In the wake of the states’ continued debate on the Medicaid expansion, recent studies have shed light on the question, “Who benefits?” More precisely, which states have the most to gain from expansion, and why? There are several ways to answer that question. We could start with the most basic questions:
- How many, i.e., what percentage, of the state’s residents live in households with incomes at or below 138 percent of the federal poverty level (FPL)?
- How many, and what percentage, of the people at that income level have no health insurance? That is, how many are not covered by Medicaid (or the Children’s Health Insurance Program), employer-sponsored insurance, an individual or family policy, or other public insurance such as TriCare or veterans’ benefits?
According to the Kaiser Family Foundation, which uses federal government statistics, 28 percent of U.S. residents live in families with incomes below 139 percent of FPL. But this population is not evenly distributed among the states. The states with the highest percentages are New Mexico (36 percent), Mississippi and Louisiana (both 35 percent). Four states are tied for fourth place, with 33 percent of their residents below 139 percent of FPL—Texas, South Carolina, Hawaii, and Arkansas.
The Medicaid expansion adds adults with incomes up to 138 percent of FPL, who are not eligible as parents, pregnant women, age 65 or over, or disabled. For convenience, let’s refer to these adults as “newly eligible” and “low-income.” So how many of them are there? And how many are uninsured? In absolute numbers, California has the highest population of adults under 139 percent of FPL: more than 6.9 million. Of those, 3.2 million, or 46 percent, are uninsured. Texas has the highest percentage of uninsured adults with incomes under 139 percent of FPL —58 percent (2,531,600) of 4.389 million low-income Texans are uninsured. In six states, 50 percent or more of the newly eligible adults are uninsured; the other five are Florida and Nevada (53 percent), and, tied for fourth place, Montana, Louisiana, and Idaho.
A new study released by the Urban Institute, and funded by the Robert Wood Johnson Foundation, took the research a step further. Kyle Caswell, Timothy Waidmann, and Linda Blumberg used statistical analysis to focus on the extent to which the newly eligible, low income adults in each state had unusually high medical expenses. They measured the burden of out-of-pocket medical spending according to the percentage of their income that people spent; they considered people at the 75th percentile to have burdensome medical expenses. In other words, as a percentage of their income, these people spent more on health care than 75 percent of the population.
The researchers found that the income, and the percentage spent on medical expenses, varied among states. They attributed the differences to many causes, including: (1) the number of providers available and the extent of competition; (2) the extent of the safety net other than Medicaid; and (3) the eligibility levels for Medicaid benefits and the benefits available. There was insufficient data to determine the extent to which any of these factors contributed to the level of burden. The percentage of the population in each state that were low-income, newly eligible, and burdened with high medical expenses ranged from 3.0 percent in Vermont to 8.1 percent in Nevada. The percentage of that population who were uninsured or were covered by private insurance or public programs varied as well, and so did the amount they spent on health care. Many of the states where low-income, newly eligible adults spent the highest percentage of their incomes on health care, i.e., those with spending at the 75th percentile, were also the states with higher percentages of low-income adults generally and higher percentages of uninsured. In eight states, low-income residents with high medical expenses spent 23 percent or more of their income on medical care. Low-income Alaskans spent the highest percentage, 28.8 percent. The top ten included some states whose general population spent relatively low percentages, specifically, Maryland, New Hampshire, New Jersey, and Virginia. But some of the same states with higher percentages of low-income, uninsured residents also appeared in the top ten, including Nevada, Louisiana, and Arkansas. Texas residents whose spending reached the 75th percentile spent less of their income on health care, 14.9 percent.
Another recent article examined regional differences in women’s mortality rates—in 42.8 percent of U.S. counties, female mortality rates rose between 1992 and 2006, even while mortality rates declined in most of the country. It’s interesting to note how many of the same states with high percentages of uninsured, low-income adults also have declining life expectancy for women, as reflected in this chart.