Health Insurance Coverage
States refusing Medicaid expansion contributed to 16% of working-age Southerners lacking health insurance compared to 11% outside the South.
Workers who didn’t have full-time, year-round jobs were less likely to have health insurance coverage in 2020. Lack of health insurance rates were 3x higher among Hispanic and 2x higher for Black adults than white adults.
Lack of health insurance coverage by county, 2015-19
Population age 19-64
Source: Census Bureau’s American Community Survey. Note: WI has partially expanded Medicaid (under a Medicaid waiver) to include all adults under 100 percent federal poverty level.
Seven Southern states have not adopted Medicaid expansion (MS, AL, GA, FL, SC, NC, and TN). And according to the most recent data (2015-19), this contributed to a troubling South/non-South disparity in health insurance coverage with 16% of working-age Southerners lacking health insurance compared to only 11% in the rest of the United States.1 This is particularly true in rural counties in the South. Looking at Southern counties with particularly high rates of uninsurance (15% or more of all working-age adults lacking health insurance), 2/3 of these counties were completely or mostly rural.
The implications of not expanding Medicaid are particularly hard on rural communities. Without Medicaid expansion, hospitals don’t receive sufficient reimbursement for the care they provide to an increased number of uninsured patients and, as a result, oftentimes must close for financial reasons. Data from 2011 to 2017 reveals that the rural hospitals most likely to shutter were in the South.2 During Covid, without a hospital, many rural residents were unable to get tested and then delayed getting care. One study found that in rural counties where a hospital closed in 2020, Covid death rates were 39% higher than in their state overall.3 Moreover, when rural hospitals close, a key job center is lost, making it hard to attract new residents and thus new businesses — contributing to a downward spiral for rural communities.
Lack of health insurance also means many people incur medical debt. Nearly 1 in 5 American households have medical debt. Black households are more likely to have medical debt (27%) than non-Black households (17%) and medical debt accounts for about half of all delinquencies reported to collections agencies.4,5,6
Percent of working-age population (age 19-64) without health insurance coverage
By work status
The pandemic accelerated changes in U.S. employment, with part-time workers increasingly lacking health insurance and full-time workers increasingly securing this life-saving benefit. Workers who worked part-time or part-year were twice as likely as full-time, year-round workers to lack health insurance in 2020. Part-time workers were as likely to be uninsured as those who did not work at all in 2020.
From 2019 to 2020, the economy shed 13.7 million full-time, year-round jobs, meaning that fewer and fewer workers are in positions likely to offer health insurance. Loss of full-time, year-round jobs were concentrated in jobs paying less than $25,000. In the leisure and hospitality industry, 1 in 4 full-time year-round jobs was lost.7 Black and Hispanic workers have been hit particularly hard with employment rates down 3 to 4 percentage points in Sept 2021 compared to Feb 2020, while employment rates for white workers have declined 2 percentage points (Employment Rate by Race/Ethnicity).
Even before the pandemic, Black and Hispanic workers were more likely to be working part-time jobs but wanting full-time work. In February 2020, 14 percent of Hispanic workers and 12 percent of Black workers compared to 7 percent of white workers were underemployed — that is, working part-time but preferring more work hours.8
Not surprisingly then, in 2020, Hispanic working-age adults were 3 times more likely than white adults to lack health insurance, and Black adults were nearly 2 times more likely than white adults to lack health insurance.9 With the compounding impact of job loss, lack of access to healthy foods, and exposure to pollution, the racial and ethnic groups with the highest exposure to Covid were even more vulnerable because of lack of health insurance.10
With scientists predicting more frequent pandemics in the future, access to health insurance will be critical to ensure adults can withstand health crises and continue to provide for their families.11
“Status of State Medicaid Expansion Decisions: Interactive Map”. Kaiser Family Foundation. July, 2021. https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/
"Varying Trends In The Financial Viability Of US Rural Hospitals, 2011-2017". Bai, Yehia, Chen, and Anderson. Health Affairs. June, 2021. https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2019.01545?journalCode=hlthaff
“As Appalachian hospitals disappear, rural Americans grapple with limited care”. Sisk, Kranitz. National Geographic. July, 2021. https://www.nationalgeographic.com/history/article/appalachian-hospitals-are-disappearing
“The racial implications of medical debt: How moving toward universal health care and other reforms can address them”. Perry, Crear-Perry, Romer, and Adjeiwaa-Manu. Brookings. October, 2021. https://brook.gs/3a6zoYE
“Consumer credit reports: A study of medical and non-medical collections”. Consumer Financial Protection Bureau. December, 2014.
“The Burden of Medical Debt: Results from the Kaiser Family Foundation/New York Times Medical Bills Survey”.
Hamel, Norton, Pollitz, Levitt, Claxton, and Brodie. Kaiser Family Foundation. January, 2016. https://www.kff.org/wp-content/uploads/2016/01/8806-the-burden-of-medical-debt-results-from-the-kaiser-family-foundation-new-york-times-medical-bills-survey.pdf
“Fewer Low-Wage Full-Time, Year-Round Workers During COVID-19 Causes Increase in Median Earnings Among Those Still Employed”. Hokayem, Krohn, and Unrath. U.S. Census Bureau. September, 2021. https://www.census.gov/library/stories/2021/09/workers-earnings-decline-overall-during-pandemic-but-increase-for-full-time-year-round-workers.html
“Underemployment of Part-Time Workers Much Higher than Thought, Especially by Race, Gender”. The Center for Law and Social Policy. February, 2021. https://www.clasp.org/press-room/press-releases/underemployment-part-time-workers-much-higher-thought-especially-race
“Percentage of Working-Age Adults Without Health Insurance Coverage by Selected Characteristics: 2018 and 2020”. U.S. Census Bureau. https://www.census.gov/content/dam/Census/library/visualizations/2021/demo/p60-274/figure7.pdf
“Hospitalization and Death by Race/Ethnicity. CDC. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnic ity.html
“Coronavirus: This is not the last pandemic”. Gill. BBC News. June, 2020. https://www.bbc.com/news/science-environment-52775386