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Changes in health coverage over time reflect economic trends, demographic shifts, and changes in federal and state policy. Several such policy changes are related to the Patient Protection and Affordable Care Act (ACA). 

Many of the provisions of the ACA went into effect in 2014, including the establishment of health insurance Marketplaces (such as healthcare.gov) and the optional expansion of Medicaid eligibility by states. 

The first year, 24 states and the District of Columbia expanded eligibility thresholds for Medicaid. By 2021, all but 14 states had expanded Medicaid eligibility. As a result, many people, particularly adults aged 19 to 64, may be eligible for coverage options under the ACA. 

Based on family income, some people may qualify for subsidies or tax credits to help pay for premiums associated with health insurance plans. In addition, people with lower incomes may be eligible for Medicaid coverage if they resided in one of the states (or the District of Columbia) that expanded Medicaid eligibility. 

Notably, some provisions of the ACA no longer apply. For example, as of 2019, the individual mandate penalty requiring individuals to be covered by health insurance or pay a tax penalty was cancelled at the federal level, although several states and the District of Columbia have continued or implemented state health insurance coverage mandates.

The economic shock related to the COVID-19 pandemic in 2020 and recovery in the wake of the continued COVID-19 pandemic also may have affected health insurance coverage in 2021. 

The Families First Coronavirus Response Act required states, as a condition of receiving increased Medicaid funding, to provide continuous coverage for Medicaid beneficiaries for the duration of the COVID-19 pandemic.

An executive order signed in January 2021 extended the Special Enrollment Period for Marketplace coverage through July 15, 2021. 

The American Rescue Plan Act further increased Medicaid funding to states, expanded the income thresholds for eligibility for Marketplace tax credits, increased premium subsidies for those eligible, waived Marketplace coverage premiums for the unemployed, and introduced additional measures to increase access to care and reduce the cost of coverage.

Data from the Centers for Medicare and Medicaid Services showed that Medicaid enrollment continued to increase in 2021, following a dramatic increase in 2020 after declines in enrollment from 2017 to 2019. 

Specifically, after increasing by about 6.3 million adults and 3.3 million children between February 2020 and January 2021, Medicaid enrollment among adults aged 19 and older increased from 40.6 million to 44.7 million during the period between February 2021 and January 2022. 

Medicaid/CHIP enrollment among children under age 19 increased from 38.5 million to 40.1 million during the same period. Further, data on Marketplace enrollment also suggest an increase from 11.4 million people who enrolled or were re-enrolled in Marketplace plans during the 2020 Open Enrollment Period to 12.0 million people who enrolled or re-enrolled in Marketplace plans during the 2021 Open Enrollment Period.

An additional 2.8 million people enrolled in Marketplace coverage in 2021 during the Special Enrollment Period. The coronavirus pandemic and related stay-at-home orders during the spring of 2020 also affected how the Census Bureau collected data for the CPS ASEC. 

The edition of this report released in September 2020 (P60-271) provides an overview of the issues.8 In addition, the Census Bureau produced several working papers exploring how changes in CPS data collection in 2020 may have affected 2019 estimates. 

These analyses revealed that the 2020 CPS ASEC sample differed from the previous year with respect to a number of characteristics that are correlated with health insurance coverage. For example, the 2020 CPS ASEC sample was older, more educated, and more likely to have a disability than the 2019 sample. 

Researchers should consider the effect of the pandemic on CPS ASEC data collection when interpreting changes in health insurance coverage between 2019 and other years using the CPS ASEC. As a result, no comparisons between calendar year coverage in 2019 (collected in 2020) and other survey years are reported in this appendix.

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