How Obamacare Increased Insurance Coverage in Every State

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President Barack Obama signed the Patient Protection and Affordable Care Act (ACA) on March 23, 2010, and open enrollment for all Americans began on October 1, 2013. While the ultimate outcome of the ACA, also known as Obamacare, remains to be seen, the number of people with health insurance increased in every state since the law was enacted.

In 2012, the last year before open enrollment through the ACA began, 45.6 million people nationwide, or 14.8% of Americans did not have health insurance. 24/7 Wall St. estimated that 28.6 million people, or 9.1% of Americans did not have health insurance as of March this year — a decrease of roughly 17 million people or a drop of 5.7 percentage points. Based on the change in the rate of the uninsured population from 2012 through the first part of this year, the percentage of Kentucky’s population without health insurance declined by 10.4 percentage points, the largest improvement nationwide. Iowa, on the other end of the spectrum, had the most modest improvement, with its uninsured population shrinking by 1.7 percentage points.

The 50 states used different methods to implement the ACA. Some developed their own health insurance exchanges, while others let the U.S. government facilitate enrollment. Even within those camps, each state’s health care marketplace often had unique features. One key aspect of the legislation — the expansion of Medicaid to include those making up to 138% the federal poverty level — was optional for states. More than half of all states opted to expand Medicaid coverage, including all the states that developed their own exchanges.

According to Louise Sheiner, senior fellow and policy director of the Hutchins Center on Fiscal and Monetary Policy at the Brookings Institution, political reasons are perhaps the only explanation for not expanding Medicaid. If states choose to expand the program, the federal government would pay 100% of the costs, and over time this subsidy would decrease to 90%.

Sheiner explained that there is a coverage gap between the health insurance exchanges and Medicaid — people who are too poor to get subsidies through the exchanges but not poor enough to qualify for Medicaid fall into that gap. Most of the increase in health coverage nationwide was among low-income Americans newly eligible under the expanded Medicaid program. In the 30 states that adopted the expansion, 9.5 million people have qualified for Medicaid since the ACA rollout.

While the option to expand Medicaid is aimed at helping low-income people, states opting out often had lower median household incomes and higher poverty rates. Many people purchase health insurance in order to avoid financial catastrophe, and while low-income individuals are often among those who need health insurance the most, they are also frequently unable to afford it without help. In fact, according to several studies, unpaid medical bills are the leading cause of bankruptcy in the United States.

While the Medicaid expansion provision in Obamacare is perhaps very generous to state budgets, the act is not without its critics. For example, many conservatives consider Obamacare an overreach of government that will drive up costs and result in higher taxes. In particular, ACA opponents like House Speaker John Boehner have strongly objected to the employer mandate, a provision which levies a penalty on some employers who do not offer health insurance to their employees.

The ACA’s funding mechanism has also been criticized and remains hotly debated. In a 2010 paper, Marshall Auerback, a senior fellow at the Levy Economics Institute, predicted that more people would get insurance under Obamacare. However, Auerback questioned whether more health care would get paid for in a system funded by private insurance companies. He wrote, “any real reform which cuts costs would be far less profitable.”

Nonetheless, health insurance coverage rates have gone up. Sheiner noted it is no surprise that insurance coverage rates have gone up. “When you give people subsidized insurance and make them get it, then you’re going to get more people insured.”

For Amanda Kowalski, associate professor of economics at Yale University, the hope is that reducing the share of the uninsured population will improve health outcomes and ultimately lower health care costs. Kowalski’s research on the ACA’s early adoption argues that this has happened to some extent already. States that developed their own exchanges, for example, were able to sign up more residents, thus increasing coverage and lowering costs as a result.

1. Kentucky
> Ppt change in uninsured rate, 2012-2015: -10.4
> Expanded Medicaid?:
yes
> Pct. population without health insurance, 2012: 13.9% (23rd highest)
> Pct. population without health insurance, 2015: 3.5% (4th lowest)

Nearly 600,000 Kentucky residents did not have health insurance in 2012, or 13.9% of the state’s population. As of March 2015, since the Affordable Care Act was implemented, the percentage of Kentuckians without health insurance had dropped by 10.4 percentage points — the largest decline compared to other states. Kentucky was one of 31 states to expand Medicaid under the ACA, and low-income residents were among the primary beneficiaries of the legislation. Nearly half a million people gained health insurance as a result of the expansion.

The state also chose to run its own health care exchange, Kynect, which has been praised as among the best-run exchanges in the nation. Future reductions in the rate of the uninsured population largely depend on decisions from state officials, and future leaders could have a significant impact on the program’s success going forward, particularly in Kentucky. GOP gubernatorial candidate Matt Bevin recently vowed to dismantle the exchange and cancel the Medicaid expansion.

2. New Mexico
> Ppt change in uninsured rate, 2012-2015: -10.2
> Expanded Medicaid?:
yes
> Pct. population without health insurance, 2012: 18.4% (5th highest)
> Pct. population without health insurance, 2015: 8.2% (25th highest)

After open enrollment in the Health Insurance Marketplace began on October 1, 2013, health insurance coverage in every state increased. In New Mexico, the percentage of the population without health insurance decreased from 18.4% in 2012 to 8.2% as of March this year, the second largest improvement nationwide. With a poverty rate of 21.9% — the second highest nationwide — Medicaid expansion under the ACA had an especially large impact in New Mexico. As a result of the expansion, 230,000 New Mexicans received health insurance.

Initially, New Mexico opted to manage its own health care insurance exchange for small businesses, while the federal government managed the marketplace for individuals. Later, the state implemented its own all-encompassing exchange website, BeWellNM.com, for individuals and businesses.

3. Oregon
> Ppt change in uninsured rate, 2012-2015: -10.1
> Expanded Medicaid?:
yes
> Pct. population without health insurance, 2012: 14.9% (18th highest)
> Pct. population without health insurance, 2015: 4.8% (7th lowest)

An estimated 14.9% of Oregon residents did not have health insurance in 2012. By March this year, since the implementation of the Affordable Care Act, the percentage had fallen by 10.1 percentage points to 4.8%, the third largest drop nationwide. Low-income residents were by far the largest group to benefit from the ACA. As of January, since the state expanded Medicaid, more than 400,000 Oregon residents had received health insurance.

Oregon was one of five states that experienced significant technical issues with the rollout of its online exchange. Had the state exchange been implemented without a hitch, the 10.1 percentage point drop in the uninsured population may have been even larger.

4. California
> Ppt change in uninsured rate, 2012-2015: -9.0
> Expanded Medicaid?:
yes
> Pct. population without health insurance, 2012: 17.9% (9th highest)
> Pct. population without health insurance, 2015: 8.9% (21st highest)

California established its own state-run exchange, Covered California, early on and expanded Medicaid. To assist the state with building its health insurance exchange and expansion programs, California received more than $1 billion in federal grants between 2010 and 2014.

In 2012, before the Health Insurance Marketplace open enrollment period began, 17.9% of California’s population did not have health insurance. Since then, the uninsured rate has fallen by 9 percentage points to 8.9%, just lower than the national rate. The state’s expansion of Medicaid was by far the largest contributor to the decline in the uninsured rate. As of January, more than 3 million low-income residents in California gained health insurance under the expansion.

5. Arkansas
> Ppt change in uninsured rate, 2012-2015: -8.6
> Expanded Medicaid?:
yes
> Pct. population without health insurance, 2012: 16.4% (15th highest)
> Pct. population without health insurance, 2015: 7.8% (24th lowest)

An estimated 16.4% of Arkansas residents did not have health insurance in 2012, the 15th highest rate at the time. By March this year, the percentage had fallen by 8.6 percentage points, the fifth largest drop nationwide. After the coverage increase, 7.8% of state residents still did not have health insurance, the 24th lowest share in the country. Low-income Arkansas residents were by far the largest group to benefit from the ACA. As a result of the Medicaid expansion, 268,000 state residents gained health insurance, the vast majority of the total improvement.

Arkansas was the first state to announce its intentions to partner with the federal government to roll out the Affordable Care Act. Recently, Governor Asa Hutchinson received approval from the HHS to take full control of the health insurance exchange. The program will be fully state-run by 2016.

6. Colorado
> Ppt change in uninsured rate, 2012-2015: -8.3
> Expanded Medicaid?:
yes
> Pct. population without health insurance, 2012: 14.7% (19th highest)
> Pct. population without health insurance, 2015: 6.4% (19th lowest)

An estimated 14.7% of Colorado residents did not have health insurance in 2012. By March this year, the percentage had fallen by 8.3 percentage points to 6.4%, the sixth largest increase nationwide. The state’s recent expansion of Medicaid was by far the largest contributor to the decline in the rate of the uninsured state population. As of January, more than 400,000 low-income Colorado residents gained health insurance under the expansion.

Colorado was one of eight states to both implement its own state run exchange and expand Medicaid. The state received approximately $180 million in federal grants to implement its exchange program.

7. Nevada
> Ppt change in uninsured rate, 2012-2015: -8.2
> Expanded Medicaid?:
yes
> Pct. population without health insurance, 2012: 22.2% (2nd highest)
> Pct. population without health insurance, 2015: 14.0% (4th highest)

More than 600,000 Nevada residents did not have health insurance in 2012, or 22.2% of the state’s population. At the time, this was the second highest rate nationwide after Texas. As of March 2015, since the Affordable Care Act was implemented, that percentage had dropped by 8.2 percentage points, a more significant drop than the 5.7 percentage point decrease nationwide. Despite the drop, however, 14% of Nevada’s residents still do not have health insurance. Low-income residents were by far the largest group to benefit from the ACA. As a result of the Medicaid expansion, more than 200,000 people in the state now have health insurance.

Nevada’s state insurance marketplace, Nevada Health Link, experienced serious technical glitches upon its rollout. Despite the initial problems, the ACA has been beneficial, not only in terms of getting more Nevadans insured, but also in significant savings for seniors receiving Medicare benefits. According to the federal government, Nevada seniors have saved $87.7 million since the ACA’s implementation.

8. West Virginia
> Ppt change in uninsured rate, 2012-2015: -8.2
> Expanded Medicaid?:
yes
> Pct. population without health insurance, 2012: 14.4% (21st highest)
> Pct. population without health insurance, 2015: 6.2% (16th lowest)

After open enrollment in the Health Insurance Marketplace began on October 1, 2013, health insurance coverage in every state increased. The percentage of the population without health insurance decreased from 14.4% in 2012 to 6.2% as of March this year, the eighth largest decrease nationwide. Uninsured rates decreased the most among low-income Americans, and this was especially the case in West Virginia, where 18.5% of people lived in poverty, the 10th highest rate. More than 170,000 state residents received health insurance under the Medicaid expansion, making up the vast majority of the increase. The state did not develop its own health care exchange. Uninsured West Virginia residents need to go to the federal government’s site healthcare.gov to sign up for insurance.

9. Florida
> Ppt change in uninsured rate, 2012-2015: -7.9
> Expanded Medicaid?:
no
> Pct. population without health insurance, 2012: 20.1% (4th highest)
> Pct. population without health insurance, 2015: 12.2% (9th highest)

In 2012, before the Health Insurance Marketplace open enrollment period began, 3.8 million Florida residents, or 20.1% of the population, did not have health insurance. Since then, the state’s uninsured rate dropped by 7.9 percentage points, well above the nationwide drop of 5.7 percentage points over that period.

Like most states in the Southeast, Florida did not expand Medicaid. Though Florida had one of the 10 largest percentage point decreases in its uninsured population, the HHS estimates that another 848,000 low-income Floridians would have been covered had the state’s government decided to take advantage of the federal funds and expand Medicaid.

While average premiums were not significantly higher in states that did not expand Medicaid, the average premium for a 40-year-old, nonsmoking man was $303, the sixth highest in the country.

10. Rhode Island
> Ppt change in uninsured rate, 2012-2015: -7.7
> Expanded Medicaid?:
yes
> Pct. population without health insurance, 2012: 11.1% (15th lowest)
> Pct. population without health insurance, 2015: 3.4% (3rd lowest)

In 2012, 114,865 Rhode Island residents did not have health insurance, or 11.1% of the state’s population. As of March 2015, since the Affordable Care Act was implemented, that percentage had dropped by 7.7 percentage points, a larger drop than the national decline of 5.7 percentage points over that period.

Governor Lincoln Chafee established Rhode Island’s insurance exchange program through an executive order. Rhode Island was one of eight states that took total control of the ACA implementation and Medicaid expansion. The state received nearly $140 million in federal grants, $35.6 million of which came from an Early Innovator grant.

How did your state do? Visit 24/7 Wall St. to see how all 50 states made out.