Uninsured rates drop dramatically in US states that embraced health reform law

BMJ 2015; 351 doi: (Published 12 August 2015) Cite this as: BMJ 2015;351:h4397
  1. Michael McCarthy
  1. 1Seattle

Since the Affordable Care Act was implemented the uninsured rate in the United States has fallen 5.6 percentage points, from 17.3% in 2013 to 11.7% in the first half of 2015, and states that embraced the law have seen the greatest declines, a new survey shows.

The survey,1 conducted by the polling company Gallup, used 2013 as the benchmark, because the following year two major provisions of the law came into effect. These were the creation of the online health insurance exchanges, where individuals and families can purchase coverage, often with the help of subsidies; and federal funding to allow states to expand their Medicaid programs to cover all adults under 65 with incomes under 133% of the federal poverty level—about $16 000 (£10 280; €14 380) for an individual and $32 000 for a family of four. People aged 65 and older are eligible for coverage through Medicare, the federal insurance plan for elderly people.

The potential effect of the Medicaid expansion, however, was limited when the US Supreme Court ruled in 2012 that states did not have to expand their Medicaid programs as the law mandated, allowing 19 Republican led states to decline to expand their programs. Under the law, states also had the option not to set up their own insurance exchanges, and 27 states decided not to do so, either because their leadership opposed the Affordable Care Act or out of convenience. In those states, residents had to shop for health insurance on an exchange run by the federal government.

The Gallup poll found that the 22 states that implemented both of the law’s provisions—expanding Medicaid eligibility and setting up either their own exchange or one in partnership with the federal government—saw their uninsured rates fall on average by 7.1 percentage points, a 44% reduction in the rate. In contrast, the 28 states that implemented only one or neither of the provisions saw a decline of only 5.3 percentage points, a 28% reduction.

The two states with the sharpest reductions were Arkansas, whose uninsured rate dropped from 22.5% in 2013 to 9.1% in 2015, and Kentucky, whose rate dropped from 20.4% to 9.0%. Both states had implemented both provisions of the health reform law.

Texas, which neither expanded Medicaid nor set up its own exchange, still saw its uninsured rate drop by 6.2 percentage points; nevertheless, its uninsured rate remains the highest in the nation at 20.8%. In contrast, Rhode Island, which implemented both provisions of the law, achieved the lowest uninsured rate in the US at 2.7%, down from 13.3% in 2013. Overall, seven states now have uninsured rates of 5% or lower.

The poll had a margin of sampling error of 1 to 2 percentage points in large states, but it was as high as 4 percentage points in states with small populations, such as North Dakota, Wyoming, Vermont, and Alaska.


Cite this as: BMJ 2015;351:h4397


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