Medicaid expansion under the Affordable Care Act (ACA) in 2014 was anticipated to impact health care coverage, access, and population health outcomes. Monitoring demographic and geographic profiles of expanded Medicaid coverage would permit better understanding of which populations that qualified for coverage were successfully enrolled. Further, those metrics would help identify and target outreach efforts to those who remain uninsured. This study was undertaken to understand who enrolled in Medicaid and who remains uninsured in an urban area.
METHODS:
Medicaid enrollment data compared demographic and geographic patterns of pre-ACA (1/1/2013–12/31/2013) and post-ACA (1/1/2014 – 7/1/2015) Medicaid insured populations. Medicaid enrollee addresses were geocoded to a Denver census tract. These were compared to estimated uninsured individuals (American Community Survey) by census tract. Uninsured and Medicaid enrollee counts and rates allowed pre-/post-ACA comparisons to quantify increased insurance coverage. Sub-analyses estimated the numbers of individuals remaining uninsured and identified geographic ‘hotspots’ for outreach efforts.
RESULTS:
Of Denver’s 640,000 residents, an estimated 21% were uninsured in 2013(≈100,000). Through a major expansion of Medicaid and enrollment in the health insurance exchange, the percentage of uninsured persons decreased to 9.5% in 2015. Post-ACA, the Medicaid caseload in Denver increased 53% (average 2014/2015 monthly caseload=188,852). Most pre-ACA Medicaid members were female (57%). Forty-seven percent identified as Hispanic, 17% Black, Non-Hispanic and 14% White, Non-Hispanic. Significant demographic differences were observed for new (post-ACA) Medicaid enrollees who were more likely to be male (53%). Twenty-eight percent identified as Hispanic or White, Non-Hispanic and 14% Black, Non-Hispanic. While age distribution of those enrolling in Medicaid pre-ACA was evenly distributed between adults (50%) and children (50%), post-ACA newly enrolled individuals were more likely to be adults (88%) versus children (12%).
CONCLUSIONS:
Medicaid expansion in Colorado has dramatically changed the demographics of those qualifying and enrolling in Medicaid. Pre-ACA Medicaid enrollees were mostly young Hispanic women compared to new post-ACA enrollees who were older males identifying as either Hispanic or White, Non-Hispanic. While Denver County uninsured has decreased by more than half during this study period, we estimate that up to 50,000 Denver residents remain uninsured. Despite efforts to make health insurance more affordable, cost continues to be the number one reason for not having coverage. Remaining uninsured are likely working poor, with an income above the Medicaid eligibility level