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New York Times -
Who Is Uninsured? 2015
10%
12%
14%
16% uninsured
States That Expanded Medicaid Are Outlined in Black
Two years into Obamacare, clear regional patterns are emerging about who has health insurance in America and who still doesn’t.
The remaining uninsured are primarily in
the South and the Southwest. They tend to be poor. They tend to live in
Republican-leaning states. The rates of people without insurance in the
Northeast and the upper Midwest have fallen into the single digits since
the Affordable Care Act’s main provisions kicked in. But in many parts
of the country, obtaining health insurance is still a problem for many
Americans.
These trends emerged in an analysis we
undertook with the help of two organizations that are closely monitoring
the progress of the health law. Last year, we used similar data to show
the the substantial effects Obamacare had
on reducing the number of Americans without health insurance. This
year, the same groups updated their estimates of where America’s
uninsured live, and the change is a lot less drastic. States that were
late to expand Medicaid, including Pennsylvania and Indiana, showed
substantial reductions in their uninsured residents compared with last
year. In other places, the changes have been more modest. In a few — like Mississippi — things appear to have gotten worse, with fewer people having health insurance this year than last.
“This year it’s more of a state-specific story,” said Ed Coleman, the director of data and analytics at Enroll America, an organization devoted to finding uninsured people and signing them up for insurance. Enroll worked with the data firm Civis Analytics
to produce the numbers in our map. “There was a pronounced drop pretty
much everywhere last year, and we don’t see that pattern again this time
around.”
The incremental changes in our map are consistent with other data. Fewer people signed up for insurance this year using the new state marketplaces than some analysts had expected. Medicaid enrollment
leveled off. And many of the people who lack insurance in states with a
lot of uninsured people are effectively unable to benefit from
Obamacare programs because of their low incomes and local politicians’
decisions to forgo Medicaid expansion. More than three million people
in 19 states remain stuck in a “Medicaid gap,” too poor to qualify for
subsidies in the new marketplaces, but unable to get into a government
program.
Medicaid expansion continues to be a huge predictor
of how many people remain uninsured in a given state. We’ve outlined
the states that expanded Medicaid in black to make them easy to see. But
we almost don’t have to, because many of the state lines are so clear
from the uninsured rates alone. Look at the difference between Missouri
and Illinois, for example.
Percentage Uninsured, by County, 2013 to 2015
10%
12%
14%
16% uninsured
In 2013, there were only 10 states where the percentage of residents who lacked health insurance was lower than 9 percent.
In 2014, the Affordable Care Act was rolled
out, reducing the number of Americans without health insurance. States
that expanded Medicaid, outlined in black, saw the biggest changes.
In 2015, Pennsylvania and Indiana also
expanded their Medicaid programs. Now states with the highest rates of
uninsured residents are in the South and Southwest.
Politics matters. Though several states
with Republican leadership have expanded their Medicaid programs, many
have not. Over all, Republican-leaning states continue to have more
uninsured people than Democratic-leaning ones. But they also tended to
have many more uninsured people at the start.
More Uninsured in Red States
-20%
-10
+0
+10
+20
+30
+40
20%
15
10
5
0
Obama 2012 Vote Lead
Percentage Uninsured, 2015
Ala.
Calif.
D.C.
Del.
Fla.
Hawaii
IA
Mich.
Miss.
N.C.
N.D.
N.H.
N.M.
Okla.
Utah
2013 Trend
2015 Trend
Red and blue states have seen similar declines among the uninsured since 2013.
Source: Enroll America and the Federal Elections Committee
This year’s map looks a lot like last
year’s. When the health law passed, the hope was for new insurance
opportunities to provide coverage to some 32 million people. It has
become increasingly clear that the law will not achieve that goal. In
addition to the incomplete Medicaid expansion, the result of a 2012
Supreme Court ruling, interest in the individual marketplaces has proved
more tepid than many had hoped. The Congressional Budget Office, when
it estimated the effects of the law in 2010,
had expected that eight million people would buy marketplace plans in
2014, and 21 million would have them by the end of 2016. At the end of
2014, only 6.3 million had enrolled. This month, the Department of
Health and Human Services released its estimates for enrollment for
2016: 10 million Americans. (Over the two years, there has also been some unanticipated good news: More people have remained insured through work than the C.B.O. had estimated.)
It is undeniable, however, that the law
has had a substantial effect. Compare this year’s map, where dark purple
regions represent areas where the uninsured rate remains above 16
percent, with the map from 2013, when nearly the whole country looked
purple. Medicaid expansion is being considered in a few more states.
Montana has decided to move forward next year. (Alaska started its
expansion in September.)
The data used to make this map are unlike
any other data about the number and location of the uninsured. They’re
based on a complex model that Enroll and Civis undertook using a large
survey conducted in May and tools often used by political campaigns to
target likely voters. That strategy allows us to show more detail than
is available using more conventional surveys — like these state-level surveys from Gallup — but they also use different assumptions than more conventional polling. The census, which provides the industry gold standard
data on the uninsured and where they live, takes a long time to collect
and publish data. Last fall, Enroll’s model showed us insurance rates
around the country in 2014. The census published 2014 data with a
similar level of specificity only this week.
Some of the changes between last year’s map and this one may reflect
refinements of the Enroll model more than major shifts in the level of
the uninsured. In a few states, Enroll’s 2014 estimates differed from
the 2014 census by more than a few percentage points. The states with
these errors were those that had large rural, Hispanic or Native
American populations: Alaska, New Mexico, Texas and Arizona, for
example. On this year’s map, it looks as if New Mexico’s uninsured rate
has rebounded, but that might just be a correction from an incorrect
2014 estimate. In most states, however, Enroll has confidence in its estimates for all three years and thinks the shifts are real.
For a detailed discussion of the methods used to make these calculations, read our article from last year on this model.
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New York Times -
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