Issue: The Affordable Care Act has significantly increased health insurance coverage and access to care among U.S. adults nationwide. However, the law gives states flexibility in implementing certain provisions, leading to wide variations between states in consumers’ experiences.
Goal: To examine the differences in insurance coverage, access to care, and medical bill problems in the four largest states—California, Florida, New York, and Texas—all of which have made different choices in implementing the law.
Methods: Analysis of the Commonwealth Fund Biennial Health Insurance Survey, 2016.
Findings and Conclusions: In 2016, uninsured rates among adults ages 19 to 64 across the four states varied from 7 percent in New York and 10 percent in California to 16 percent in Florida and 25 percent in Texas. This variation was also apparent in the proportions of residents reporting problems getting needed care because of the cost—significantly lower in California and New York than in Florida and Texas. Lower percentages of Californians and New Yorkers reported having a medical bill problem in the past 12 months or having accrued medical debt compared to Floridians and Texans. These variations might be explained by several factors: whether the state expanded Medicaid eligibility; whether it ran its own health insurance marketplace; what the uninsured rate was prior to the Affordable Care Act; differences in the cost protections provided by private health plans; and demographic differences.
More than 30 million Americans now have health insurance under the provisions of the Affordable Care Act.1 These provisions include those that have allowed or encouraged people to enroll in coverage through expanded Medicaid eligibility, tax credits to help pay for premiums, state and federal outreach efforts, and consumer-friendly market regulations.2 A recent analysis found that the percentage of uninsured working-age adults dropped from 20 percent in 2010 to 12 percent in 2016.3
The law gives states flexibility in implementing provisions, including the choice of operating their own health insurance marketplace or leaving that task to the federal government. Moreover, in 2012, the U.S. Supreme Court gave states the option to decide whether or not to expand Medicaid eligibility to more lower-income adults. These choices, combined with each state’s unique demographics and history, have resulted in varying experiences among Americans. In this brief, we use data from the Commonwealth Fund Biennial Health Insurance Survey to examine differences in health insurance coverage, problems getting needed care because of costs, and medical bill and debt problems among 19-to-64-year-old adults in the nation’s four largest states: California, Florida, New York, and Texas.4
These states fall into two distinct categories. The first group, California and New York, both operate their own health insurance marketplaces and have expanded eligibility for Medicaid to adults with incomes at or below 138 percent of the federal poverty level—$16,394 for an individual or $33,534 for a family of four. Florida and Texas, the second group, are using the federal marketplace to enroll residents in health plans and have declined to expand Medicaid eligibility (Exhibit 1).
Texas Has Highest Uninsured Rate of the Four Largest States
The uninsured rate has fallen in all four states since 2012, prior to the implementation of the ACA’s major coverage expansions (Exhibit 2).5,6 Analyses of federal surveys have found similar declines in the uninsured rate during this period.7,8
Among the four states, the proportion of working-age adults without health coverage in 2016 was highest in Florida and Texas, at 16 percent and 25 percent, respectively (Exhibit 2).9 In California, the uninsured rate was 10 percent; in New York, it was 7 percent.
Young adults have experienced the largest gains in coverage nationally (Exhibit 3). According to the survey, by 2016 the national uninsured rate for 19-to-34-year-olds was 15 percent, compared to 27 percent in 2010 (the year adult children became eligible to remain on a parent’s health plan until age 26).10 But the rate varied by state. In California, 8 percent of young adults were uninsured, compared with 10 percent in New York, 23 percent in Florida, and 30 percent in Texas.
There are also significant differences in coverage rates for adults with low incomes. Adults with incomes below 100 percent of the federal poverty level—that is, $11,880 for an individual or $24,300 for a family of four—are faring best in California and New York (Exhibit 4). Nine percent of low-income Californians and 15 percent of low-income New Yorkers are uninsured, compared with 22 percent of low-income adults in Florida and 39 percent in Texas.11
Adults in small firms are more likely to be uninsured in Florida and Texas than those in California and New York. Fourteen percent of adults in small firms are uninsured in California, 12 percent in New York, 24 percent in Florida, and 37 percent in Texas. These differences are likely partly explained by states’ decisions on expanding Medicaid.
Demographics also likely contribute to differences in coverage rates. Undocumented immigrants are ineligible for subsidized coverage or Medicaid under the law. According to the Pew Research Center, undocumented immigrants make up 6.1 percent of the Texas population, one of the highest proportions in the country.12
Californians and New Yorkers Have Lower Rates of Problems Getting Needed Health Care Because of Cost
Expanded insurance coverage is helping people get the care they need. In 2012, an estimated 43 percent of working-age adults, or about 80 million people, did not get needed care because of cost. By 2016, this had dropped to 34 percent, or 63 million people.13 There is significant variation among the four states. Twenty-eight percent of Californians and 29 percent of New Yorkers reported at least one cost-related access problem, compared with 41 percent of Floridians and 45 percent of Texans (Exhibit 5).14 These differences remain statistically significant even after taking into account the variations in states’ demographic profiles, including age, gender, income, health status, race and ethnicity, education level, and immigration status (Appendix Table 1).
There is a range of factors associated with state variation in responses to the cost-related survey questions (Exhibit 5). First, insurance coverage itself plays a large role. Across the U.S., insured adults have historically reported cost-related access problems at much lower rates than uninsured adults.15 In California and New York, the higher rates of insurance coverage likely play a role in the two states’ lower rates of cost-related access problems. Fewer people in California and New York have to pay for the full costs of their care when they get sick.
But the quality of health insurance coverage—particularly, how much people have to pay out of pocket relative to their income when they get sick—also makes a difference. For example, the survey found that a significantly smaller share of insured New Yorkers and Californians (8% and 13%, respectively) had large deductibles—5 percent or more of income—compared with Texans (17%) and Floridians (19%) (data not shown).16 Even among people with employer plans, which tend to be more cost-protective, more people in Florida and Texas had higher deductibles than did those in California and New York. Recent federal data showed that in 2015, 67 percent of employees with single-person insurance plans in California, and 74 percent in New York, had a deductible compared to 91 percent in Florida and 93 percent in Texas.17
People in California and New York Have Lower Rates of Medical Bill and Debt Problems
Nationally, there has been a modest but significant reduction in the percentage of adults who report medically related financial difficulties. In 2012, 41 percent of working-age adults, or an estimated 75 million people, said they had problems paying their medical bills in the past 12 months or were paying off medical debt. In 2016, this had dropped to 37 percent, an estimated 70 million people.18
Fewer adults in California and New York said they had problems paying their medical bills or were paying off medical debt than did adults in Florida and Texas (Exhibit 6). Twenty-eight percent of Californians and New Yorkers said that in the past 12 months they had a problem or were unable to pay their medical bills, had been contacted by a collection agency for unpaid medical bills, had to change their way of life to pay medical bills, or were paying off medical bills over time. In contrast, 41 percent of adults in Florida and 44 percent in Texas reported at least one of these problems.19 These differences remained even after taking into account the states’ demographic profiles, including age, gender, income, health status, race and ethnicity, education level, and immigration status.
The Affordable Care Act has significantly affected health insurance coverage and access among U.S. adults. But the decisions made by state leaders in implementing federal policy, along with other state laws, have ongoing implications for their residents. California and New York began seeing declines in their adult uninsured rate earlier than other states because of such choices. California expanded eligibility for Medicaid even before 2014 by creating the Low Income Health Program, which provided coverage to adults with incomes less than 200 percent of poverty.20 New York expanded Medicaid eligibility to parents with incomes up to 150 percent of poverty and childless adults up to 100 percent of poverty starting in 2000.21 In addition, both states opted to establish their own marketplaces and have conducted expansive outreach campaigns to increase awareness of coverage options. Alternatively, Florida and Texas—although they have experienced robust enrollment in private plans through the federal health insurance marketplace—have not expanded Medicaid eligibility and have made less progress covering uninsured residents.
However, the variation in insured rates is not entirely the result of states’ decision. The ACA does not provide access to any new coverage options for undocumented immigrants. They are ineligible for Medicaid coverage and cannot purchase private plans through the marketplace, subsidized or unsubsidized. This is likely a contributing factor in Texas’s higher uninsured rate.
While expanded coverage is the necessary first step to improving timely access to care and reducing medical financial burdens among U.S. families, the quality and comprehensiveness of coverage across all sources of insurance—marketplace plans, individual market plans, employer-provided coverage, and Medicaid—also has a significant impact.
The gains documented in this survey and many other private and federal analyses indicate that the Affordable Care Act has been successful in insuring millions of Americans and enabling them to get health care they may not have been able to afford previously. Further expanding coverage and improving affordability should remain a priority. Alternatively, repealing the law without a replacement that is at least equally effective will risk reversing the substantial gains the nation has made.
How This Study Was Conducted
The Commonwealth Fund Biennial Health Insurance Survey, 2016, was conducted by Princeton Survey Research Associates International, with a random nationally representative sample of nonelderly adults collected from July 12, 2016, to November 20, 2016, and an oversampling of adults in the four largest states, California, Florida, New York, and Texas. The survey consisted of 25-minute telephone interviews in either English or Spanish with adults age 19 and older living in the continental United States. A combination of landline and cellular phone random-digit-dial samples was used to reach people.
The study was designed to generalize to the U.S. adult population and to allow for separate analyses of responses of low-income households as well as adults in the four largest states. Most of this analysis looks at adults ages 19 to 64 in the four largest states. The sample sizes are: California=716, Florida=663, New York=739, and Texas=699. Statistical results are weighted to correct for the stratified sample design, the overlapping landline and cellular phone sample frames, and disproportionate nonresponse that might bias results. Each state sample is weighted to match population parameters for sex by age, sex by education, age by education, race/ethnicity, population density, household telephone use, household size, and region, using the U.S. Census Bureau’s 2016 American Community Survey data.
The resulting weighted national sample is representative of the approximately 187.4 million U.S. adults ages 19 to 64 and has an overall margin of sampling error of +/– 1.9 percentage points at the 95 percent confidence level. The California sample has a margin of error of +/– 4.2 percentage points at the 95 percent confidence level; the Florida sample margin of sampling error is +/– 3.7 percentage points; the New York sample margin of sampling error is +/– 3.8 percentage points; and the Texas sample margin of sampling error is +/– 3.8 percentage points. The landline portion of the survey achieved a 10 percent response rate and the cellular phone component achieved an 8 percent response rate.
1 D. Blumenthal and S. R. Collins, “Why One in Ten Americans Will Feel the Pain of ACA Repeal Without an Effective Replacement,” To the Point, The Commonwealth Fund, March 8, 2017.
2 Analysis of the Commonwealth Fund Biennial Health Insurance Survey, 2016; Office of the Assistant Secretary for Planning and Evaluation, About 2.5 Million People Who Currently Buy Coverage Off-Marketplace May Be Eligible for ACA Subsidies, ASPE Data Point (ASPE, Oct. 4, 2016); R. Rudowitz, S. Artiga, and K. Young, What Coverage and Financing Is at Risk Under Repeal of the ACA Medicaid Expansion? (Kaiser Commission on Medicaid and the Uninsured, Dec. 2016); and Centers for Medicare and Medicaid Services, 2017 Marketplace Open Enrollment Period Public Use Files (CMS, n.d.).
3 S. R. Collins, M. Z. Gunja, M. M. Doty, and S. Beutel, How the Affordable Care Act Has Improved Americans’ Ability to Buy Health Insurance on Their Own (The Commonwealth Fund, Feb. 2017). These estimates are in the range of those found in other recent surveys. The federal government and a number of private organizations including The Commonwealth Fund have used different surveys and methodologies aimed at measuring the change in insurance coverage as a result of the coverage expansions under the Affordable Care Act. Most recently, the Center for Disease Control and Prevention’s National Health Interview Survey found that in the first nine months of 2016, 8.8 percent of the U.S. population, or 28.2 million people, and 12.3 percent of adults ages 18 to 64, or 24.3 million people, were uninsured; see M. E. Martinez, E. P. Zammitti, and R. A. Cohen, Health Insurance Coverage: Early Release Estimates from the National Health Interview Survey, January–September 2016 (NHIS, Feb. 2017). Data from the U.S. Census Bureau’s Current Population Survey (CPS) showed that 12.6 percent of adults ages 19 to 64, or 24.3 million people, were uninsured in 2015 (http://www.census.gov/library/publications/2016/demo/p60-257.html; and analysis of 2015 Current Population Survey by Sherry Glied and Ougni Chakraborty of New York University for The Commonwealth Fund). The Commonwealth Fund reported in May 2016 using its ACA Tracking Survey that the uninsured rate among adults ages 19 to 64 had declined from 19.9 percent in July–September 2013 to 12.7 percent in February–April 2016, or by an estimated 24 million people (http://www.commonwealthfund.org/publications/issue-briefs/2016/may/aca-tracking-survey-access-to-care-and-satisfaction).
4 This is an update of P. W. Rasmussen, S. R. Collins, M. M. Doty, and S. Beutel, Health Care Coverage and Access in the Nation’s Four Largest States (The Commonwealth Fund, April 2015).
5 The state-level estimates from the Commonwealth Fund Biennial Health Insurance Survey are similar to those reported by Center for Disease Control and Prevention’s National Health Interview Survey (NHIS) in all three years, with the exception of New York in 2012, which is higher in the Biennial Survey than in NHIS. For this reason, we report the 2012 uninsured rate for New York using the NHIS estimate: R. A. Cohen and M. E. Martinez, Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, 2012 (NHIS, June 2013). This estimate was similar to the estimate from the U.S. Census Bureau’s 1-Year American Community Survey (ACS), which reported a 10.9% uninsured rate in New York among all individuals: J. C. Smith and C. Medalia, Health Insurance Coverage in the United States: 2013 (CPS Reports, Sept. 2014).
6 The margin of sampling error in the Biennial Survey for each state was between 3.7 and 4.2 percentage points at the 95 percent level. This meant that the decline in the uninsured rate in Texas was not statistically significant in the Biennial. However, the declines in uninsured rates have been statistically significant in these states in the NHIS and ACS, which have much larger sample sizes.
7 The Biennial Survey estimates in 2016 were similar to those reported by the NHIS, which found that in the first nine months of 2016, the uninsured rate among 18–64-year-olds in California was 9.3%, in New York was 7.3%, in Florida was 19.5%, and in Texas was 24.7%: M. E. Martinez, E. P. Zammitti, and R. A. Cohen, Health Insurance Coverage: Early Release Estimates From the National Health Interview Survey, January-September 2016 (NHIS, Feb. 2017). The NHIS found that in 2014 the uninsured rate in California was 16.7%, 12.9% in New York, 23.0% in Florida, and 25.7% in Texas: R. A. Cohen and M. E. Martinez, Health Insurance Coverage: Early Release Estimates from the National Health Interview Survey, 2014 (NHIS, June 2015). The NHIS found that in 2012, the uninsured rate in California was 24.4%, 14.7% in New York, 28.9% in Florida, and 28.6% in Texas: R. A. Cohen and M. E. Martinez, Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, 2012 (NHIS, June 2013). The estimates from the Biennial Health Insurance Survey, 2016, were also similar to those reported by the U.S. Census Bureau 1-Year American Community Survey (ACS), 2015. ACS reported uninsured rates for 19–64-year-olds in California as 12%, in Florida as 20%, in New York as 10%, and in Texas as 23%: S. L. Hayes, S. R. Collins, D. C. Radley, D. McCarthy, and S. Beutel, A Long Way in a Short Time: States’ Progress on Health Care Coverage and Access, 2013–2015 (The Commonwealth Fund, Dec. 2016).
8 For a recent 50-state analysis of changes in coverage and access, see D. C. Radley, D. McCarthy, and S. L. Hayes, Aiming Higher: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition (The Commonwealth Fund, March 2017).
9 All reported differences are statistically significant at the p≤0.05 level or better unless otherwise noted.
10 S. R. Collins, M. Z. Gunja, M. M. Doty, and S. Beutel, How the Affordable Care Act Has Improved Americans’ Ability to Buy Health Insurance on Their Own (The Commonwealth Fund, Feb. 2017).
11 The difference between New York and Florida is not significant. The difference between New York and Texas, Florida and Texas, California and Florida, and California and Texas is significant.
12U.S. Unauthorized Immigration Population Estimates (Pew Research Center, Nov. 3, 2016).
13 S. R. Collins, M. Z. Gunja, M. M. Doty, and S. Beutel, How the Affordable Care Act Has Improved Americans’ Ability to Buy Health Insurance on Their Own (The Commonwealth Fund, Feb. 2017).
14 The reported weighted (unadjusted) estimates are similar to regression-adjusted estimates.
15 S. R. Collins, M. Z. Gunja, M. M. Doty, and S. Beutel, How the Affordable Care Act Has Improved Americans’ Ability to Buy Health Insurance on Their Own (The Commonwealth Fund, Feb. 2017).
16 Insured adults in New York (28%) and California (26%) reported far lower rates of problems getting needed care in the past 12 months than did insured adults in Texas (41%) and Florida (38%).
17 S. R. Collins, D. C. Radley, M. Z. Gunja, and S. Beutel, The Slowdown in Employer Insurance Cost Growth: Why Many Workers Still Feel the Pinch (The Commonwealth Fund, Oct. 2016).
18 S. R. Collins, M. Z. Gunja, M. M. Doty, and S. Beutel, How the Affordable Care Act Has Improved Americans’ Ability to Buy Health Insurance on Their Own (The Commonwealth Fund, Feb. 2017).
19 The reported weighted (unadjusted) estimates are similar to regression-adjusted estimates.
20 R. Thomason and P. Long, “California’s Low Income Health Program: A Public-Private Partnership That Worked,” Health Affairs Blog, Feb. 14, 2014.
21 L. Norris, “New York and the ACA’s Medicaid Expansion,” Healthinsurance.org, Jan. 10, 2017.
The authors thank David Blumenthal, Kathleen Regan, Don Moulds, Barry Scholl, Eric Schneider, Meredith Brown, Arnav Shah, Deborah Lorber, Chris Hollander, Christine Haran, Paul Frame, and Jen Wilson of The Commonwealth Fund for helpful comments, data checking, and editorial support and design.