The 5 best and worst states for health insurance
Key Takeaways
As physicians are well aware, American citizens are not guaranteed healthcare coverage. This isn’t the case throughout much of the developed world, where universal healthcare is the norm.
Here in the United States, access to insurance depends on several factors, and differs from state to state, with enormous implications for health. Whether a patient has health insurance can heavily influence their decision to seek care, or the type of care they will seek. If patients are uninsured and unable to afford good primary care, preventable chronic health problems can develop or worsen.
The Affordable Care Act (ACA), enacted in 2010, mandated that all states implement an online “marketplace” for health insurance plans, and gave states the choice to expand Medicaid availability to more low-income households. Coverage under the Medicaid expansion became effective in most states in January 2014—all but 12 states have adopted it to date.
The ongoing COVID-19 pandemic has made ripples in health insurance costs, which could affect insured rates—though the effects, so far, have been moderate and vary by state. The pandemic has, however, painted a stark picture of population health variance among the most- and least-insured states, and in many cases COVID-19 vaccination rates also correlate with a state’s insured rate.
Read on to learn which states are the best and worst for health insurance coverage and care availability, according to a ranking recently published by 24/7 Wall St., and other sources. Of note: All of the top five states for health insurance are also in the top 25 for primary care provider (PCP) availability, while the inverse is true for the bottom five insurance states.
The 5 worst states for health insurance
The five states with the most dismal overall health insurance coverage rates—Mississippi (#5), Georgia (#4), Florida (#3), Oklahoma (#2), and the worst, Texas (#1)—have a lot in common.
In addition to all being clustered in the Southern part of the country, they also all failed to adopt the ACA Medicaid expansion prior to 2021 (Oklahoma finally changed its tune and approved the expansion in 2020 by a margin of less than 1%; implementation of the expansion began this summer). Of the dozen states that refused Medicaid expansion, all but Wisconsin are in the bottom 20 for health insurance rates.
Among those aged 65 or younger—not yet eligible for Medicare—more than 15% of residents in all of the bottom five states lack health insurance, according to the aforementioned 24/7 Wall St. report. Texas has a reputation for going its own way, and when it comes to health insurance availability, it certainly has: It is the only state in the country where one in five residents under the age of 65 are uninsured.
In addition to the challenge of treating patients who are often uninsured or under-insured, doctors in these five states are dealing with patient populations that exhibit elevated incidence of severe chronic health issues. According to the United Health Foundation, in 2019, all five states had diabetes prevalence above the national average of 10.8%—topped by Mississippi, where nearly 15% of residents have the disease. Heart disease prevalence is also at or above the national average in these states.
According to the CDC, four of these five states are in the bottom half in terms of life expectancy, with only Florida breaking the top 25. Likewise, Florida is the only one of the five whose COVID-19 vaccination rate exceeds the national rate of 56.7%, as of writing this article—and it’s the only one of the bunch with more than 130 primary care providers per 100,000 people.
Here are some key metrics that make these five states the worst for health insurance coverage rates. (Editor’s note: The COVID vaccination data is current as of October 5, 2021, when this article was published; rates may rise).
5th Worst: Mississippi
Population under 65 without insurance: 15.4%
Population under 65 on Medicaid: 25.1%
Population fully vaccinated against COVID-19: 43.6%
Primary care providers per 100,000: 108.6
ACA Medicaid expansion: Not adopted
4th Worst: Georgia
Population under 65 without insurance: 15.5%
Population under 65 on Medicaid: 17.5%
Population fully vaccinated against COVID-19: 45.7%
Primary care providers per 100,000: 121.9
ACA Medicaid expansion: Not adopted
3rd Worst: Florida
Population under 65 without insurance: 16.3%
Population under 65 on Medicaid: 18.1%
Population fully vaccinated against COVID-19: 57.4%
Primary care providers per 100,000: 131.3
ACA Medicaid expansion: Not adopted
2nd Worst: Oklahoma
Population under 65 without insurance: 16.8%
Population under 65 on Medicaid: 18.7%
Population fully vaccinated against COVID-19: 47.9%
Primary care providers per 100,000: 129.4
ACA Medicaid expansion: Implemented in July 2021
Worst: Texas
Population under 65 without insurance: 20.8%
Population under 65 on Medicaid: 16.2%
Population fully vaccinated against COVID-19: 51.4%
Primary care providers per 100,000: 113.2
ACA Medicaid expansion: Not adopted
The 5 best states for health insurance
Unlike the worst five states for health insurance, the five best—Minnesota (#5), Vermont (#4), Hawaii (#3), Rhode Island (#2), Massachusetts (#1)—are not clustered in one corner of the country. Hawaii is nearly 5,000 miles from Vermont, yet they sit at third and fourth on the list, respectively.
Vermont is joined by fellow New England states Rhode Island and Massachusetts, which fall first and second among the top five, rounded out by midwestern Minnesota. These represent the only five states in the country where more than 94% of non-Medicare-aged residents have health insurance.
Unlike the five states with the poorest health insurance coverage rates, every one of the top five states implemented ACA Medicaid expansion at its earliest availability in 2014.
Massachusetts, the national leader, has a 96.5% insured rate among non-Medicare eligible residents. One reason for that is the state’s early efforts toward comprehensive health policy. Nearly a decade before ACA Medicaid expansion came into effect, the state approved its own MassHealth Medicaid expansion program that helped drive health insurance rates to the top of the heap.
There are definite commonalities among the top five, though. Widespread availability of health insurance, for instance, is often paired with more access to primary care. With a nation-leading 264.5 primary care physicians per 100,000 people, Rhode Island has more than twice as many PCPs per capita as any of the states in the bottom five groups in these rankings.
These states also have comparatively high COVID vaccination rates. While Minnesota (58.4%) and Hawaii (58.1%) are both slightly above the 55.5% full-vaccination rate against COVID-19, more than 67% of residents in the three New England states are fully vaccinated.
Still, these states are not immune to challenging chronic health conditions. Drawing from CDC data, United Health Foundation lists the adult excessive drinking rate at 18.6% among legal-age adults nationwide—which all of the five most-insured states exceeded in 2019, the most recent data-year available.
5th Best: Minnesota
Population under 65 without insurance: 5.8%
Population under 65 on Medicaid: 18.9%
Population fully vaccinated against COVID-19: 58.4%
Primary care providers per 100,000: 165.9
ACA Medicaid expansion: Implemented 2014
4th Best: Vermont
Population under 65 without insurance: 5.6%
Population under 65 on Medicaid: 25.8%
Population fully vaccinated against COVID-19: 69.6%
Primary care providers per 100,000: 183.3
ACA Medicaid expansion: Implemented 2014
3rd Best: Hawaii
Population under 65 without insurance: 5.0%
Population under 65 on Medicaid: 19.5%
Population fully vaccinated against COVID-19: 58.1%
Primary care providers per 100,000: 187.6
ACA Medicaid expansion: Implemented 2014
2nd Best: Rhode Island
Population under 65 without insurance: 4.8%
Population under 65 on Medicaid: 21.6 %
Population fully vaccinated against COVID-19: 68.6%
Primary care providers per 100,000: 264.5
ACA Medicaid expansion: Implemented 2014
Best: Massachusetts
Population under 65 without insurance: 3.5%
Population under 65 on Medicaid: 23.0%
Population fully vaccinated against COVID-19: 68.1%
Primary care providers per 100,000: 245
ACA Medicaid expansion: Implemented 2014
In related coverage, health insurance is just one of the numerous healthcare disparities in this country. Click here to read more about this topic on MDLinx.