The Five Worst States

State of residence increasingly determines physical and economic wellbeing. Nowhere is this more obvious than in the latest statistics on health insurance coverage. Among the population under age 65, those living in states that refused to expand Medicaid coverage as intended by the Affordable Care Act are much more likely to be without health insurance, according to a National Center for Health Statistics report. 

As of 2020, 35 states had expanded Medicaid coverage to include all adults with incomes up to and including 138 percent of the federal poverty level. In the Medicaid expansion states, only 8.5 percent of people under age 65 were uninsured. 

Fifteen states had not expanded Medicaid coverage as of 2020. In those states, fully 17.1 percent of the population under age 65 was uninsured—double the uninsured rate of the expansion states. These were the holdout states at the time: Alabama, Florida, Georgia, Kansas, Mississippi, Missouri, Nebraska, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming. Three of these states have expanded Medicaid since 2020—Missouri, Nebraska, and Oklahoma.

Which states are the worst when it comes to health insurance? These are the top five...

Five states with the largest percentage of uninsured among population under age 65, 2020

24.0% in Oklahoma

23.1% in Texas

20.3% in Georgia

16.9% in North Carolina

16.7% in Florida

Source: National Center for Health Statistics, Geographic Variation in Health Insurance Coverage: United States, 2020 (PDF)

The Cost of Health Insurance in 2020

The 54 percent majority of Americans had employment-based health insurance in 2020, according to the Census Bureau's Current Population Survey. Employer-provided health insurance is costly for both employers and employees—and increasingly so, according to the Medical Expenditure Panel Survey. Here is how much employers and employees paid for health insurance in 2020 and how much those costs have grown since 2020, after adjusting for inflation...

Annual cost of health insurance for employers, 2020 (and % change 2010-20 in 2020$)

Single premium: $7,149 (22%)

Employee plus one: $14,191 (24%)

Family premium: $20,758 (26%)

Annual employee contribution for insurance, 2020 (and % change 2010-20 in 2020$)

Single coverage: $1,532 (27%)

Employee plus one: $4,035 (36%)

Family coverage: $5,978 (35%)

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, Statistical Brief 536: Trends in Health Insurance at Private Employers, 2008–2020

The Worst States for Health Insurance

Nationally, 14.5 percent of adults aged 18 to 64 did not have health insurance in 2019, according to the National Center for Health Statistics. Texas is number one in the percentage of working-age adults without health insurance. Nearly one-third of Texans aged 18 to 64 does not have health insurance—more than double the national rate. In Oklahoma, one in four lacks health insurance. In Georgia and Florida, the figure is one in five. Why are these states doing so poorly? They have refused to expand Medicaid to all low-income adults (up to 138 percent of poverty level), as provided by the Affordable Care Act. 

States with the largest percentage of adults aged 18 to 64 without health insurance

Texas: 30.5%

Oklahoma: 25.6%

Georgia: 22.3%

Florida: 20.6%

Arkansas and North Carolina tie for 5th place on the list of the worst, with 17.8 percent of working-age adults uninsured. 

In states that have refused to expand Medicaid, an average of 20.8 percent of working-age adults do not have health insurance. In states that have expanded Medicaid, a much smaller 10.9 percent of adults aged 18 to 64 lack health insurance. The 17 states that had not expanded Medicaid as of 2019 were: Alabama, Florida, Georgia, Idaho, Kansas, Mississippi, Missouri, Nebraska, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Wisconsin, and Wyoming. 

Note: As of 2021, five additional states have adopted Medicaid expansion: Idaho, Missouri, Nebraska, Oklahoma, and Utah. 

Source: National Center for Health Statistics, Geographic Variation in Health Insurance Coverage: United States, 2019 (PDF)

How Many Will Lose Their Health Insurance?

The official unemployment rate climbed to 14.7 percent in April, the Bureau of Labor Statistics reports, a level of unemployment not seen since the Great Depression. Sky high unemployment is not just an economic problem for the United States, but also a public health problem. Most Americans depend on employer-provided health insurance. As they lose their jobs, they lose their insurance.

An Urban Institute study tallies up just how many are likely to lose their health insurance in the months ahead, and the results are not for the faint of heart. Urban Institute researchers examined the health insurance consequences of an unemployment rate of 15, 20, and 25 percent. Here are the findings...

15% unemployment rate: 17.7 million would lose insurance (5.1 million more uninsured)
20% unemployment rate: 25.4 million would lose insurance (7.3 million more uninsured)
25% unemployment rate: 33.0 million would lose insurance (9.6 million more uninsured)

Note that the number of people losing employer-provided health insurance far surpasses the number who join the ranks of the uninsured. That's because many of the uninsured would qualify for Medicaid because of their lower incomes, and many others would purchase marketplace health insurance through the Affordable Care Act. Despite these safety nets, however, the Urban Institute projects a painful rise in the number of Americans without health insurance. With unemployment at 15 percent, the number of uninsured would rise 18 percent. At 20 percent unemployment, the number of uninsured would increase by 26 percent. At 25 percent unemployment, the uninsured would expand by 34 percent.

But the situation might become even uglier than these numbers suggest. That's because, once again, the Affordable Care Act is before the Supreme Court, with a number of states arguing that the law should be declared unconstitutional. If the Supreme Court agrees and strikes down the ACA, warns the Urban Institute, our Great Depression level of unemployment will lead to many more uninsured Americans than the estimates indicate. "Reversing the ACA, and thereby strengthening the relationship between joblessness and uninsurance, would counteract efforts to contain the virus, improve public health, and stabilize the economy."

Source: Urban Institute, How the Covid-19 Recession Could Affect Health Insurance Coverage

10 Questions: An Update (Part 2)

Two years ago Demo Memo presented 10 vital demographic questions and asked how many answers to these questions we would have once we had more data in hand. Two years later, the same questions are still of great importance. We have more data. So how much more do we know? Questions 1 through 5 were examined in this post. Here's a look at the rest...

6. Is the average American getting richer? With the benefit of hindsight, the answer to this question is yes and no. The wealth of American households plunged in the aftermath of the Great Recession. Median household net worth fell from $139,700 in 2007 to a post-Great Recession low of $83,700 in 2013, then climbed to $97,300 in 2016, after adjusting for inflation—still 30 percent below the 2007 peak. An analysis by the Federal Reserve Bank of St. Louis finds that the wealth of Americans born in the 1950s and earlier has recovered from the Great Recession losses, while the wealth of those born in the 1960s, 1970s, and 1980s has not.

7. Who voted in the 2016 election? This question was answered by the Census Bureau's survey of voting and registration, released in the spring of 2017. We now know that the number of older non-Hispanic White voters surged in 2016. Largely because of the aging of the baby-boom generation, 2.8 million more non-Hispanic Whites aged 65 or older voted in 2016 than in 2012. This trend is only going to intensify as the baby-boom generation continues to fill the 65-plus age group. While minorities will become the majority of the population in 2044, they will not become the majority of voters until 2064.

8. Are we back to square one with health insurance? Although Republican efforts to repeal the Affordable Care Act have not been successful, this question still matters after a federal judge in Texas declared the entire Affordable Care Act invalid—a case that may be headed for the Supreme Court. Meanwhile, a growing share of the public has a favorable view of the ACA, the figure rising from 43 percent in November 2016 to 53 percent in November 2018. This battle is ongoing.

9. How big is the gig economy? Are gig workers a tiny and stable fraction of the workforce, or are they an enormous and growing share of workers—24 percent according to one study and 31 percent according to another? We still don't know. In the past year, the BLS failed in its attempt to measure the gig economy, but nevertheless claimed gig workers to be few, far between, and not growing as a share of workers. Researchers scoffed at the BLS findings, theorizing that the Current Population Survey's labor force questions failed to capture gig work. The BLS fired back with a defense of the CPS. As the dust settles from this kerfuffle, all we know is that the size of the gig economy ranges from negligible to enormous.

10. Are we over the automobile? The evidence is building that we are past the point of peak transportation spending. The percentage of the household budget devoted to transportation is well below the all-time high of 19-plus percent of the mid-1980s and early 2000s. In 2017, transportation consumed a smaller 15.9 percent of the household budget. With transportation the second biggest expense for the average household, helping Americans cut their transportation costs is a no-brainer for both businesses and governments. It also helps explain the appeal of cities: urban households spend much less than their rural counterparts on transportation.

27% Say They Have a Pre-existing Condition

Only 27 percent of Americans aged 18 or older say they have a pre-existing condition, according to a Gallup poll. Among people aged 65 or older, just 38 percent say they have such a condition. These unrealistically low figures show that the public either doesn't understand the meaning of "pre-existing condition" or is afraid to admit they have one—even to a pollster. Government data show that a much larger share of Americans have what could be considered a pre-existing condition. For example...

• 40% of people aged 18 or older are obese, according to the National Health and Nutrition Examination Survey. 
• 57% of people aged 65 or older have hypertension, according to the National Health Interview Survey. 
• 67% of people aged 65 or older have taken three or more prescription drugs in the past month, according to the National Health and Nutrition Examination Survey.

Clearly, millions more Americans have pre-existing conditions than are willing to admit it, including the majority of older Americans. Why, then, is there any debate at all about whether health insurance companies should be prohibited from denying coverage because of a person's medical history?

Source: Gallup, One in Four U.S. Adults Say They Have a Pre-Existing Condition

How Much Do You Pay for Health Insurance?

The nation's private-sector workers who receive health insurance from an employer pay only a fraction of the cost. Their employer pays the rest. Here are the latest health insurance cost estimates from the Medical Expenditure Panel Survey and how they compare to costs in 2004...

Average annual cost for single coverage in 2017 (and 2004)
Total premium: $6,368 ($3,705)
Employer contribution: $4,953 ($3,034)
Employee contribution: $1,415 ($671)

Average annual cost for employee plus-one coverage in 2017 (and 2004)
Total premium: $12,789 ($7,056)
Employer contribution: $9,258 ($5,390)
Employee contribution: $3,531 ($1,667)

Average annual cost for family coverage in 2017 (and 2004)
Total premium: $18,687 ($10,006)
Employer contribution: $13,469 ($7,568)
Employee contribution: $5,218 ($2,438)

Employee contributions for health insurance have more than doubled since 2004, and employer contributions have grown 63 to 78 percent. Employer contributions grew more slowly during those years because private-sector businesses are requiring their employees to pay a higher share of the total. For employees with single coverage, their share of the health insurance premium grew from 18 to 22 percent between 2004 and 2017. For those with plus-one or family coverage, their share of the bill climbed from 24 to 28 percent.

Source: Medical Expenditure Panel Survey, MEPS Insurance Component Chartbook 2017

Trends in Health Insurance, 2013 to 2017

How has health insurance coverage changed with the implementation of the Affordable Care Act? Surprisingly, it hasn't changed all that much. Most Americans get their health insurance through an employer (either their own employer or a spouse's or parent's employer). The percentage of the population with employer-provided health insurance in 2017 was identical to the percentage who had it in 2013—before most provisions of the ACA went into effect. Here is the distribution of the population by type of health insurance in 2017 and the trend since 2013...

• 56.0% of the population has employment-based health insurance, nearly identical to the 55.7 percent of 2013.
• 19.3% of the population has Medicaid coverage, higher than the 17.5 percent of 2013 because of the ACA's Medicaid expansion.
• 17.2% of the population has Medicare coverage, higher than the 15.6 percent of 2013 because the large baby-boom generation is filling the 65-plus age group.
• 16.0% of the population has direct-purchase health insurance, up from 11.4 percent in 2013. Behind the increase are the ACA's marketplace plans, providing access to health insurance for millions who were once shut out because of preexisting conditions or price. The number of people with direct-purchase health insurance grew by 16 million between 2013 and 2017— a 45 percent increase and the single biggest change in health insurance coverage during the time period.
• 4.8% of the population has military coverage, up from 4.5 percent in 2013.
• 8.8% of the population had no health insurance at any time during 2017, down from 13.3 percent who were without health insurance in 2013. The number of people without health insurance fell by 13 million during those years, a 32 percent decline. 

Note: The percentage of the population with health insurance by type sums to more than 100% because some people have more than one type of coverage.
Source: Census Bureau, Current Population Survey Tables for Health Insurance Coverage

47% of Private-Sector Employers Provide Health Insurance

Only 47 percent of private-sector businesses provided health insurance for their employees in 2017, according to the Employee Benefit Research Institute. This is well below the 56 percent of 2008, but higher than the 45 percent of 2016. By size of establishment, this is the percentage of businesses that offer health insurance...

Percent of establishments offering health insurance to employees, 2017
Less than 10 employees: 23.5%
10 to 24 employees: 49.2%
25 to 99 employees: 74.6%
100 to 999 employees: 96.3%
1,000 or more employees: 99.3%

One factor behind the decline in the provision of employer-provided health insurance since 2008, says EBRI, was the introduction of the Affordable Care Act. The ACA allowed those working for smaller establishments to get health insurance in the marketplace. A factor behind the increase in the provision of health insurance between 2016 and 2017, says EBRI, is the low unemployment rate. The provision of health insurance has become a tool for recruiting and retaining workers in a tight labor market.

Source: Employee Benefit Research Institute, After Years of Erosion, More Employers are Offering Health Coverage; Worker Eligibility Higher

What If Every State Expanded Medicaid?

The percentage of Americans who do not have health insurance has plummeted over the past few years, thanks to the Affordable Care Act. When the ACA was enacted in 2010, a substantial 18.2 percent of people under age 65 did not have health insurance. By 2017, just 10.7 percent did not have health insurance, according to the National Center for Health Statistics. The decline would be even greater if every state adopted Medicaid expansion, according to an analysis by Matthew Buettgens of the Urban Institute.

One of the provisions of the Affordable Care Act was to expand the Medicaid program in every state, providing insurance to people with incomes up to 138 percent of poverty level. As of March 2018, however, only 31 states and the District of Columbia had chosen to expand the program. If the 19 holdout states had a change of heart, according to Buettgens' analysis, the number of Americans without health insurance would fall by more than 4 million. Expanding Medicaid would reduce the number of nonelderly without health insurance by at least 20 percent in each of the 19 states and by an even larger 34 percent in Mississippi, 32 percent in Idaho, and 30 percent in Missouri. The percentage of the nonelderly without insurance in those states would drop from 16.9  to 12.6 percent on average, and it would fall into the single digits in six states including Maine and Wisconsin.

While Medicaid expansion would increase a state's Medicaid spending, the savings in other areas would more than make up for the cost, Buettgens says. "The research shows that, compared with nonexpansion states, Medicaid expansion states have seen larger declines in the number of uninsured people, lower uncompensated care, economic benefits from additional health care spending, and net gains to state budgets."

Source: Urban Institute, The Implications of Medicaid Expansion in the Remaining States: 2018 Update

County Extremes: Health Insurance Coverage

The percentage of Americans aged 21 to 64 who do not have health insurance varies greatly by county, according to the Census Bureau's small area health insurance estimates. At one extreme is Norfolk County, Massachusetts, where only 2.6 percent of people aged 21 to 64 were not insured in 2016. At the other extreme is Hidalgo County, Texas, where 40.9 percent were not insured.

A look at the Census Bureau's interactive map accompanying the data reveals Texas to be a hot spot of the uninsured. Of the 10 counties in the nation with the highest percentage of people aged 21 to 64 who are uninsured, all are in Texas. At the other extreme, 7 of the 10 counties with the smallest percentage of uninsured are in Massachusetts.

Source: Census Bureau, Small Area Health Insurance Estimates

26% of Low-Income Full-time Workers Are Uninsured

Many low-income workers with full-time jobs are uninsured, according to a study by Jessica A Carson of the University of New Hampshire's Carsey School of Public Policy. The study defines low-income workers as those with household incomes below 200 percent of the poverty level—or an income below about $25,000 for a single person and below about $49,000 for a family with two adults and two children.

Among low-income full-time year-round workers aged 25 to 64, a substantial 26 percent were not covered by health insurance at any time in 2016 versus only 8 percent of their counterparts with higher incomes. Just 33 percent of the low-income workers were covered by their employer's health insurance plan versus the 57 percent majority of those with higher incomes.

When low-income workers were asked why they did not have health insurance through their employer, the largest share—40 percent—said their employer does not offer health insurance. Among higher-income workers, only 18 percent work for an employer who does not offer insurance. Other reasons given by low-income workers for not signing for employer-provided health insurance were cost and ineligibility—they worked too few hours, they were a temporary or contract employee, or they hadn't been on the job long enough.

"As changes to health insurance policy continue to evolve," the report concludes, "it is critical to keep in mind that full-time employment isn't necessarily a ticket to health insurance, and that access to employer-based health insurance is stratified by income and industry."

Source: University of New Hampshire Carsey School of Public Policy, Full-Time Employment Not Always a Ticket to Health Insurance

How Workers Manage Increases in Health Care Costs

Among American workers aged 21 to 64, health care is the most critical issue in the United States, according to the 2017 EBRI/Greenwald and Associates Health and Workplace Benefits Survey. Thirty-one percent of workers say health care is the number-one issue, well above second-place terrorism, cited by 21 percent.

Most workers consider health insurance extremely important when considering whether to stay with an employer or take a new job. Fully 60 percent say health insurance benefits are extremely important versus a smaller 42 percent who feel that way about retirement benefits.

Nearly half of workers say their health care costs increased in the past year. Among those who reported an increase, here's how they managed the higher cost...

43% decreased their contributions to savings
36% had difficulty paying other bills
34% increased their credit card debt
30% used up most or all of their savings
28% had difficulty paying for basic necessities
27% delayed retirement
26% decreased their contributions to retirement plans
22% borrowed money

Source: Employee Retirement Research Institute and Greenwald and Associates, Workers Rank Health Care as the Most Critical Issue in the United States

Private-Sector Health Insurance Costs, 2016

Several years ago Demo Memo noted that most Americans were "health insurance dummies," sheltered from an understanding of the full cost of health insurance by employer-provided plans. Here is how much those employer-provided plans cost in 2016...

Average total cost of employer-provided health insurance in the private sector, 2016
Single coverage: $6,101
Family coverage: $17,710

Fortunately for most private-sector workers, their employer pays the bulk of the bill. For single coverage, the average employee paid $1,325 of the $6,101 cost in 2016. For family coverage, the average employee paid $4,956 of the $17,710 premium.

Source: Medical Expenditure Panel Survey, Results from the 2016 MEPS-IC Private-Sector National Tables

Making Health Insurance Unaffordable

How much would essential health benefits cost if they were no longer required, as they currently are under the Affordable Care Act, and only those who opted for the service financed the cost? An Urban Institute study has calculated the cost, and it's steep.

The average nongroup marketplace premium was $4,700 in 2017, reports the Urban Institute. But start cherry-picking benefits, and premiums will be much higher. Take maternity care for example. Maternity care accounts for just $278 of the $4,700 annual cost of a typical health insurance plan—not all that much. But if health insurance buyers could opt out of maternity care benefits so that only those who needed maternity care had to pay for it, then those who chose maternity care would see their annual health insurance premium rise by $13,388.

Cherry picking health benefits will greatly increase the cost of health insurance for those who need essential services...

Additional health insurance premium cost if only users finance the service
Inpatient care: $19,071
Maternity care: $13,388
Outpatient care: $5,755
Emergency care: $4,251
Rehabilitative care: $2,247
Office-based care: $1,947
Prescription drugs: $1,836

Source: Urban Institute, The Implications of Cutting Essential Health Benefits: An Analysis of Nongroup Insurance Premiums Under the ACA

Big Decline in Chronically Uninsured

The percentage of 18-to-64-year-olds who are "chronically uninsured"—meaning they have not had health insurance for more than one year—has fallen by more than half, thanks to the Affordable Care Act.

Percent of people aged 18 to 64 who are chronically uninsured 
2016: 7.6%
2015: 9.1%
2014: 12.3%
2013: 15.7%
2012: 16.2%
2011: 16.3%
2010: 16.8%

Source: National Center for Health Statistics, Changes in the Characteristics of Chronically Uninsured Adults: Early Release of Estimates from the National Health Interview Survey, 2010–September 2016

Americans Don't Know Much about the ACA

Americans are really confused about the Affordable Care Act. A survey by the Kaiser Family Foundation shows just how confused they are. Kaiser says these are the five biggest misconceptions...

1. Most do not know that the ACA reduced the percentage of Americans without health insurance. The 57 percent majority thinks the ACA increased the uninsured or had no effect on the number. In fact, the ACA reduced the uninsured to an historic low. 
2. Half says the ACA covers undocumented immigrants. It does not.
3. Half does not know that the ACA eliminated out-of-pocket costs for birth control, annual checkups, well-child visits and vaccinations. 
4. Forty percent of the public think the ACA cut Medicare benefits. It did not.
5. 29 percent of the public think most Americans get their health insurance through the ACA. In fact, only 10 percent of Americans are covered by ACA marketplace plans. Most Americans have employer-provided health insurance coverage.

Source: Kaiser Family Foundation, Data Note: 5 Misconceptions Surrounding the ACA

Really Long Term Trends in Health Insurance Coverage

The number of Americans under age 65 who do not have health insurance is lower today than it was all the way back in 1972, reports the National Center for Health Statistics, despite a 46 percent increase in the population under age 65.

As recently as 2013, the percentage of the population under age 65 without health insurance was the same as in 1972—so, in four decades no progress had been made in expanding insurance coverage. Enter the Affordable Care Act, with marketplace plans up and running by January 2014, an effort that finally moved the needle. The percentage of Americans under age 65 who did not have health insurance fell from 16.7 percent in 2013 to the all-time low of 10.6 percent in 2015.

Number (and percent) of population under age 65 without health insurance
2015: 28.7 million (10.6%)
1972: 30.7 million (16.7%)

Source: National Center for Health Statistics, National Health Interview Survey, Long-Term Trends in Health Insurance Coverage

Birth Control and Health Insurance Coverage

Women with health insurance are much more likely to use birth control consistently than those without health insurance, according to an Urban Institute study. Among women aged 18 to 44 at risk of an unplanned pregnancy, 73 percent of those with health insurance coverage say they always use birth control. Among their counterparts without health insurance, a much smaller 42 percent always use it.

There are differences in consistent birth control use by income as well. Among women with family incomes at or above 400 percent of poverty level, 82 percent always use birth control versus just 53 percent of women with family incomes below 138 percent of poverty level.

These findings raise concerns about the possible repeal of the Affordable Care Act, says the Urban Institute: "Repealing the ACA could increase financial barriers to contraception by increasing the number of uninsured women—particularly low-income women."

Source: Urban Institute, Access to Contraception in 2016 and What It Means to Women

10 Questions for 2017 (Part 2)

As demographic trends unfold, questions arise. This is the second of a two-part post with 10 vital questions about ongoing demographic trends. The fresh data to be released in 2017 may answer some of these questions. (Click here for Part 1.)

6. Is the average American getting richer? It's been a long three years since we had an update on American household wealth. This year, the wait is over. In a few months, the Federal Reserve Board will release the 2016 Survey of Consumer Finances, providing the first comprehensive look at household net worth and asset ownership since 2013. The past two surveys have produced unsettling results, with a steep decline in net worth recorded in 2010 and a continuing decline in 2013. The new numbers will tell us whether American households have begun to rebuild their wealth.

7. Who voted in the 2016 election? Another important piece of the demographic puzzle will be revealed in a few months when the Census Bureau releases results from the Voting and Registration supplement to the November 2016 Current Population Survey. Shortly after the election, the Census Bureau was in the field asking a nationally representative sample of Americans whether they voted and linking answers to demographics. Was there a surge in voting among older, non-Hispanic whites? Soon we will know.

8. Are we back to square one with health insurance? Between 2013 and 2015, the percentage of Americans without health insurance plunged from 20.4 percent to 12.9 percent—an unprecedented, historic decline. Are we about to see a reversal of this trend? If Republicans carry out their threat to repeal the Affordable Care Act, the percentage of Americans without health insurance is projected to climb all the way back up to 21 percent by 2019.

9. How big is the gig economy? This year the Bureau of Labor Statistics will field a long awaited and much needed update to its 2005 "contingent" workforce survey. A number of studies have revealed tremendous growth in the gig economy, a phenomenon transforming the American workforce. The BLS update, hopefully, will capture this growth and give us a better picture of the gig economy and its workers.

10. Are we over the automobile? Transportation spending may have peaked. In 2015, the average household devoted slightly less than 17 percent of its budget to transportation, down from more than 19 percent in the early 2000s. Americans are keeping their vehicles longer, increasing their use of public transportation, and adopting ride-sharing with enthusiasm. This year is likely to provide more evidence of the cooling American love affair with the automobile.