Citizenship

More than four in five (81.7 percent) uninsured nonelderly Kansas adults were U.S. citizens (Figure 2). The proportion of individuals who were U.S. citizens was 78.8 percent for uninsured parents with family income <38 percent FPL and 89.1 percent for uninsured nonelderly adults with income >400 percent FPL.

Uninsured Rate by Category

Higher income is associated with being more likely to have insurance. At most income levels, however, individuals who were unemployed, with less than a high school education or without U.S. citizenship, were more likely to be uninsured than were their counterparts (i.e., full-time year-round workers, some college or above and U.S. citizens; Figure 3).

Employment

Overall, unemployed individuals were 2.4 times more likely to be uninsured than were those who worked full-time year-round (19.1 percent compared to 8.0 percent; Figure 3). However, among those with family income less than 138 percent FPL, the uninsured rate was not better for those employed full-time year-round compared to those who were unemployed (the small differences shown were not statistically significant). This raises important questions about the often-cited assumption that obtaining low-wage employment — even if it is full-time year-round — is a good way to get insurance coverage. For those with family income over 138 percent FPL, unemployed individuals were 1.5 to 2 times more likely to be uninsured than were those who worked full-time year-round. This suggests that for better paying jobs, the benefit of full-time employment related to gaining insurance coverage holds true.

Education

Individuals with less than a high school education were 4.6 times more likely to be uninsured than were those with some college education or higher (32.8 percent compared to 7.2 percent; Figure 3). For nonelderly adults whose family income was >400 percent FPL, those who had not completed high school were 6.7 times more likely to be uninsured than were those who had completed some college or higher (14.0 percent compared to 2.1 percent).

Citizenship

Nonelderly adults who were not U.S. citizens were 3.6 times (37.3 percent compared to 10.4 percent) more likely to be uninsured than were U.S. citizens (Figure 3). The difference ranged from 2.0 times (49.5 percent compared to 25.3 percent) more likely for uninsured nonelderly adults with family income 100-138 percent FPL to 4.1 times (11.9 percent compared to 2.9 percent) more likely among those with income >400 percent FPL.

Discussion and Conclusions

Approximately 200,000 nonelderly Kansas adults were uninsured in 2017, despite existing coverage options and financial assistance. Although most (73.4 percent) were working, they might have worked for an employer that did not offer health insurance, they could not afford premiums or out-of-pocket expenses, or they worked part-time and were ineligible for coverage. Targeted outreach efforts could help some of these working individuals gain coverage; however, several groups of uninsured nonelderly adults still face barriers to coverage.

One in four (25.2 percent) uninsured nonelderly Kansas adults were parents with family income 38-<100 percent FPL or childless individuals with income <100 percent FPL. They fell into the “coverage gap,” in which their income is too low to qualify for marketplace financial assistance and they were not eligible for Medicaid, unless expanded.

Nearly one in five (18.3 percent) uninsured nonelderly Kansas adults were not U.S. citizens, a group that includes those here legally and illegally. Undocumented immigrants are not eligible for Medicaid and cannot purchase marketplace plans. Lawfully present immigrants can purchase marketplace plans and qualify for financial assistance, and while eligible for Medicaid or CHIP in Kansas, there is a five-year waiting period. As of January 2019, 33 states and Washington, D.C., have waived the waiting period for immigrant children and 24 states and Washington, D.C., have waived it for pregnant women. Kansas has not waived the waiting period for either group. Some states also have state-funded health care programs for noncitizens regardless of immigration status.

During the 2019 Kansas legislative session, several bills focused on the eligibility and affordability of health insurance, including House Bills (HB) 2209 and 2066.

• • House Bill 2209 allowed the Kansas Farm Bureau to sell health care benefits that are not considered insurance and will not be regulated by the Kansas Insurance Department. It also amended Kansas law regulating association health plans, which may expand the use of these plans in the future. HB 2209 became law without Governor Kelly’s signature.
  • House Bill 2066 would have expanded Medicaid eligibility to nonelderly Kansas adults with income up to 138 percent FPL. The bill was passed by the House but remained in the Senate Public Health and Welfare Committee. Attempts to pull the bill out of committee and place it on the Senate calendar for a vote failed

Although additional strategies for increasing health insurance coverage have been introduced, concerns have been raised in several areas, such as consumer protection, the loss of healthy individuals from the ACA compliant individual and small group markets, and the cost to the state. While the overall effects of Medicaid expansion in Kansas have been estimated, including the number of enrollees and projected cost to the state, the effects of HB 2209 on health insurance coverage and on the health insurance market itself have not been examined. Continued monitoring of changes in the uninsured rate and the health insurance market in Kansas is warranted.