States adopting ACA’s health care provisions provide more access to care

The Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) “has significantly affected health insurance coverage and access among U.S. adults. However, the law gives states flexibility in implementing certain provisions, leading to wide variations between states in consumers’ experience,” according to a report issued on March 22, 2017, by the Commonwealth Fund. The Commonwealth Fund analyzed the Commonwealth Fund Biennial Health Insurance Survey, 2016, which was conducted by Princeton Survey Research Associates International, to compare the differences in insurance coverage, access to care, costs of care, and medical bill and debt problems in California, Florida, New York, and Texas, the nation’s four largest states.


The uninsured rate has fallen in all four states since 2012. The report noted the following variations for 2016:

  • The uninsured rates among adults age 19 to 64 varied from 7 percent in New York and 10 percent in California to 16 percent in Florida and 25 percent in Texas.
  • The proportions of residents reporting problems getting needed care because of cost was significantly lower in California and New York than in Florida and Texas.
  • Lower percentages of Californians and New Yorkers reported having a medical bill problem in the past 12 months or have accrued medical debt compared to Floridians and Texans.
  • The uninsured rates for young adults were 8 percent in California, 10 percent in New York, 23 percent in Florida, and 30 percent in Texas.
  • The uninsured rates for adults with incomes below the federal poverty level were 9 percent in California, 15 percent in New York, 22 percent in Florida, and 39 percent in Texas.
  • Adults in small firms are more likely to be uninsured in Florida (24 percent) and Texas (37 percent) than in California (14 percent) or New York (12 percent).
  • Cost-related access problems impacted 28 percent of Californians, 29 percent of New Yorkers, 41 percent of Floridians, and 45 percent of Texans.
  • Medical debt impacted 29 percent of Californians and New Yorkers, while 41 percent of Floridians and 44 percent of Texans were impacted by medical debt.

Factors influencing variations

Factors that might explain the variations include (1) whether the state expanded Medicaid eligibility, (2) whether it ran its own health insurance marketplace, (3) what the uninsured rate was prior to the ACA, (4) differences in the cost protections provided by private health plans; and (5) demographic differences.

California and New York both operate their own health insurance marketplaces and have expanded eligibility for Medicaid to adults with incomes at or below the federal poverty level. Florida and Texas use the federal marketplace to enroll residents in health plans and did not expand Medicaid eligibility. In addition, the report noted that the higher rate of insurance coverage and lower deductibles in California and New York likely played a role in the two states’ lower rates of cost-related access problems.

Although Florida and Texas experienced enrollments in private plans through the health insurance marketplace, they have made less progress covering uninsured residents. Of the four states included in the report, Texas had the highest uninsured rate in every age group for 2016. A contributing factor for Texas’ higher uninsured rate is the number of undocumented immigrants residing in Texas. The ACA does not provide access to any new coverage options for undocumented immigrants.