econ

Health Policy Fact Sheet February 2020

Despite Gains From ACA, Lower Rates of Health Insurance Coverage Persist Among Those Lacking Housing Basics Deborah Freund, Chengcheng Zhang, Petra W. Rasmussen, Safia Hassan, and Gerald Kominski

Since the passage in 2010 of the Patient Protection and Affordable Care Act (PPACA, most commonly called the ACA), a great deal of literature has emerged showing that states that have embraced the law’s Medicaid expansion have seen significant reductions in the number of uninsured, though disparities in coverage persist by race/ ethnicity, employment, and other factors.1-3 Similarly, in recent years, other research has shown that there is an important relationship between housing and health outcomes,4 and that improving housing quality and safety improves overall health. Individuals experiencing unstable housing and poor housing safety, defined in a variety of ways— including instability, an unsafe environment, water leaks, poor ventilation, and pest infestation—have poorer health.4 However, there is virtually no literature that focuses on the question of whether having stable and safe housing is related to the likelihood of having health insurance coverage. A study by Carroll et al. in 2017 assessed the extent to which housing instability is linked to insurance status in a preschool population. The study found that preschool-age children residing in unstable housing were 27% more likely than stably housed preschool-age children to have gaps in health insurance.5

Using data from the American Community Survey for 2013 and 2018, with responses from almost 3 million individuals, we compared

those ages 0-64 who had complete housing amenities with those whose housing lacked one basic necessity. Basic necessities are defined as these:

• bathtub or shower

• sink with a faucet

• stove or range

• refrigerator

We stratified the data based on the following income categories: up to 100% of the federal poverty level (FPL), 100– 399% FPL, and 400% FPL or greater. For 2018, 100% FPL was $12,060 for an individual and $24,600 for a family of four; 400% FPL was $48,240 for an individual and $98,400 for a family of four.

Our findings suggest that having housing that lacks at least one basic necessity is associated with being uninsured. Prior to the implementation of the ACA’s main coverage provisions, individuals whose housing lacked at least one basic necessity had higher rates of being uninsured than individuals with complete housing. While this disparity still exists after implementation of the ACA, rates of uninsurance have decreased for those whose incomes would qualify them for Medicaid coverage under Medicaid expansion or for individual market subsidies, both for those with complete housing and those whose housing lacks a basic necessity.

This study was conducted jointly by the UCLA Center for Health

Policy Research and the Claremont Graduate University with support

from the A-Mark Foundation.

UCLA CENTER FOR HEALTH POLICY RESEARCH

Uninsured Rate by Housing Index, Ages 0-64, 2013 and 2018Exhibit 1

0% 5% 10% 15% 20% 25% 30% 35% 40%

26.2%

16.3%

17.8%

10.2%

33.5%

27.4%

23%

17%

28.8%

20.6%

19.3%

13.5%

10.2%

5.8%

9%

4.2%

2013

2018

2013

2018

2013

2018

2013

2018

< 1 0

0 %

F P

L 1

0 0

–3 9

9 %

F P

L 4

0 0

% +

F P

L T O

TA L

Home missing at least 1 basic necessity Home has all basic necessities

But more importantly, large disparities in coverage persist.

Overall, in a comparison of the pre-ACA implementation (2013) with the most recently available post-ACA implementation year (2018), the reduction in the uninsured rate was dramatic. However, individuals with homes that had all the basic necessities had lower uninsured rates and higher rates of decline in their uninsured rates in comparison to those lacking at least one basic necessity (Exhibit 1). Those having all the basic necessities had much lower rates of being uninsured than those whose

housing lacked at least one basic necessity, regardless of income.

Among those living in homes absent one basic necessity, the rate of uninsurance declined from 33.5% to 23% for individuals with incomes below 100% FPL, and from 28.8% to 19.3% among those with incomes of 100–399% FPL. In comparison, those living in homes with all the basic necessities had better coverage rates in 2013, and their coverage rates as a percentage change declined more than the rates for those living without one

UCLA CENTER FOR HEALTH POLICY RESEARCH

basic necessity. Between 2013 and 2018, the insured rate for this group declined from 27.4% to 17% for those with incomes below 100% FPL, and from 20.6% to 13.5% among those with incomes of 100–399% FPL.

Individuals with incomes of 400% FPL or greater started out with much lower rates of being uninsured than the other two income groups, regardless of their housing status. However, among this population, there was not a significant decrease in the uninsured rate: The rate declined only from 5.8% to 4.2 % for those with all the basic necessities, and from 10.2% to 9% for those without at least one basic necessity. Thus, disparities still exist, as not all groups shared equally in the decline, and those that had full housing had lower uninsured rates than those that had a missing basic necessity.

We also compared the rates of being uninsured for each income group in states that expanded Medicaid in 2014 versus states that did not expand. Whether or not the individual or family had all the basic necessities, there was a larger percentage of decline in uninsured rates for all income groups in those states that expanded than in those states that did not take part in the Medicaid expansion.

Housing has been a relatively unexplored topic since the passage of the ACA. Though many health organizations — whether in the private, nonprofit, or government sectors — have begun to discuss and create interventions to tackle the social determinants of health, the role of housing as a variable that puts individuals at greater risk of being uninsured has never been highlighted. Our analyses demonstrate that individuals with housing issues, as measured by the lack of a basic necessity, are more likely to be uninsured than those without housing issues. The reasons why are not clear, though the finding may reflect a higher budgetary priority on housing and food than on health insurance. Further investigation is necessary to determine why individuals whose housing lacked at least

one basic necessity and whose income was less than 100% FPL did not see a larger increase in their uninsured rate, as they would be eligible for Medicaid in expansion states. More research will be needed in the future to assess the relationship between insurance and housing.

Data Data for this fact sheet are from the 2013 and 2018 American Community Survey.

Author Information Deborah Freund is a university professor and president emerita in the Department of Economic Sciences and School of Global Public Health at Claremont Graduate University. Chengcheng Zhang is a PhD candidate in the Department of Economic Sciences at Claremont Graduate University. Petra Rasmussen is a graduate student researcher at the UCLA Center for Health Policy Research in the UCLA Fielding School of Public Health. Safia Hassan is an undergraduate student at Scripps College. Gerald F. Kominski is a senior fellow at the UCLA Center for Health Policy Research and a professor in the Department of Health Policy and Management at the UCLA Fielding School of Public Health.

Suggested Citation Freund D, Zhang C, Rasmussen PW, Hassan S, Kominski GF. 2020. Despite Gains From ACA, Lower Rates of Health Insurance Coverage Persist Among Those Lacking Housing Basics. Los Angeles, CA: UCLA Center for Health Policy Research.

Endnotes 1 Buchmueller TC et al. 2016. Effect of the Affordable

Care Act on Racial and Ethnic Disparities in Health Insurance Coverage. American Journal of Public Health 106(8): 1416-1421.

2 Agarwal SD, Goldman AL, and Sommers BD. 2019. Blue-Collar Workers Had Greatest Insurance Gains After ACA Implementation. Health Affairs 38(7):1140-1144.

3 O’Hara B and Brault MW. 2013. The Disparate Impact of the ACA-Dependent Expansion Across Population Subgroups. Health Services Research 48(5):1581-1592.

4 Taylor L. 2018. Housing and Health: An Overview of the Literature. Health Affairs Health Policy Brief.

5 Carroll A et al. 2017. Housing Instability and Children’s Health Insurance Gaps. Academic Pediatrics 17(7): 732-738.

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