New York, NY, December 21, 2016—The percentage of uninsured working age adults declined in every state and Washington, D.C., by 2015, following full implementation of the Affordable Care Act’s (ACA) health coverage provisions in 2014, according to a new Commonwealth Fund report. Uninsured rates for low-income adults also fell everywhere in the U.S., with Kentucky’s 25-percentage-point drop leading the nation.
The report, A Long Way in a Short Time: States’ Progress on Health Care Coverage and Access, 2013–2015, is part of the Commonwealth Fund’s ongoing evaluation and ranking of how the health care system is working state by state. The study also finds that the uninsured rate for children declined by two percentage points or more in 28 states since 2013 and that people in 38 states and D.C. were less likely to say costs prevented them from going to a doctor when they needed health care. In 16 states and D.C., the percentage of people at risk for poor health outcomes who did not have a routine doctor's visit declined.
While states that expanded Medicaid under the ACA were the most likely to see big declines in their uninsured rates, even states that had not expanded as of January 2015 saw large shares of their residents gain health insurance. Uninsured rates in several states that had not expanded, including Florida, Georgia, Louisiana, Montana, North Carolina, South Carolina, and Texas, dropped between seven and nine percentage points between 2013 and 2015, as people gained coverage by enrolling through the ACA marketplaces and by learning they qualified for their state’s existing Medicaid program.
“The Affordable Care Act’s health insurance coverage expansions are working to get people covered and help them afford health care,” said Sara Collins, Vice President for Coverage and Access at The Commonwealth Fund and a coauthor of the report. “We know that health insurance is essential for people to get the care they need. In this time of uncertainty about the ACA, it’s important to keep in mind the financial and health protection health insurance provides for families.”
Access to Care State by State
To present a fuller picture of how states compare on access to health care, the report also ranks states on measures such as out-of-pocket health spending relative to income, and dental visits. Some key findings:
- Vermont, Massachusetts, Minnesota, Rhode Island, Connecticut, Delaware and the District of Columbia were top-ranked overall for access and affordability, while Mississippi, Oklahoma, and Texas ranked at the bottom. Kentucky and New Mexico moved up the most in the state rankings, gaining 10 and nine spots, respectively, compared to last year’s access rankings.
- When looking just at low-income adults, the report found at least a two-percentage-point decline across 37 states in the share of adults who had not gone to the doctor when they needed to because of costs. In Kentucky, New Hampshire, Oregon, Washington, and West Virginia—all states that had expanded Medicaid by January 2015—the percentage drop was between 10 and 14 points.
- During 2014–15, 18 percent to 19 percent of people under age 65 in Arkansas, Idaho, Louisiana, Mississippi, Montana, Oklahoma, and Tennessee spent a high share of their income on out-of-pocket health care costs. By comparison, only 10 percent to 11 percent in Connecticut, Delaware, the District of Columbia, Maryland, Massachusetts, Minnesota, New York, Rhode Island, and Vermont had high out-of-pocket spending.
“Tracking state-level progress is essential as we work toward a health system that offers affordable, high-quality health care for everyone,” said Commonwealth Fund President David Blumenthal, M.D. “These findings reveal that states have come a long way in the past few years and uninsured rates are at historic lows. It’s important to hold on to these gains and continue to make progress in ensuring that people can get and afford the health care they need.”
Additional Report Findings
- With regard to forgoing health care because of costs, Kentucky was the most improved: 12 percent of adults reported they had done so in 2015 compared to 19 percent in 2013.
- The uninsured rate for children younger than 19 was below 5 percent in 25 states by the end of 2015. Nevada saw the greatest improvement on this measure, with the rate dropping six percentage points between 2013 and 2015. Texas had the highest percentage of uninsured children in the country, 10 percent.
- Adults in all states continued to go without dental care, which traditionally is covered under a separate insurance policy. Adults were most likely to go without dental care in Louisiana, Mississippi, Texas, and West Virginia, where 20 percent went a year or more without a dental visit.
The six health care access and affordability indicators that are featured in this brief are:
Findings are based on the authors’ analysis of the most recent publicly available data from the U.S. Census Bureau and the Behavioral Risk Factor Surveillance System. See “How This Study Was Conducted” in the report for more detailed information.