New York, NY, December 14, 2017 — Forty-seven states saw their adult uninsured rate drop by five percentage points or more in the first three years following the Affordable Care Act’s major health coverage expansions, according to a new Commonwealth Fund scorecard assessing access to health care. New Mexico’s rate dropped the most between 2013 and 2016, from 28 percent to 13 percent. A dozen other states, meanwhile, saw double-digit drops: Arizona, Arkansas, California, Florida, Kentucky, Louisiana, Montana, Nevada, Oregon, Rhode Island, Washington, and West Virginia.
The uninsured rate for children under age 19 also fell in most places, dropping by at least two percentage points in 33 states. Nevada saw the biggest drop — eight points — with Montana next at six points.
Recent policy actions, however, could reverse these gains in many states, the report concludes. If Congress repeals the ACA’s individual mandate, premiums for people buying health insurance on their own could become unaffordable for many. Of the 39 states using the federal marketplace, Nebraska, Wyoming, Alaska, and Iowa would see the biggest average dollar increases in premiums for people who buy coverage without subsidies.
In addition, the shortened open-enrollment period, cuts in advertising and outreach for ACA marketplace coverage, and failure to renew federal funding for the Children’s Health Insurance Program could potentially reverse states’ gains in access to health care.
“The Affordable Care Act has successfully allowed states to expand health insurance to millions of their residents,” said Sara Collins, Vice President for Health Care Coverage and Access at the Commonwealth Fund and a coauthor of the study. “If people are going to continue to be able to get and afford the health care they need, it will be essential to hold on to and build on these coverage gains.”
People in Many States Are Better Able to Get and Afford Health Care
The report, States’ Progress on Health Coverage and Access to Care, 2013–2016, analyzes state performance based on six measures of access and affordability. Massachusetts, the District of Columbia, Rhode Island, Connecticut, Hawaii, and Minnesota were top-ranked overall, while South Carolina, Mississippi, Wyoming, Texas, and Oklahoma came in at the bottom. When looking at trends over time, the scorecard found substantial improvement between 2013 and 2016 in most states, with some exceptions.
- In nearly three-quarters of states, fewer people skipped needed health care because of costs in 2016 compared to 2013. Arkansas, California, Kentucky, New Mexico, Oregon, Tennessee, and Washington saw drops of between five and seven percentage points in the share of people who said they didn’t see a doctor because it was too expensive.
- In more than half of states (30 states plus D.C.) the percentage of people at risk for poor health outcomes who did not have a recent routine doctor's visit declined by at least two points. Arizona, Arkansas, California, Kentucky, Oklahoma, and Oregon saw gains of five points on this access measure.
- The share of working-age adults and children in each state living in households that spent a large portion of their income on medical care was at least two percentage points lower in 25 states and the District of Columbia in 2015–2016 compared to 2013–2014. Alaska, Idaho, Nevada, Oregon, and Tennessee saw the greatest improvement — a five-to-six-point reduction.
Medicaid Expansion Key to Improving Access to Health Care
States that expanded eligibility for Medicaid as allowed by the ACA were the most likely to see big declines in their uninsured rate. Montana and Louisiana, which both recently expanded their Medicaid programs, saw uninsured rates drop four and three percentage points, respectively, between 2015 and 2016 alone.
Low-income adults fared better in Medicaid expansion states than their counterparts in non-expansion states:
- Nine expansion states slashed their uninsured rate for low-income adults by more than 20 percentage points between 2013 and 2016.
- The share of low-income adults going without health care because of costs declined by more than seven points, on average, in the states that expanded Medicaid, compared to three points in states that did not.
All the top-ranked states, as well as those that climbed the most in the rankings since 2013 — prior to the ACA’s coverage expansions —had expanded their Medicaid program by January 2016. Arkansas, California, Kentucky, Montana, Oregon and Rhode Island all made double-digit jumps in the rankings. Other expansion states also improved: Nevada jumped eight places in the rankings, while Washington State and the District of Columbia each moved up six places. Conversely, Wyoming, which did not expand Medicaid, dropped 19 places, from 30th in the baseline ranking (prior to the ACA coverage expansions) to 49th.
“The scorecard clearly demonstrates the effectiveness of policies that make it easier for people to get and afford the health care they need,” said Commonwealth Fund President David Blumenthal, M.D. “Moving forward, we should continue to evaluate the Affordable Care Act’s impacts and support successful efforts to ensure high-quality, affordable health care for everyone.”
The six indicators of health care access and affordability featured in the scorecard are:
- percent of uninsured adults ages 19–64
- percent of uninsured children ages 0–18
- percent of adults age 18 and older who went without care because of cost during past year
- percent of at-risk adults without a routine doctor visit in past two years
- percent of adults age 18 and older without a dental visit in the past year
- percent of individuals under age 65 with high out-of-pocket medical spending relative to their annual income
Findings are based on the authors’ analysis of the most recent publicly available data from the U.S. Census Bureau and from the Behavioral Risk Factor Surveillance System. See “How This Study Was Conducted” in the report for more detailed information.