Health Insurance Coverage

States refusing Medicaid expansion had large uninsured populations in 2020 when Covid hit, leading hospitals to close under financial strain and saddling individuals with medical debt.

Lack of health insurance coverage by state, 2020 

Population age 19-64

Source: Census Bureau’s 2020 ACS 1-Year Experimental Data. Note: WI has partially expanded Medicaid (under a Medicaid waiver) to include all adults under 100 percent federal poverty level.

12 states (most located in the Southeastern U.S.), have not adopted Medicaid expansion, which has contributed to disparities in health insurance coverage between states. In Texas, 24% of the working-age population lacked coverage, as did 18% in Florida, Georgia, and Mississippi. In comparison, only 4% in MA were without coverage. 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. 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. ¹ Moreover, when rural hospitals close, a key job center is lost, making it hard to attract new residents and thus new businesses.

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%). ^2,3 In states that expanded Medicaid in 2014, medical debt declined by 34 percentage points more than in states that did not expand Medicaid. ⁴

1. “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

2. “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

3. “Consumer credit reports: A study of medical and non-medical collections”. Consumer Financial Protection Bureau. December, 2014.  https://files.consumerfinance.gov/f/201412_cfpb_reports_consumer-credit-medical-and-non-medical-collections.pdf

4. “Medical Deb in the US, 2009-2020”. Kluender, Mahoney, Wong, et al. JAMA Network. July, 2021. https://jamanetwork.com/journals/jama/fullarticle/2782187