Uninsured Veterans and 

Family Members:

National and State Estimates and 

New Coverage Options Under the ACA*

Jennifer Haley and Genevieve M. Kenney, Urban Institute

21 November 2013

U.S. Department of Veterans Affairs Cyber-Seminar

*Based on research funded by the Robert Wood Johnson Foundation
Overview

• Data source and methods

• Uninsured veterans and family members

• Uninsurance among veterans and their families

• Differences across subgroups and states

• Associations between coverage status and health care access 

• Coverage options currently and under the Affordable Care 

Act (ACA)

• Medicaid

• Subsidized exchange coverage

• Veterans’ Affairs (VA) care

• Research questions

2 
Data Source and Methods

• 2008-2010 American Community Survey (ACS), U.S. Census Bureau

• 2010 ACS: national public use sample of nearly 129,000 nonelderly 

veterans; state samples range from 169 in the District of Columbia to 

10,700 in California

• Nonelderly veterans: those ages 19 to 64 who had ever served on 

active duty (or reservists who have served in active roles) but are no 

longer serving

• Nonelderly members of veterans’ families: those ages 0 to 64 in a 

household with a 19-to-64-year-old veteran who is their spouse or 

biological, adoptive, or stepparent

• To approximate eligibility for coverage under the ACA, individuals 

categorized by Modified Adjusted Gross Income (MAGI) 

• Additional analysis uses the 2009 and 2010 National Health 

Interview Survey (NHIS)

• Associations between insurance coverage and health care access 

among veterans and their family members

3 
Measurement of Insurance Coverage

• Respondents were asked about coverage of each individual in the 

household by any of the following types of health insurance or health 

coverage plans at the time of the survey: 

• a. Insurance through a current or former employer or union (of this person or 

another family member)

• b. Insurance purchased directly from an insurance company (by this person or 

another family member)

• c. Medicare, for people 65 and older, or people with certain disabilities

• d. Medicaid, Medical Assistance, or any kind of government-assistance plan 

for those with low incomes or a disability

• e. TRICARE or other military health care

• f. VA (including those who have ever used or enrolled for VA health care)

• g. Indian Health Service

• h. Any other type of health insurance or health coverage plan—specify

• We classify veterans as uninsured if they report neither using VA 

services nor having comprehensive health insurance coverage 4 
Study Limitations

• Inherent imprecision in estimates based on survey data due to 

sampling error

• Potential measurement error in coverage status, veterans 

status, income, and Medicaid eligibility status

• Estimates will vary across data sources, time periods, and 

methodologies

• Nevertheless, the main findings presented here appear to be 

quite robust

5 
Estimated Number of Uninsured Veterans 

and Family Members

Nonelderly Uninsured 

(2008-2010) 

Veterans 1,311,500 

Spouses of Veterans 645,100 

Children of Veterans 318,000 

Veterans and Their

Family Members 

Combined

2,274,600 

• 10.5 percent of 

nonelderly veterans 

are uninsured

• 7.4 percent of 

nonelderly family 

members are 

uninsured

• Lower rates than 

among the U.S. 

population overall 

(17.9 percent)

Source: Based on 2008–2010 American Community Survey data from the Integrated Public Use Microdata Series. 

Estimates reflect additional Urban Institute adjustments to coverage status.

6 
State Variation in Estimated Uninsurance 

Among Veterans (US Total: 10.5 percent)

7 

Source: Based on 2009–2010 American Community Survey data from the Integrated Public Use Microdata Series. 

Estimates reflect additional Urban Institute adjustments to coverage status. (*) indicates the state rate is significantly 

different from the national average at the 0.05 level. Medicaid expansion status reflects decisions as of October 2013 

according to the Centers for Medicare and Medicaid Services.
Uninsured Veterans and Family Members

• Compared with insured veterans, uninsured veterans:

• Have served more recently 

• More than 4 in 10 served most recently between September 2001 

and 2010 (22.1 percent) or between August 1990 and August 2001 

(21.2 percent) 

• Are younger

• 45.5 percent of uninsured veterans are below age 45, compared with 

29.5 percent of insured veterans

• Uninsurance rates among Hispanic (12.9%) and Black (11.9%) 

veterans were significantly higher than the rate for White

(9.9%) veterans. 

8 
Uninsured Veterans and Family Members 

(continued)

• Uninsured veterans report fewer service-related 

disabilities/functional limitations

• But 17.3 percent of the uninsured report a disability/functional 

limitation

• In contrast, uninsured family members of veterans have higher 

rates of functional limitations than their insured counterparts 

• Uninsured veterans report lower levels of education, higher 

levels of unemployment, and lower rates of full-time work, 

and they are less likely to be married 

• These likely contribute to their lack of coverage, as these 

attributes are related to access to employer coverage

• Characteristics of veterans’ family members also indicate lower 

access to employer coverage 9 
Uninsured Veterans/Family Members are More 

Likely to Have Unmet Health Needs

Veterans Family Members of Veterans

Uninsured Insured Uninsured Insured

Any Unmet

Health Needs

41.2%* 12.7% 54.8%* 12.3% 

Delayed Care 

Due to Cost

33.7%* 8.4% 44.1%* 7.6% 

Notes: Based on the 2009 and 2010 National Health Interview Survey. Indicators for unmet needs and delayed 

care refer to problems in access over the past 12 months. Unmet health needs exclude dental needs. * indicates 

that the insured percentage is significantly different from the uninsured percentage at the 0.01 level. 

In addition, some uninsured veterans appear to have health problems: 

• 33.0 percent report at least one chronic health condition

• 15.3 percent report being in fair or poor health

• 15.9 percent report being limited by physical, mental, or emotional problems

• 40.1 percent report experiencing negative feelings that interfered with their activities

10 
Medicaid and CHIP Under Current Law

• Medicaid created in 1965 – jointly funded by the federal 

government and states and overseen by Centers for Medicare 

and Medicaid Services

• Most care obtained through private providers/managed care

• States are required to cover certain categories of people (e.g., 

low-income children, pregnant women, people with 

disabilities, etc.) and provide certain mandatory services but 

have flexibility over eligibility, benefits, payment, delivery 

systems, etc.

• For children, additional coverage provided through the 

Children’s Health Insurance Program (CHIP), enacted in 1997 

and currently authorized through 2015 11 
Medicaid and CHIP Under Current Law: 

Eligibility

• Expansive Medicaid/CHIP thresholds for children 

• Eligibility levels: 24 states at 250 percent of the federal poverty 

level (FPL) or higher

• Around two-thirds of uninsured children qualify

• Much lower Medicaid thresholds for adults

• Majority of states do not provide any Medicaid coverage to 

nondisabled adults without dependent children

• Median eligibility thresholds in 2013: 61 percent of FPL for 

working parents and 37 percent of FPL for jobless parents

• Relatively few adults qualify for Medicaid: Only about 1 in 10 

uninsured veterans and spouses qualify under current rules

12 
Medicaid/CHIP Under Current Law: 

Estimated Eligibility

10.0% 

90.0% 

Uninsured Veterans

Eligible for

Medicaid

Ineligible for

Medicaid

25.5% 

74.5% 

Uninsured Family Members 

of Veterans

Eligible for

Medicaid/CHIP

Ineligible for

Medicaid/CHIP

13 

Source: Based on 2009–2010 American Community Survey data from the Integrated Public Use Microdata Series. 

Estimates reflect additional Urban Institute adjustments to coverage status. Medicaid/CHIP eligibility indicates 

eligibility for comprehensive Medicaid using states rules in place at the time of the survey.
Care through the Veterans’ Health 

Administration

• Priority is based on veteran status, discharge status, servicerelated disabilities, income level, and other factors

• Income threshold is higher than Medicaid thresholds

• Over 8 million veterans enrolled (both nonelderly and 65+)

• Dual coverage is common (Medicare, Medicaid, private 

insurance)

• Of the 12.5 million nonelderly veterans identified in the ACS, an 

estimated 2.8 million (22.9 percent) report VA use, of whom an 

estimated 883,000 report VA only

• Many low-income uninsured veterans likely qualify

• Most spouses and children of veterans not eligible for VA 

care

14 
Affordable Care Act (ACA)

• The ACA does not change the VA or other military health care 

systems and is not targeted specifically at veterans

• But it includes a number of provisions aimed at increasing 

health insurance coverage that could affect veterans and their 

families: 

• Individual requirement to have health insurance (VA coverage 

satisfies coverage mandate)

• Navigators

• Screening questions/data matches/simplified applications

• Increased awareness of coverage options

• New coverage options

• Expanded Medicaid coverage

• Subsidized exchange coverage (subsidies not available for VA 

enrollees) 15 
Medicaid Under the ACA

• Medicaid expansion: nonelderly adults below 138 percent of 

FPL (about $24,000 for a family of 3 in 2012), regardless of 

parental status, could qualify for Medicaid

• At this point, however, not all states are choosing to expand 

Medicaid, which became a state option in June 2012

• This analysis uses state decisions as of October 2013

• Original analysis used governors’ positions as of February 2013; 

this presentation updates those estimates using decisions as of 

October 2013 (findings are similar)

• Participating in expansion in January 2014: 26 states (including 

the District of Columbia) 

• Ohio recently announced its intention to expand Medicaid; other 

states (New Hampshire, Pennsylvania, etc.) are still exploring 

options 

16 
Subsidized Exchange Coverage 

Under the ACA

• Newly established health insurance marketplaces with 

subsidies for those below 400 percent of FPL who do not have 

access to affordable employer coverage

• Eligibility for subsidized coverage:

• Legal resident

• Not eligible for any form of public coverage (or enrolled in VA 

care)

• Have family MAGI of up to 400 percent FPL

• Do not have an offer of affordable employer coverage in the 

family (offer for worker costing less than 9.5 percent of family 

income, even if cost of family coverage is higher)

• Above 100 percent of FPL in states not expanding Medicaid, 

above 138 percent of FPL in states expanding Medicaid 17 
Potential Changes in VA Coverage 

Under the ACA

• VA officials at the House Committee on Veterans’ Affairs 

estimated a net increase of 66,000 veterans seeking VA care

• ACA coverage requirement could boost enrollment 

• However, some could leave VA when other options become 

available 

• Others could supplement VA care with Medicaid coverage or 

unsubsidized marketplace coverage

• Dual enrollment could increase

• Increased concern with fragmentation of care

18 
Of the Estimated 1.3 Million Uninsured Veterans, 

More than 4 in 10 Could Qualify for Expanded 

Medicaid Under the ACA if All States Expanded

414,000 

120,800 

776,400 

Below 100% of FPL

100-138% of FPL

Above 138% of FPL

An estimated half a 

million uninsured 

veterans would 

qualify for Medicaid 

expansion under full 

implementation

19 

Source: Based on 2008–2010 American Community Survey data from the Integrated Public Use Microdata Series. 

Estimates reflect additional Urban Institute adjustments to coverage status.
Of the Estimated 645,000 Uninsured Spouses, 

More than 1 in 4 Could Qualify for Expanded 

Medicaid Under the ACA if All States Expanded

112,500 

471,300 

Below 100% of FPL

100-138% of FPL

Above 138% of FPL

61,300 

An estimated 

173,800 uninsured 

spouses of veterans 

would qualify for 

Medicaid expansion 

under full 

implementation

20 

Source: Based on 2008–2010 American Community Survey data from the Integrated Public Use Microdata Series. 

Estimates reflect additional Urban Institute adjustments to coverage status.
But Most Veterans Below 138% FPL Are In States Not 

Currently Expanding Medicaid

21 

Source: Based on 2008–2010 American Community Survey data from the Integrated Public Use Microdata Series. 

Estimates reflect additional Urban Institute adjustments to coverage status. Medicaid expansion status reflects 

decisions as of October 2013 according to the Centers for Medicare and Medicaid Services.

<100% FPL - 

State 

Expanding, 

183,600 

100-138% FPL - 

State 

Expanding, 

<100% FPL - 

State NOT 

Expanding , 

230,700 

100-138% FPL - 

State NOT 

Expanding, 

69,200 
Most Spouses of Veterans Below 138% FPL Are In 

States Not Currently Expanding Medicaid

22 

Source: Based on 2008–2010 American Community Survey data from the Integrated Public Use Microdata Series. 

Estimates reflect additional Urban Institute adjustments to coverage status. Medicaid expansion status reflects 

decisions as of October 2013 according to the Centers for Medicare and Medicaid Services.

<100% FPL - 

State 

Expanding, 

45,600 

100-138% 

FPL - State 

Expanding, 

24,800 

<100% FPL - 

State NOT 

Expanding , 

67,000 

100-138% FPL - 

State NOT 

Expanding, 

36,500 
Eligibility for Exchange Coverage

• An estimated 4 in 10 uninsured veterans have incomes above 

the ACA Medicaid threshold but below 400 percent of FPL –

they could qualify for subsidized exchange coverage if they do 

not have access to affordable employer coverage

• Just under half of veterans’ family members (spouses and 

children) are estimated to qualify if they do not have access to 

affordable employer coverage

• Veterans with VA coverage alone may drop VA coverage to 

purchase on the exchange or could sign up for exchange 

coverage to supplement VA coverage (but would not be 

eligible for subsidies)

23
Priority Research Questions

• How well are ACA outreach and enrollment efforts working 

for veterans and their families?

• Are navigators trained on the options for veterans?

• How do websites/enrollment systems handle VA eligibility and enrollment?

• How does this vary across the country?

• In states with their own marketplaces vs. federal marketplaces

• In states expanding Medicaid vs. not expanding at this time

• In states with high vs. low levels of enrollment assistance

• To what extent are uninsured veterans and family members 

gaining coverage in 2014 and beyond?

• Who is tracking VA, Medicaid, and exchange enrollment for veterans and 

their families?

• Which groups are gaining? Which are remaining uninsured? 

• To what extent are coverage gaps shrinking across states? In what states 

are coverage gaps highest for vets and their family members?

• What is the role of cost-sharing in veterans’ coverage decisions?

• Cap on cost sharing in Medicaid; low copays for VA coverage; potentially much 

higher on the Marketplace

24
Priority Research Questions (continued)

• What are ongoing barriers to obtaining VA coverage, Medicaid, and 

coverage through the marketplaces? 

• What are the impacts of ACA coverage expansions on access to 

care, financial burdens, and health and functioning of veterans and 

families?

• For instance, how is access to providers (including specialists) in rural areas for both 

Medicaid and VA?

• What policies and practices promote better outcomes for vets with 

dual coverage?

25
More Information

• “Uninsured Veterans and Family Members: State and National 

Estimates of Expanded Medicaid Eligibility under the ACA.” 

2013. Princeton, NJ: Robert Wood Johnson Foundation. 

www.urban.org/publications/412775.html

• “Uninsured Veterans and Family Members: Who Are They and 

Where Do They Live?” 2012. Princeton, NJ: Robert Wood 

Johnson Foundation. www.urban.org/UploadedPDF/412577-

Uninsured-Veterans-and-Family-Members.pdf

• Jennifer Haley, Urban Institute Health Policy Center, 

jhaley@urban.org

• Genevieve M. Kenney, Urban Institute Health Policy Center, 

jkenney@urban.org 1