America’s Underinsured A State-by-State Look at Health Insurance Affordability Prior to the New Coverage Expansions Cathy Schoen, Susan L. Hayes, Sara R. Collins, Jacob A. Lippa, and David C. Radley March 2014 The Commonwealth Fund, among the first private foundations started by a woman philanthropist— Anna M. Harkness—was established in 1918 with the broad charge to enhance the common good. The mission of The Commonwealth Fund is to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. An international program in health policy is designed to stimulate innovative policies and practices in the United States and other industrialized countries. America’s Underinsured A State-by-State Look at Health Insurance Affordability Prior to the New Coverage Expansions Cathy Schoen, Susan L. Hayes, Sara R. Collins, Jacob A. Lippa, and David C. Radley March 2014 ABSTRACT The Affordable Care Act insurance reforms seek to expand coverage and to improve the affordability of care and premiums. Before the implemen- tation of the major reforms, data from U.S. census surveys indicated nearly 32 million insured people under age 65 were in households spend- ing a high share of their income on medical care. Adding these “underin- sured” people to the estimated 47.3 million uninsured, the state share of the population at risk for not being able to afford care ranged from 14 percent in Massachusetts to 36 percent to 38 percent in Idaho, Florida, Nevada, New Mexico, and Texas. Nationally, more than half of people with low incomes and 20 percent of those with middle incomes were either underinsured or uninsured in 2012. The report provides state base- lines to assess changes in coverage and affordability and compare states as insurance expansions and market reforms are implemented. Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff. To learn more about new Fund publications when they become available, visit the Fund’s website and register to receive email alerts. Commonwealth Fund pub. no. 1736. CONTENTS List of Exhibits and Tables................................................................................................................vi About the Authors.........................................................................................................................viii Executive Summary..........................................................................................................................ix Introduction...................................................................................................................................... 1 How This Study Was Conducted............................................................................................... 1 Findings............................................................................................................................................. 2 Nearly 32 Million People Underinsured: Insured but Spent High Share of Income on Medical Care............................................................................................................ 2 Wide State Differences in the Share of Population Underinsured or Uninsured.................. 3 Low- and Middle-Income Households Most at Risk................................................................ 5 Premiums for Employer-Sponsored Insurance Have Risen More Rapidly Than Incomes, Value of Benefits Declined........................................................................................ 8 Major Insurance and Market Reforms............................................................................................ 8 Medicaid and Income-Related Premium Assistance................................................................ 8 Medicaid Expansion Makes a Critical Difference................................................................... 11 Income-Related Reduced Cost-Sharing and New Market Standards................................... 12 Changing the Insurance Map of the Country........................................................................ 13 Conclusion...................................................................................................................................... 14 Notes............................................................................................................................................... 15 Tables.............................................................................................................................................. 17 LIST OF EXHIBITS AND TABLES Exhibit ES-1 Summary Highlights: National and State-Level Estimates, Under-65 Population Exhibit 1 Uninsured or Underinsured: National Trends, Under-65 Population Exhibit 2 Distribution of Underinsured by Poverty, Under-65 Population, 2012 Exhibit 3 Underinsured by State, 2011–2012 Exhibit 4 Underinsured or Uninsured by State, 2011–2012 Exhibit 5 Distribution of Underinsured or Uninsured by Poverty, Under-65 Population, 2012 Exhibit 6 At Risk: 79 Million Uninsured or Underinsured, 2012 Exhibit 7 Middle-Income Uninsured or Underinsured by State, 2011–2012 Exhibit 8 Total Premiums for Employer-Sponsored Insurance Rise Sharply as Share of Median Income for Under-65 Population, 2003 and 2012 Exhibit 9 Premium Tax Credits and Cost-Sharing Protections Under the Affordable Care Act Exhibit 10 Twenty-Nine Million Insured Paid Premiums in Excess of Affordable Care Act Thresholds, 2011–2012 Exhibit 11 Distribution of Uninsured or Underinsured by Poverty, 2012 Exhibit 12 Status of State Participation in Medicaid Expansion, as of March 2014 vi America’s Underinsured: A State-by-State Look at Health Insurance Affordability Prior to the New Coverage Expansions Table 1 National Distribution of U.S. Population Under Age 65 by Federal Poverty Level, 2012 Table 2 State Population Demographics by Federal Poverty Level, Under Age 65, 2011–2012 Table 3 Uninsured or Underinsured Under Age 65, Total, by State, 2011–2012 Table 4 Underinsured Under Age 65, Total and by Federal Poverty Level, by State, 2011–2012 Table 5 Uninsured Under Age 65, Total and by Federal Poverty Level, by State, 2011–2012 Table 6 Uninsured or Underinsured Under Age 65, Total and by Federal Poverty Level, by State, 2011–2012 Table 7 Average Health Insurance Premiums as Percent of Median Household Income, by State, 2003 and 2012 Table 8 Insured Individuals Under Age 65 with Premiums That Exceed the Affordable Care Act Threshold, Total and by Federal Poverty Level, by State, 2011–2012 Table 9 Distribution of Insured Population Under Age 65 with High Out-of-Pocket Medical Costs or High Premiums, by Federal Poverty Level, 2012 Table 10 Poor Under Age 65 Who Are Uninsured, Underinsured, or Paying High Premiums in States Not Yet Expanding Medicaid, 2011–2012 www.commonwealthfund.orgvii and policy. She has provided invited testimony before sev- ABOUT THE AUTHORS eral Congressional committees and subcommittees. Prior Cathy Schoen, M.S., is senior vice president at The to joining the Fund, Dr. Collins was associate director/ Commonwealth Fund and a member of the Fund’s execu- senior research associate at the New York Academy of tive management team. Her work includes strategic over- Medicine, Division of Health and Science Policy. Earlier in sight of surveys, research, and policy initiatives to track her career, she was an associate editor at U.S. News & health system performance. Previously Ms. Schoen was on World Report, a senior economist at Health Economics the research faculty of the University of Massachusetts Research, and a senior health policy analyst in the New School of Public Health and directed special projects at the York City Office of the Public Advocate. She holds an A.B. UMass Labor Relations and Research Center. During the in economics from Washington University and a Ph.D. in 1980s, she directed the Service Employees International economics from George Washington University. She can be Union’s research and policy department. Earlier, she served e-mailed at src@cmwf.org. as staff to President Carter’s national health insurance task Jacob A. Lippa, M.P.H., is a former senior research associate force. Prior to federal service, she was a research fellow at for The Commonwealth Fund’s Health System Scorecard the Brookings Institution. She has authored numerous and Research Project at the Institute for Healthcare publications on health policy and insurance issues, and Improvement in Cambridge, Mass. While at the Fund, he national/international health system performance, had primary responsibility for conducting analytic work to Including the Fund’s national, state, local, and vulnerable populations scorecards on U.S. health system performance, update the ongoing series of health system scorecard and coauthored the book Health and the War on Poverty. reports. He managed data collection and analysis and She holds an undergraduate degree in economics from served as coauthor both of reports and other related Smith College and a graduate degree in economics from analyses for publication. Prior to joining the Fund, Mr. Boston College. She can be e-mailed at cs@cmwf.org. Lippa was senior research analyst at HealthCare Research, Susan L. Hayes, M.P.A., is research associate for Policy, Inc., in Denver, where for more than six years he designed, Research, and Evaluation in The Commonwealth Fund’s executed, and analyzed customized research for health New York office. Ms. Hayes also works closely with the care payer, provider, and government agency clients. Mr. Fund’s Scorecard team in Boston. Ms. Hayes joined the Lippa graduated from the University of Colorado at Fund after completing the Master in Public Administration Boulder in 2002 and received a master of public health program at New York University’s Wagner School of Public degree with a concentration in health care policy and Service where she specialized in health policy, with exten- management from Columbia University’s Mailman School sive coursework in economics and policy analysis, and she of Public Health in December 2011. won the Martin Dworkis Memorial Award for academic achievement and public service. Ms. Hayes graduated from David C. Radley, Ph.D., M.P.H., is senior scientist and project Dartmouth College with an A.B. in English in 1988 and director for The Commonwealth Fund’s Health System began a distinguished career in journalism working as an Scorecard and Research Project, a team based at the editorial assistant at PC Magazine and a senior editor at Institute for Healthcare Improvement in Cambridge, Mass. National Geographic Kids and later at Woman’s Day maga- Dr. Radley and his team develop national, state, and sub- zine. Following that period, Ms. Hayes was a freelance state regional analyses on health care system performance health writer and a contributing editor to Parent & Child and related insurance and care system market structure magazine and cowrote a book on raising bilingual children analyses. Previously, he was associate in domestic health with a pediatrician at Tufts Medical Center. policy for Abt Associates, with responsibility for a number Sara R. Collins, Ph.D., is vice president for Affordable of projects related to measuring long-term care quality Health Insurance at The Commonwealth Fund. An econo- and evaluating health information technology initiatives. mist, Dr. Collins joined the Fund in 2002 and has led the Dr. Radley received his Ph.D. in health policy from the Fund’s national program on health insurance since 2005. Dartmouth Institute for Health Policy and Clinical Practice, Since joining the Fund, she has led several national surveys and holds a B.A. from Syracuse University and an M.P.H. on health insurance and authored numerous reports, issue from Yale University. briefs, and journal articles on health insurance coverage viii America’s Underinsured: A State-by-State Look at Health Insurance Affordability Prior to the New Coverage Expansions EXECUTIVE SUMMARY care before the major reforms of the Affordable Care The United States is in the midst of the most signif- Act took hold. icant health insurance expansion and market At the state level, the percentage of the reforms since Medicare and Medicaid were enacted under-65 population who were either uninsured or in 1965. The Affordable Care Act aims to insure underinsured ranged from 14 percent in millions of people without health care coverage and Massachusetts to 36 percent to 38 percent in the make medical care and premiums more affordable five highest-rate states—Idaho, Florida, Nevada, with coverage. Enrollment began in October 2013; New Mexico and Texas (Exhibit ES-1). major coverage reforms started in January 2014. In all states, people with low incomes are at The twin goals of health insurance are to greatest risk for being underinsured or uninsured. enable affordable access to health care and to allevi- Nationally, in 2012, nearly two-thirds (63%) of ate financial burdens when injured or sick. It is well those with incomes below the federal poverty level known that the uninsured are at high risk of forgo- were either underinsured or uninsured. Among ing needed care and of struggling to pay medical those with incomes between 100 percent and 199 bills when they cannot postpone care. Studies fur- percent of poverty, nearly half (47%) were underin- ther find that insured people who are poorly pro- sured or uninsured. tected based on their households’ out-of-pocket A decade or more of people losing health costs for medical care are also at risk of not being coverage and a steady erosion in the financial pro- able to afford to be sick. tection of insurance has also put middle-income Using newly available data from census sur- families at risk. In 2012, one of five people (20%) veys, this report provides national and state-level under age 65 with middle incomes (between 200% estimates of the number of people and share of the and 399% of poverty)—an estimated 15.6 million population that were insured but living in house- people—were either underinsured or had no health holds that spent a high share of annual income on insurance. The share of middle-income people who medical care in 2011–12. In the analysis, we refer to were underinsured or uninsured reached highs of 28 these people as “underinsured.” However, this group percent to 31 percent in Texas, Alaska, and is only one subset of the underinsured. Our esti- Wyoming. mates do not include insured people who needed Historically, states with high uninsured rates care but went without it because of the out-of- have had lower rates of job-based insurance and pocket costs they would incur, or the insured who more restrictive Medicaid eligibility and often high stayed healthy during the year but whose health rates of poverty, making it more difficult to expand insurance would have exposed them to high medical coverage from state resources alone. To overcome costs had they needed and sought care. these historic barriers, insurance reforms provide for The analysis finds that in 2012, there were federal subsidies to reduce premium costs and out- 31.7 million insured people under age 65 who were of-pocket medical costs for eligible low- and middle- underinsured. Together with the 47.3 million who income families who buy plans through the new were uninsured, this means at least 79 million peo- state-based insurance marketplaces. Federal resources ple were at risk for not being able to afford needed also support expanding state Medicaid programs to www.commonwealthfund.orgix Exhibit ES-1. Summary Highlights: National and State-Level Estimates, Under-65 Population PEOPLE PERCENT OF POPULATION Millions National 2012 2012 Lowest state Highest state Total: Insured but 14% 38% underinsured* or 79.0 29.5% uninsured Insured but 31.7 11.8% 8% 17% underinsured Uninsured 47.3 17.7% 4% 27% Premiums exceed 29.2 10.9% 7% 14% ACA thresholds** * Underinsured defined as insured in household that spent 10% or more of income on medical care (excluding premiums) or 5% or more if income under 200% poverty. ** Affordable Care Act (ACA) thresholds refers to the maximum premium contribution as a share of income in marketplaces or Medicaid. Data source: March 2012 and 2013 Current Population Surveys. citizens and legal residents with incomes near or regarding Medicaid. Income eligibility levels for pre- below poverty. mium tax credits start at 100 percent of poverty, For those eligible to participate, income- with the law designed to expand Medicaid to cover related tax credits for premiums and Medicaid will people with incomes up to 138 percent of poverty. limit the share of income individuals and families As of yet, 24 states have opted not to expand their are required to contribute toward their premiums. Medicaid programs to 138 percent of poverty. Of Using newly available census data on out-of-pocket these states, only Wisconsin will cover adults up to premium costs compared with incomes, we estimate the federal poverty level. An estimated 15.2 million that 29 million insured people were in households people who are either uninsured or underinsured that spent more on premiums as a share of income who have incomes below poverty live in the 23 in 2012 than the new premium contribution limits states where Medicaid eligibility for adults is well set by the Affordable Care Act for those eligible for below poverty. Although some may be ineligible subsidized coverage. Across states, the share of the based on immigration status and others may be eli- population paying high premiums relative to their gible under current Medicaid but not yet signed up, incomes ranged from 8 percent to 17 percent of the unless these states participate in the Medicaid insured. Although only a portion of those with expansion, there will be no new subsidized coverage high-premiums compared to income (an estimated option for these people since their income is too low 11 million) will be eligible to participate in to qualify for premium assistance. expanded Medicaid or to receive premium assistance State-level data indicate the law’s income- for plans purchased in the marketplaces, the state related reforms are well-targeted to help people with level estimates provide a baseline to assess changes in incomes in ranges that put them at greatest risk for premiums affordability relative to income over time. being either uninsured or underinsured. The The impact of insurance expansions on cov- Affordable Care Act thus has the potential to reduce erage, premium, and out-of-pocket costs for medical high medical care cost burdens while also covering care will depend critically on state decisions the uninsured. However, the extent of improvement x America’s Underinsured: A State-by-State Look at Health Insurance Affordability Prior to the New Coverage Expansions will critically depend on state decisions and the plans people select. To the extent the law’s coverage provisions reach low- and middle-income families who are uninsured or underinsured, we may change the access and affordability map of the country. However, this will depend on states seizing the opportunity to invest and use new federal resources well, combined with effective oversight of private insurance plans. The number of uninsured declined by nearly 2 million from 2010 to 2012 following implemen- tation of early Affordable Care Act reforms, includ- ing expansion of coverage to young adults. National surveys in 2013 and early 2014 indicate further decline in the number of uninsured, providing con- tinuing positive news. As of March 2014, 5 million people had selected a plan through the new market- places and 10.3 million adults and children had been determined eligible for Medicaid and the Children’s Health Insurance Program (CHIP). With reforms to ensure more comprehensive benefits, there is the potential to improve affordability across states. For the first time, the nation has committed resources with the goal of achieving near-universal coverage with financial protection to ensure care as well as insurance is affordable. These are ambitious goals given the wide geographic gaps in coverage and affordability evident before reforms took hold. This report provides state-by-state baseline data to assess changes in coverage and affordability and compare states as reforms are implemented. www.commonwealthfund.orgxi INTRODUCTION HOW THIS STUDY WAS CONDUCTED The United States is in the midst of the most signif- The report draws on data from the U.S. Census icant health insurance expansion and market Bureau’s Current Population Surveys (CPS) for reforms since Medicare and Medicaid were enacted 2012 and 2013. Historically, the CPS has tracked in 1965. Aiming to expand coverage and make health insurance coverage to allow for estimates of medical care and premiums more affordable, the the uninsured in all states. Starting in 2010, the sur- Affordable Care Act major coverage expansions and vey added questions about out-of-pocket spending market reforms commenced in January 2014. for medical care and premiums. In the analysis we The twin goals of health insurance are to used this newly available data to estimate the num- enable affordable access to health care and to allevi- ber of insured people under age 65 who were in ate financial burdens when injured or sick. It is well families (including single-person households) that known that the uninsured are at high risk of forgo- paid a high share of their annual income on medical ing needed care and of struggling to pay medical care, indicating they were “underinsured.” bills when they cannot postpone care. Studies fur- Building on earlier studies,1 we used two ther find that insured people who are poorly pro- thresholds to identify people who were insured with tected based on their households’ out-of-pocket high medical-cost burden: people with insurance in costs for medical care are also at risk of not being households that spent 10 percent or more of total able to afford to be sick. income on medical care (not including premiums); Using newly available data from census sur- or 5 percent or more, if annual income was less than veys on out-of-pocket costs for medical care, this 200 percent of poverty. We refer to these people as report provides national and state-level estimates of “underinsured.”2 Our earlier work also included the number of people and share of the population insured people with deductibles that were high rela- that were insured but living in households that tive to family incomes, since they had great poten- spent a high share of annual income on medical care tial financial risk even if they did not incur high in 2011–12. In the analysis, we refer to these people medical costs during the year. This information is as “underinsured.” Adding the underinsured to peo- not available in the CPS survey: thus the estimate of ple uninsured, this report provides estimates of the people who are insured yet underinsured is a more share of each state’s population at risk of not being conservative estimate and a subset of the at-risk able to afford care before major insurance expan- population. sions and reforms We also estimated the number of insured We also analyze the share of each state’s people who paid a relatively high share of their under-65 population that were paying a high share incomes on premiums. To do this, we compare the of their family income on premiums before major amount spent on premiums relative to incomes to reforms. The report thus provides state baseline data threshold limits for premium tax credits or to assess changes in coverage and affordability and Medicaid set by the Affordable Care Act. This pro- to compare states as reforms are implemented. vides an estimate of the number of people who spent more on premiums as a share of incomes than www.commonwealthfund.org1 they might have if they were eligible for subsidized estimated number of people (and percent of the coverage or Medicaid.3 state population) who are uninsured, underinsured, or paying premiums that are high relative to their We profile national and state-level estimates for four income groups using poverty thresholds: income. • below poverty: annual income of less than $11,490 if single; less than $23,550 FINDINGS for a family of four in 2013; • low income: 100 percent to 199 percent of Nearly 32 Million People Underinsured: poverty—annual income of $11,490 to less Insured but Spent High Share of Income than $22,980 if single; $23,550 to less than $47,100 for a family of four in 2013; on Medical Care • middle income: 200 percent to 399 per- In 2012, 42.5 million people under age 65 spent a cent of poverty—annual income of high share of their income on medical costs, not $22,980 to less than $45,960 if single; $47,100 to less than $94,200 for a family including insurance premiums.4 Of these, 31.7 mil- of four in 2013; lion were insured yet underinsured, based on the • higher income: 400 percent of poverty or costs they or their families incurred for medical care more—annual income at or above $45,960 if single and at or above $94,200 for a relative to their incomes.5 Overall, about one of family of four in 2013. eight (12%) of the under-65 population were underinsured, putting them at risk of going without Nationally, and in many states, these groups needed care or for incurring medical bill problems represent the bottom (poor and low income), mid- and debt (Exhibit 1 and Table 1). dle and top one-third of the income distribution for From 2010 to 2012, following early the under-65 population. Tables 1 and 2 provide Affordable Care Act reforms that expanded coverage national and state total populations and income to young adults, the number of uninsured declined distributions. by nearly 2 million (Exhibit 1). However, during In the analysis, we report national-level esti- this same time period, the estimated number of peo- mates for 2012, which are the most recent CPS data ple who were insured but underinsured grew from available. To ensure adequate sample size, state-level 29.9 million to 31.7 million, nearly offsetting the estimates use an average of two years, 2011–2012 gain in coverage. As a result, in 2012, before the (March 2012 and 2013 CPS). The tables at the end launch of major insurance reforms, 79 million of the report provide details by state for the Exhibit 1. Uninsured or Underinsured: National Trends, Under-65 Population MILLIONS MILLIONS MILLIONS PERCENT OF 2010 2011 2012 POPULATION Uninsured 49.2 47.9 47.3 17.7% Insured but 29.9 30.6 31.7 11.8% underinsured Total: Insured but underinsured* or 79.1 78.5 79.0 29.5% uninsured * Underinsured defined as insured in household that spent 10% or more of income on medical care (excluding premiums) or 5% or more if income under 200% poverty. Data source: March 2011, 2012, and 2013 Current Population Surveys. 2 America’s Underinsured: A State-by-State Look at Health Insurance Affordability Prior to the New Coverage Expansions people were either underinsured (31.7 million) or Nationally, nearly one of five people under uninsured (47.3 million)—nearly 30 percent of the age 65—47.3 million—were uninsured in 2012. under-65 population. The share of states’ nonelderly population who were Nationally, half of the estimated 32 million uninsured ranged from a low of 4 percent in underinsured people had incomes below 100 per- Massachusetts to a high of 27 percent in Texas cent of poverty; nearly one-third (9.7 million peo- (Table 3). Combining estimates of the underinsured ple) had incomes between 100 percent and 199 per- and uninsured, the share of people at risk of not cent of poverty. Another 13 percent—4.2 million— being able to afford care before the launch of the were in middle-income families with incomes Affordable Care Act’s major coverage reforms ranged between 200 percent and 399 percent of poverty from a low of 14 percent in Massachusetts to highs (Exhibit 2 and Table 4). of 36 percent to 38 percent in Idaho, Florida, Nevada, New Mexico, and Texas (Exhibit 4 and Wide State Differences in the Share of Table 3). Population Underinsured or Uninsured There is a distinct regional pattern: several The percent of states’ under-65 population who of the states with the lowest rates of uninsured or were insured but underinsured ranged more than underinsured were in the Northeast (Massachusetts, two-fold across states: from a low of 8 percent in Connecticut, Vermont, and New Hampshire) or New Hampshire to highs of 16 percent to 17 per- upper Midwest (Minnesota, North Dakota). States cent in Tennessee, Mississippi, Utah, and Idaho with the highest rates were in the South and West (Exhibit 3 and Table 3). Exhibit 2. Distribution of Underinsured by Poverty, Under-65 Population, 2012 Insured but underinsured:* 31.7 million people 1.7 million 5% 4.2 million 13% Less than 100% poverty 100%–199% poverty 16.0 million 200%–399% poverty 50% 400% poverty or more 9.7 million 31% Note: Sum of percentages or people may not equal total because of rounding. * Underinsured defined as insured in household that spent 10% or more of income on medical care (excluding premiums) or 5% or more if income under 200% poverty. Data source: March 2013 Current Population Survey. www.commonwealthfund.org3 Exhibit 3. Underinsured by State, 2011–2012 Ranges from 8 percent to 17 percent of population Percent of under-65 population 25 20 15 National average (2012): 12% 10 5 0 Nevada South Carolina Minnesota Kansas North Carolina Arkansas Rhode Island Pennsylvania Arizona Kentucky Montana Utah Massachusetts Illinois Indiana Colorado Delaware Washington New Hampshire Dist. of Columbia Maryland Virginia New Jersey Connecticut North Dakota California New York Vermont Michigan Iowa Texas South Dakota Alaska Missouri Georgia Florida Oklahoma Wisconsin Nebraska Maine Hawaii West Virginia New Mexico Alabama Oregon Wyoming Tennessee Mississippi Idaho Ohio Louisiana Note: Underinsured defined as insured in household that spent 10% or more of income on medical care (excluding premiums) or 5% or more if income under 200% poverty. Data source: March 2012–2013 Current Population Survey (states: two-year average). Exhibit 4. Underinsured or Uninsured by State, 2011–2012 Ranges from 14 percent to 38 percent of population Percent of under-65 population Insured but underinsured* 50 Uninsured 40 30 National average (2012): 29% 20 10 0 Nevada South Carolina North Carolina Minnesota Kansas Arkansas Pennsylvania Rhode Island Kentucky Arizona Utah Montana Massachusetts Colorado Delaware Washington Indiana Illinois Dist. of Columbia Connecticut Vermont Hawaii North Dakota New Hampshire Iowa Wisconsin Maryland Maine New York Michigan Virginia Nebraska New Jersey South Dakota Missouri Alabama West Virginia Oregon California Oklahoma Tennessee Alaska Georgia Wyoming Mississippi Idaho Florida New Mexico Texas Ohio Louisiana * Underinsured defined as insured in household that spent 10% or more of income on medical care (excluding premiums) or 5% or more if income under 200% poverty. Data source: March 2012–2013 Current Population Survey (states: two-year average). 4 America’s Underinsured: A State-by-State Look at Health Insurance Affordability Prior to the New Coverage Expansions (Montana, Arkansas, Idaho, Florida, Nevada, New uninsured in 2012 (Exhibit 6). At the state level, Mexico and Texas). Four states (Massachusetts, with the exception of Massachusetts, Delaware, and Minnesota, Connecticut, North Dakota) and the the District of Columbia, at least half of the poorest District of Columbia stand out for having unin- residents of states either had no health insurance or sured and underinsured rates that were relatively low were underinsured (Table 6). In Nevada and Utah, compared with other states (Table 3). at least three-quarters of residents with incomes below poverty were uninsured or underinsured. Low- and Middle-Income Households Among people with incomes near poverty Most at Risk (100% to 199% of poverty), nearly half (47%) were The vast majority of the 79 million uninsured or uninsured or underinsured. Across states, this underinsured—more than nine of 10—had incomes ranged from a low of 30 percent or less in below 400 percent of poverty (Exhibit 5 and Table Massachusetts, Hawaii, and the District of 6). More than two of five (33.3 million) had Columbia to highs of 55 percent to 56 percent in incomes below poverty. Idaho and Texas (Table 6). People living in low- or middle-income Reflecting the ongoing erosion of coverage, households are most at risk of being either unin- 20 percent of people with middle-class incomes sured or insured but poorly protected. Nationally, (200% to 399% of poverty) were also uninsured or nearly two-thirds (63%) of those with incomes underinsured in 2012. This amounts to an esti- below poverty were either underinsured or mated 15.6 million people with incomes well above Exhibit 5. Distribution of Underinsured or Uninsured by Poverty, Under-65 Population, 2012 Insured but underinsured* or uninsured: 79 million people 6.8 million 9% Less than 100% poverty 100%–199% poverty 15.6 million 20% 33.3 million 200%–399% poverty 42% 400% poverty or more 23.2 million 29% * Underinsured defined as insured in household that spent 10% or more of income on medical care (excluding premiums) or 5% or more if income under 200% poverty. Data source: March 2013 Current Population Survey. www.commonwealthfund.org5 Exhibit 6. At Risk: 79 Million Uninsured or Underinsured, 2012 Percent of under-65 population 75 Insured but underinsured* 63 Uninsured 50 47 30 20 29 25 20 12 33 6 27 8 18 15 2 6 0 Total Below 100% 100%–199% 200%–399% 400% FPL FPL FPL FPL or above Notes: FPL = federal poverty level. Percentages may not sum to total because of rounding. * Underinsured defined as insured in household that spent 10% or more of income on medical care (excluding premiums) or 5% or more if income under 200% poverty. Data source: March 2013 Current Population Survey. Exhibit 7. Middle-Income Uninsured or Underinsured by State, 2011–2012 Percent of middle-income population under age 65 Insured but underinsured* 50 Uninsured 40 30 National average (2012): 20% 20 10 0 Arkansas South Carolina North Carolina Pennsylvania Kentucky Rhode Island Utah Montana Massachusetts Indiana Delaware Washington Colorado Nevada Hawaii Dist. of Columbia Minnesota Connecticut Vermont New York Iowa Alabama Michigan Tennessee Virginia North Dakota Maine Wisconsin New Hampshire Mississippi South Dakota Missouri Georgia Louisiana West Virginia Maryland Oklahoma Oregon Arizona Nebraska California Idaho Florida New Mexico Texas Alaska Wyoming Illinois Ohio New Jersey Kansas Note: Middle income = 200% to 399% of poverty. * Underinsured defined as insured in household that spent 10% or more of income on medical care (excluding premiums) or 5% or more if income under 200% poverty. Data source: March 2012–2013 Current Population Survey (states: two-year average). 6 America’s Underinsured: A State-by-State Look at Health Insurance Affordability Prior to the New Coverage Expansions poverty who were either uninsured or insured but in terms of access to health care and financial well- incurring medical bills that were high relative to being. Studies indicate that low- and middle-income their incomes. insured individuals and families who face high out- Combining the numbers of uninsured and of-pocket costs for medical care relative to their underinsured, the percent of states’ middle-income incomes are nearly as likely as the uninsured popula- population at risk of not being able to afford care tion to go without care because of costs, forgo care ranged from 9 percent in Hawaii and Massachusetts when sick, struggle to pay medical bills, or incur to highs of 28 percent to 31 percent in Texas, Alaska medical debt.7 Both population groups—underin- and Wyoming. In seven states—Idaho, Nevada, sured and uninsured—are at far higher risk of access Florida, New Mexico, Texas, Alaska, and or medical bill concerns than those with more pro- Wyoming—at least one of four middle-income resi- tective coverage. dents were uninsured or insured but poorly pro- In all states, people with higher incomes—at tected (Exhibit 7 and Table 6). or above 400 percent of poverty—have more protec- The exposure to high out-of-pocket medical tive coverage. The combined share of the states’ care costs even when people have insurance reflects higher-income population who were uninsured or insurance trends—including higher deductibles and underinsured before reforms ranged from 3 percent cost-sharing, as well as gaps in benefits or limits on in Massachusetts to 13 percent in Alaska and coverage—in both the employer and individual Wyoming (Table 6). insurance markets.6 This puts insured families at risk Exhibit 8. Total Premiums for Employer-Sponsored Insurance Rise Sharply as Share of Median Income for Under-65 Population, 2003 and 2012 Less than 17% 17%–19% 20%–22% 23%–28% 2003 2012 Note: Premiums include employer and employee shares. Data sources: 2003, 2012 Medical Expenditure Panel Survey–Insurance Component; March 2004 and March 2013 Current Population Surveys for median income. www.commonwealthfund.org7 Premiums for Employer-Sponsored MAJOR INSURANCE AND Insurance Have Risen More Rapidly Than MARKET REFORMS Incomes, Value of Benefits Declined Responding to widespread concerns about access to Over the past decade, the cost of health insurance care and affordability, the Affordable Care Act seeks has risen far faster than incomes for middle- and to expand and improve insurance coverage with sub- low-income working-age families. Nationally by sidies aimed to reach those with low or middle 2012, average annual premiums for employer-spon- incomes. In October 2013, enrollment opened for sored health insurance (including the employer and the Affordable Care Act’s new coverage options that employee share) equaled about 22 percent of commenced in 2014 with the joint goals of expand- median household income for the under-65 popula- ing coverage and making insurance and care more tion, up from 15 percent in 2003. In each state, affordable. The law’s major insurance reforms average premiums were a greater share of median include three main provisions: 1) expansion of income in 2012 than they were in 2003 (Exhibit 8 Medicaid eligibility to people with incomes up to and Table 7). 138 percent of poverty; 2) income-related tax credits Maps detailing these changes reveal the to reduce the cost of premiums for people with starkly altered landscape. In 2003, in three-fourths incomes between 100 percent and 399 percent of of the states, the average premiums for employer- poverty who are eligible to purchase plans through sponsored health insurance amounted to less than state-based insurance marketplaces; and 3) lower 17 percent of state median incomes. In all but two cost-sharing for people with low or modest incomes states, premiums as a share of median state incomes who are eligible for Medicaid or to participate in the were below 20 percent. By 2012, average premiums new insurance marketplaces. In addition, insurance were at least 17 percent of median incomes in all market reforms effective in January 2014 set new but one state, Minnesota, and 23 percent to 28 per- standards for insurance and established new market cent of median income in 18 states, including the rules that prohibit turning people away or charging four most populous: California, Texas, New York, them more because of health status or gender. and Florida. Market reforms also limit the amount insurers can At the same time that premiums have risen, charge based on enrollees’ age, limit annual out-of- the value of benefits has declined. Deductibles more pocket costs, and require plans to include essential than doubled for plans provided by larger and small benefits.9 employers.8 This increase—plus other cost-sharing or limits on benefits—has left insured patients pay- Medicaid and Income-Related Premium Assistance ing a higher share of medical bills. With little or no The Affordable Care Act provides federal support to growth in incomes over a decade, insurance and care expand Medicaid for all citizens and legal residents have become less affordable. with incomes up to 138 percent of the federal pov- erty level. This represents a significant expansion of the program for adults. Before reform, in most states, nondisabled adults without children were not eligible for Medicaid regardless of income level, and 8 America’s Underinsured: A State-by-State Look at Health Insurance Affordability Prior to the New Coverage Expansions the income eligibility thresholds for parents were total under-age-65 population and 13 percent of the well below poverty.10 The expansion is fully funded insured population under age 65—paid premiums by the federal government through 2016 with the that exceeded the Affordable Care Act premium federal share declining to 90 percent by 2020.11 contribution thresholds for those at their household People with incomes between 100 percent income level before reforms (Table 8). In other and 400 percent of poverty can receive tax credits to words, they had high premium out-of-pocket costs help pay insurance premiums if they do not have compared with incomes, with “high” defined as in access to public insurance or an affordable excess of Affordable Care Act contribution employer-based plan.12 For those eligible, tax credits thresholds. will cap premium costs at 2 percent to 9.5 percent Across states, the share of the insured popu- of annual income, relative to various thresholds of lation paying high premiums relative to income in the federal poverty level (Exhibit 9). 2011–12 ranged from an estimated 8 percent to 17 The premium assistance and Medicaid percent (Exhibit 10). Table 8 provides baseline esti- expansion have the potential to lower costs for many mates by state for the number of insured people in low- and middle-income individuals and families households paying a high share of their incomes on who have insurance and expand coverage to people premiums before the implementation of reforms. In who do not. Using newly available information on the larger states, this amounts to millions of people. out-of-pocket payments for premiums, we estimate For example, an estimated 3.1 million insured in that 29 million insured people—11 percent of the California, 2.3 million in Texas, 1.9 million in Exhibit 9. Premium Tax Credits and Cost-Sharing Protections Under the Affordable Care Act PREMIUM CONTRIBUTION AS OUT-OF-POCKET ACTUARIAL VALUE: FPL INCOME A SHARE OF INCOME LIMITS IF IN SILVER PLAN S: <$11,490 <100% 0% (Medicaid) $0 (Medicaid) 100% (Medicaid) F: <$23,550 S: $11,490 – <$15,856 100%–137% 2%, or 0% if Medicaid 94% F: $23,550 – <$32,499 S: $15,856 – <$17,235 S: $2,250 138%–149% 3.0%–4.0% 94% F: $32,499 – <$35,325 F: $4,500 S: $17,235 – <$22,980 150%–199% 4.0%–6.3% 87% F: $35,325 – <$47,100 S: $22,980 – <$28,725 S: $5,200 200%–249% 6.3%–8.05% 73% F: $47,100 – <$58,875 F: $10,400 S: $28,725 – <$34,470 250%–299% 8.05%–9.5% 70% F: $58,875 – <$70,650 S: $34,470 – <$45,960 S: $6,350 300%–399% 9.5% 70% F: $70,650 – <$94,200 F: $12,700 S: $45,960+ 400%+ — — F: $94,200+ Four levels of cost-sharing: Bronze: actuarial value 60% Silver: actuarial value 70% Gold: actuarial value 80% Platinum: actuarial value 90% Note: FPL refers to federal poverty level as of 2013. Actuarial values are the average percent of medical costs covered by a health plan. Premium and cost- sharing credits are for silver plan. Out-of-pocket limits for 2014. Source: Commonwealth Fund Health Reform Resource Center: What’s in the Affordable Care Act? (PL 111-148 and 111-152), http://www.commonwealthfund.org/Health-Reform/Health-Reform-Resource.aspx. www.commonwealthfund.org9 Florida, and 1.6 million in New York paid a high income. Among the 29 million insured with high share of income on premiums. premium costs in 2012, 11.7 million had employer- However, not everyone who pays high pre- sponsored coverage and incomes that would be too miums relative to income will be eligible for help. high to qualify for expanded Medicaid.13 Only a The 29 million insured people includes 13.7 million portion of this group will be eligible for premium with incomes below 138 percent of poverty who are assistance. In addition, those who are employed by paying premiums above the Affordable CareAct small employers may benefit from insurance market thresholds for this group. Of these, 8.8 million had reforms and the small business marketplaces that private insurance they bought on their own or may yield more affordable options for some of those through employers (Table 9). Based on their income businesses. Another 2.2 million with high-premium alone, they would likely be eligible for expanded costs and incomes above Medicaid levels bought Medicaid if their state decides to participate in insurance on their own.14 All would likely be eligible Medicaid expansions. for premium assistance (Table 9). For those with incomes above Medicaid eli- The baseline data on premiums relative to gibility, the law restricts eligibility for premium incomes indicate that if all states participate in assistance in marketplaces to people buying insur- Medicaid expansions, at least 11 million insured ance on their own and to workers who have people with high premiums compared with incomes employer coverage where the employee’s premium could receive premium help based on their income costs for self-only coverage exceeds 9.5 percent of alone.15 Exhibit 10. Twenty-Nine Million Insured Paid Premiums in Excess of Affordable Care Act Thresholds, 2011–2012 PERCENT OF INSURED UNDER AGE 65 WHO PAID PREMIUMS THAT EXCEED ACA THRESHOLDS 8%–11% (8 states + D.C.) 12%–14% (27 states) 15%–17% (15 states) Note: Affordable Care Act thresholds refers to the maximum premium contribution as a share of income in marketplaces or Medicaid if eligible to participate. Data source: March 2012–2013 Current Population Survey (states: two-year average). 10 America’s Underinsured: A State-by-State Look at Health Insurance Affordability Prior to the New Coverage Expansions Medicaid Expansion Makes a Critical have chosen to participate in the Medicaid expan- Difference sion and 24 states have either said they are not As originally enacted, the insurance reforms expanding or had not yet decided to expand expanded Medicaid to people with incomes up to Medicaid to 138 percent of poverty (Exhibit 12).17 138 percent of poverty in all states to ensure that Of the states that have not yet decided to partici- low-income individuals and families would have pate, only Wisconsin will provide Medicaid up to access to comprehensive coverage with little or no the federal poverty level for childless, nondisabled premiums or cost-sharing.16 As Exhibit 11 illus- adults.18 trates, a substantial share of the uninsured and The law was written assuming that all states underinsured have incomes within the range to would participate in the Medicaid expansion. qualify for expanded Medicaid. An estimated 23.6 Therefore, premium assistance in the marketplaces million uninsured—half of the total 47.3 million will be available only to people with incomes of at uninsured—had incomes below 138 percent of pov- least 100 percent of poverty. In states that do not erty in 2012. Of the 31.7 million underinsured— expand Medicaid, those with income below poverty nearly two-thirds, or 20.1 million—had incomes will have no new options available. below the new Medicaid threshold. Based on the most recent census data, 15.2 In June 2012, the Supreme Court ruled that million uninsured or underinsured people with state participation in Medicaid is optional. As of incomes below poverty live in the 23 states (exclud- March 2014, 26 states plus the District of Columbia ing Wisconsin) where existing Medicaid eligibility Exhibit 11. Distribution of Uninsured or Underinsured by Poverty, 2012 Less than 100% poverty 100%–137% poverty 138%–199% poverty 200%–399% poverty 400% poverty or more 37% 13% 15% 24% 11% 17.4 million 6.2 million 7.3 million 11.3 million 5.1 million 47.3 million uninsured under age 65 in 2012 5% 50% 13% 18% 13% 1.7 16.0 million 4.1 million 5.7 million 4.2 million mil- lion 31.7 million underinsured under age 65 in 2012 Notes: Percentages may not add to 100% because of rounding. Underinsured defined as insured in household that spent 10% or more of income on medical care (excluding premiums) or 5% or more if income under 200% poverty. Data source: March 2013 Current Population Survey. www.commonwealthfund.org11 Exhibit 12. Status of State Participation in Medicaid Expansion, as of March 2014 WA MT ME ND VT MN OR NH ID WI NY MA SD WY MI CT RI IA PA NJ NE NV OH IL IN UT DE CA CO WV KS VA MD MO KY DC NC TN AZ OK NM AR SC MS AL GA Expanding (22 states + D.C.) TX LA Expanding with variation (4 states) AK Options under discussion (5 states) FL Not expanding (19 states) HI Note: The Centers for Medicare and Medicaid Services (CMS) has approved waivers for expansion with variation in Arkansas, Iowa, and Michigan. Pennsylvania’s waiver is currently under review by CMS. Source: Avalere, State Reform Insights; Center on Budget and Policy Priorities; Politico.com; Commonwealth Fund analysis. standards exclude childless, nondisabled adults and eligible for Medicaid nor premium assistance through where income eligibility levels are often well below tax credits. poverty for adults with dependent children. Only Many of the states not participating in four of these states have Medicaid income eligibility Medicaid expansion have among the highest rates of for parents at or above the poverty level—Alaska, uninsured or underinsured people as a share of their Maine, Tennessee, and Wisconsin.19 Some of the total state populations. Without Medicaid expan- uninsured or underinsured poor in these states may sion, this vulnerable group will remain at high risk be ineligible for Medicaid based on immigration sta- for access, health, and financial problems. tus and others may be eligible under current Medicaid or the Children’s Health Insurance Income-Related Reduced Cost-Sharing and New Market Standards Program (CHIP) but not yet signed up.20 However, The health plans available in the new marketplaces unless these states decide to participate in the expan- are required to provide essential health benefits, sion, the poorest residents will have no new insur- including preventive care and other benefits typi- ance options available to them. cally covered in employer plans. Insurers must offer Excluding Wisconsin, an estimated 3.5 mil- these benefits in four categories, or “metal tiers,” lion of the insured poor who paid premiums live in based on the percentage of medical costs covered: states that are not participating in the Medicaid bronze (covering an average of 60% of a person’s expansion (Table 10). They will not be newly 12 America’s Underinsured: A State-by-State Look at Health Insurance Affordability Prior to the New Coverage Expansions annual medical costs), silver (70% of costs), gold potentially eligible for substantial premium assis- (80% of costs), and platinum (90% of costs).21 tance and reduced cost-sharing. Many may also ben- People with incomes below 250 percent of efit from new insurance market rules that apply poverty who select silver plans are also eligible for broadly across the country. There is the potential to cost-sharing subsidies that increase the amount of reduce the number of uninsured and underinsured medical costs covered by their plan, thereby lower- compared with the 2012 baseline. ing the amount they have to spend out-of-pocket on Substantial gains, however, will depend on deductibles, copayments, and coinsurance. However, the plans people choose and state efforts to ensure people must enroll in silver plans in order to receive high-value benefit designs and accessible networks. this benefit (Exhibit 9). These provisions could help One concern is to what extent people with low or reduce the number of underinsured people to the modest incomes will opt for “bronze” level plans. extent that those who were uninsured or underin- These plans may be attractive because they have the sured before reforms are eligible to participate in the lowest premiums. For people with low incomes, tax marketplaces and select silver plans. credits may offset most or all of the out-of-pocket The insurance market reforms also provide premium costs for these plans. However, people new protections against high out-of-pocket medical choosing bronze-level plans will pay 40 percent of care costs. The law caps the amount people will pay medical care costs on average and thus remain at out-of-pocket annually for covered medical and pre- financial risk. Additionally, in choosing a bronze scription drug benefits, with the lowest out-of- plan, people with low incomes forgo the cost-shar- pocket limits for people with incomes below 200 ing subsidies that are tied to silver plans that sub- percent of poverty. It also prohibits plans from stantially reduce out-of-pocket spending for medical imposing annual dollar limits on covered benefits. care. As of February 2014, 62 percent of those This latter provision protects the insured from sim- enrolling in the new marketplaces selected silver ply running out of coverage. Effective this year, plans, 19 percent had selected gold or platinum, reforms prohibit insurers from denying or limiting and 19 percent had selected bronze.22 It will be coverage or charging higher premiums based on important to track the pattern of plan choices by gender or poor health. These reforms potentially income to assess the impact on affordability. make premiums and health care more affordable In addition, it is important to note that the across lifetimes. Affordable Care Act’s limits on out-of-pocket costs for covered benefits also apply only to in-network Changing the Insurance Map of the Country providers. As discussed in a recent report profiling The Affordable Care Act insurance reforms were insured people with medical debt, even with the well-targeted to provide assistance to those currently new limits, the insured may encounter high medical uninsured or insured but poorly protected—that is, care costs if they receive care from out-of-network the underinsured. As Exhibit 11 illustrates, approxi- clinicians.23 This can happen even if the patient mately two-thirds of the uninsured and four-fifths selects an in-network surgeon and hospital, if anes- (81 percent) of the underinsured have incomes thesiologists or other clinicians involved in the hos- below 200 percent of poverty—the income range pital care are allowed to stay out-of-network. www.commonwealthfund.org13 CONCLUSION erosion in insurance protections for people with pri- If the Affordable Care Act’s major coverage provi- vate insurance coverage.27 sions, which went into effect in January 2014, per- To assess the impact of reforms will require form near expectations, the United States will come monitoring affordability of care for the insured as closer to achieving near-universal coverage. By mak- well as the number of people remaining uninsured. ing affordable, comprehensive coverage available, Preventing more people from becoming underin- the reforms have the potential to reduce the ranks of sured will depend on state action, oversight of insur- the uninsured and the insured with high cost bur- ance plans offered, and the individual choices con- dens. To the extent insurance reforms achieve this sumers make when selecting coverage. potential, they will improve access to care, decrease This report offers baseline data for states and the number of people who go without care because the nation to track and assess changes over the next of costs, and reduce medical debt and struggles with several years. Millions of people in low- and middle- unaffordable medical bills. More protective insur- income families stand to gain more affordable insur- ance could also allow for more equitable access to ance and access to care if states use the new primary and preventive care.24 resources wisely and creatively. The major insurance reforms that began this year have the potential to change the insurance and access map of the country. The number of unin- sured declined by nearly 2 million from 2010 to 2012 following implementation of early Affordable Care Act reforms, including expansion of coverage to young adults. National surveys in 2013 and early 2014 indicate further decline in the number of uninsured, providing continuing positive news. As of March 2014, 5 million people had selected a plan through the new marketplaces25 and 10.3 million adults and children had been determined eligible for Medicaid and the Children’s Health Insurance Program (CHIP).26 With reforms to ensure more comprehensive benefits, there is the potential to improve affordability across states. However, the new marketplaces offer plans that include substantial cost-sharing and annual caps on out-of-pocket patient costs that apply to in- network providers only. With these benefit designs, there is the risk that the nation could convert the uninsured into the underinsured and fail to stop the 14 America’s Underinsured: A State-by-State Look at Health Insurance Affordability Prior to the New Coverage Expansions 9 NOTES K. Davis, A New Era in American Health Care: 1 Realizing the Potential of Reform (New York: The C. Schoen, M. M. Doty, R. H. Robertson, and S. R. Commonwealth Fund, June 2010); and K. Pollitz, C. Collins, “Affordable Care Act Reforms Could Reduce Cost, K. Lucia et al., Medical Debt Among People with the Number of Underinsured U.S. Adults by 70 Health Insurance (Washington, D.C.: Henry J. Kaiser Percent,” Health Affairs, Sept. 2011 30(9):1762–71. The Family Foundation, Jan. 2014). 10 percent threshold dates back to early studies by 10 Pamela Farley Short. The 5 percent threshold comes C. Schoen, S. Hayes, and P. Riley, The Affordable Care from the Child Health Insurance program standard for Act’s New Tools and Resources to Improve Health and low-income families where some cost-sharing was Care for Low-Income Families Across the Country (New allowed above 100 percent of poverty. We apply the 5 York: The Commonwealth Fund, Oct. 2013). percent threshold to all below 200 percent—although 11 S. Glied and S. Ma, How States Stand to Gain or Lose one could argue for much lower for below poverty. Federal Funds by Opting In or Out of the Medicaid 2 Expansion (New York: The Commonwealth Fund, Analysis of the Current Population Survey data was conducted by Claudia Solis-Roman at New York Dec. 2013). University, working with Sherry Glied. Schoen and 12 By regulations to implement the Affordable Care Act, Collins developed the specifications for the high-cost an employer-sponsored plan is considered affordable burden and high premium variables. if the portion of the annual premium an employee 3 must pay for self-only coverage does not exceed 9.5% Programmers at the New York University Robert F. Wagner Graduate School of Public Service conducted of the employee’s household income and the plan cov- the analysis of Current Population Survey data using ers at least 60 percent, on average, of medical costs. specifications provided by the authors. Plan affordability is based on the cost of self-only cov- 4 erage regardless of whether employees have family We categorized insured individuals or insured families coverage and may pay more than 9.5 percent of their being underinsured if out-of-pocket costs relative to income for that coverage. their income for medical expenses (excluding health 13 insurance premiums) were 10 percent or more of their Calculated from Table 9. The 11.7 million includes peo- annual income, or 5 percent or more if their income ple with employer-sponsored insurance (ESI) with was below 200 percent of poverty. incomes from 138 percent to 399 percent of poverty. 5 Only some of these people will be eligible for pre- The other 10.8 million with high out-of-pocket medi- mium tax credits. Those with ESI with incomes below cal care expenses compared with their incomes were 138 percent of poverty will be eligible for Medicaid if uninsured. their state takes part in the expansion. 6 C. Schoen, J. A. Lippa, S. R. Collins, and D. C. Radley, 14 The sum of those with individual coverage with State Trends in Premiums and Deductibles, 2003–2011: incomes from 138 percent to 399 percent of poverty Eroding Protection and Rising Costs Underscore Need adds to 2.2 million when including the estimate to for Action (New York: The Commonwealth Fund, Dec. two decimal places; Table 9 adds to 2.1 million 2012); and S. R. Collins, R. H. Robertson, T. Garber, and because of rounding. M. M. Doty, Insuring the Future: Current Trends in 15 Health Coverage and the Effects of Implementing the See Table 9. The 11 million number includes those Affordable Care Act (New York: The Commonwealth with employer-sponsored insurance or individual insur- Fund, April 2013). ance under 138% poverty plus those with individual 7 insurance with incomes from 138% poverty to 399% Schoen, Doty, Robertson, and Collins, “Affordable Care poverty. Act Reforms Could Reduce,” 2011. 8 Schoen, Lippa, Collins, and Radley, State Trends in Premiums and Deductibles, 2012. www.commonwealthfund.org15 16 23 R. Rudowitz and L. Snyder, Premiums and Cost-Sharing Pollitz, Cost, Lucia et al., Medical Debt Among People in Medicaid (Washington, D.C.: Kaiser Commission on with Health Insurance, 2014. Medicaid and the Uninsured, Feb. 2013); T. Jost, 24 S. R. Collins, R. H. Robertson, T. Garber, and M. M. “Implementing Health Reform: Final Rule on Premium Doty, The Income Divide in Health Care: How the Tax Credit, Medicaid, and CHIP Eligibility Affordable Care Act Will Help Restore Fairness to the Determinations (Part 2),” Health Affairs Blog, July 7, U.S. Health System (New York: The Commonwealth 2013; and U.S. Department of Health and Human Fund, Feb. 2012); and C. Schoen, S. L. Hayes, J. A. Services, Centers for Medicare and Medicaid Services, Lippa, and D. C. Radley, Insurance Matters: Primary “Medicaid and Children’s Health Insurance Programs: and Preventive Care Access by State Before Major Essential Health Benefits in Alternative Benefit Plans, Insurance Expansions (New York: The Commonwealth Eligibility Notices, Fair Hearing and Appeal Processes, Fund, forthcoming 2014). and Premiums and Cost Sharing; Exchanges: Eligibility 25 and Enrollment,” Final Rule, Federal Register, July 15, M. Tavenner, “Marketplace Enrollment Hits 5 Million 2013 (78)135:42279. Milestone,” HHS.gov/Health Care Blog, March 17, 17 2014; and U.S. Department of Health and Human Avalere, State Reform Insights; Center for Budget and Services, Assistant Secretary for Planning and Policy Priorities; Politico.com; and Commonwealth Evaluation, Office of Policy, Health Insurance Fund analysis. Marketplace: March Enrollment Report, For the Period: 18 Kaiser Commission of Medicaid and the Uninsured, October 1, 2013–March 1, 2014, ASPE Issue Brief Where Are States Today? Medicaid and CHIP Eligibility (Washington, D.C.: ASPE, March 11, 2014). Levels for Children and Non-Disabled Adults as of 26 January 1, 2014 (Washington, D.C.: Henry J. Kaiser Centers for Medicare and Medicaid Services, Medicaid Family Foundation, Jan. 13, 2014); and Wisconsin and CHIP: January 2014 Monthly Applications and Department of Health Services, “BadgerCare+ Eligibility Determinations Report (Washington, D.C.: Demonstration Project Waiver,” Jan. 9, 2014, www. CMS, Feb. 28, 2014). The 10.3 million number includes dhs.wisconsin.gov/badgercareplus/waivers.htm. the 8.9 million determined eligible through state agencies and another 1.4 million determined eligible 19 Kaiser Commission, Where Are States Today? 2014. through the federally facilitated exchanges. 20 27 Kaiser Commission on Medicaid and the Uninsured, J. Gruber and I. Perry, Realizing Health Reform’s The Coverage Gap: Uninsured Poor Adults in States Potential: Will the Affordable Care Act Make Health That Do Not Expand Medicaid (Washington, D.C.: Insurance Affordable? (New York: The Commonwealth Henry J. Kaiser Family Foundation, Oct. 23, 2013). Fund, April 2011). 21 Collins, Robertson, Garber, and Doty, Insuring the Future, 2013. 22 U.S. Department of Health and Human Services, Assistant Secretary for Planning and Evaluation, Office of Policy, Health Insurance Marketplace: February Enrollment Report, For the Period: October 1, 2013– February 1, 2014, ASPE Issue Brief (Washington, D.C.: ASPE, Feb. 12, 2014). 16 America’s Underinsured: A State-by-State Look at Health Insurance Affordability Prior to the New Coverage Expansions Table 1. National Distribution of U.S. Population Under Age 65 by Federal Poverty Level, 2012 UNDER-65 POPULATION POPULATION PERCENT OF IN MILLIONS POPULATION GROUP Total population under age 65 267.7 100% <100% poverty 52.9 20% 100%–137% poverty 20.3 8% 138%–199% poverty 29.3 11% 200%–399% poverty 76.2 28% 400% poverty or more 89.1 33% Uninsured population under age 65 47.3 100% <100% poverty 17.4 37% 100%–137% poverty 6.2 13% 138%–199% poverty 7.3 15% 200%–399% poverty 11.3 24% 400% poverty or more 5.1 11% Insured population under age 65 who are underinsureda 31.7 100% <100% poverty 16.0 50% 100%–137% poverty 4.1 13% 138%–199% poverty 5.7 18% 200%–399% poverty 4.2 13% 400% poverty or more 1.7 5% Insured population under age 65 with premiums that 29.2 100% exceed ACA threshold or Medicaidb <100% poverty 8.1 28% 100%–137% poverty 5.6 19% 138%–199% poverty 6.5 22% 200%–399% poverty 9.0 31% 400% poverty or more 0 0% Underinsureda or with premiums that exceed the ACA 50.6 100% threshold or Medicaidb under age 65 <100% poverty 19.3 38% 100%–137% poverty 7.7 15% 138%–199% poverty 9.7 19% 200%–399% poverty 12.1 24% 400% poverty or more 1.7 3% Note: Sum of people and percentages in population subgroups may not equal total because of rounding. a Underinsured defined as insured in household that spent 10% or more of income on medical care (excluding premiums) or 5% or more if income under 200% poverty. b Affordable Care Act (ACA) thresholds refers to the maximum premium contribution as a share of income in marketplaces or Medicaid if eligible to participate. Data source: Analysis of March 2013 Current Population Survey (CPS). www.commonwealthfund.org17 Table 2. State Population Demographics by Federal Poverty Level, Under Age 65, 2011–2012 UNDER-65 POPULATION LESS THAN 100% 400% POVERTY TOTAL POVERTY 100%–199% POVERTY 200%–399% POVERTY OR MORE State People People Percent People Percent People Percent People Percent United States 267,740,038 52,870,157 20% 49,599,636 19% 76,163,816 28% 89,106,429 33% (2012) United States 267,575,496 53,286,976 20% 49,448,659 18% 76,421,641 29% 88,418,220 33% (2011–2012) Alabama 4,150,585 865,456 21% 807,823 19% 1,242,164 30% 1,235,142 30% Alaska 643,903 95,910 15% 105,539 16% 190,260 30% 252,194 39% Arizona 5,689,270 1,337,661 24% 1,117,468 20% 1,582,745 28% 1,651,396 29% Arkansas 2,451,343 590,794 24% 533,052 22% 747,682 31% 579,815 24% California 33,389,710 7,760,875 23% 6,547,421 20% 8,543,102 26% 10,538,312 32% Colorado 4,473,497 724,488 16% 671,523 15% 1,267,786 28% 1,809,700 40% Connecticut 3,011,169 425,092 14% 413,529 14% 741,321 25% 1,431,227 48% Delaware 760,994 148,053 19% 136,056 18% 216,849 28% 260,036 34% District of 549,330 134,666 25% 70,774 13% 99,661 18% 244,229 44% Columbia Florida 15,687,963 3,285,656 21% 3,096,387 20% 4,599,910 29% 4,706,010 30% Georgia 8,598,462 1,990,122 23% 1,575,700 18% 2,546,942 30% 2,485,698 29% Hawaii 1,143,348 246,812 22% 232,677 20% 327,325 29% 336,534 29% Idaho 1,350,649 249,423 18% 327,601 24% 426,499 32% 347,126 26% Illinois 10,984,776 2,035,642 19% 2,093,103 19% 3,014,759 27% 3,841,272 35% Indiana 5,427,533 1,096,482 20% 1,040,346 19% 1,572,488 29% 1,718,217 32% Iowa 2,609,741 346,733 13% 467,042 18% 893,099 34% 902,867 35% Kansas 2,411,193 437,664 18% 448,672 19% 746,953 31% 777,904 32% Kentucky 3,756,355 791,378 21% 776,419 21% 1,142,092 30% 1,046,466 28% Louisiana 3,874,266 1,014,970 26% 743,493 19% 1,087,136 28% 1,028,667 27% Maine 1,123,414 170,260 15% 197,208 18% 366,073 33% 389,873 35% Maryland 5,094,796 722,262 14% 734,338 14% 1,338,707 26% 2,299,489 45% Massachusetts 5,585,276 859,153 15% 752,301 13% 1,380,846 25% 2,592,976 46% Michigan 8,258,807 1,549,186 19% 1,425,631 17% 2,308,308 28% 2,975,682 36% Minnesota 4,598,136 566,426 12% 645,490 14% 1,387,942 30% 1,998,278 43% Mississippi 2,512,432 650,764 26% 543,632 22% 743,450 30% 574,586 23% Missouri 5,063,833 1,018,114 20% 872,743 17% 1,494,555 30% 1,678,421 33% Montana 817,238 156,182 19% 167,441 20% 272,654 33% 220,961 27% Nebraska 1,590,083 217,221 14% 271,872 17% 513,180 32% 587,810 37% Nevada 2,349,645 498,649 21% 499,976 21% 727,119 31% 623,901 27% New Hampshire 1,120,722 114,162 10% 136,324 12% 331,201 30% 539,035 48% New Jersey 7,445,027 1,136,072 15% 1,165,245 16% 1,874,067 25% 3,269,643 44% New Mexico 1,741,452 479,812 28% 336,644 19% 432,176 25% 492,820 28% New York 16,608,850 3,702,305 22% 2,904,750 17% 4,519,562 27% 5,482,233 33% North Carolina 8,170,616 1,651,823 20% 1,718,327 21% 2,366,414 29% 2,434,052 30% North Dakota 598,390 72,059 12% 81,041 14% 200,124 33% 245,166 41% Ohio 9,636,202 1,922,676 20% 1,747,696 18% 3,032,866 31% 2,932,964 30% Oklahoma 3,216,702 654,515 20% 610,814 19% 981,237 31% 970,136 30% Oregon 3,311,824 611,014 18% 678,195 20% 995,626 30% 1,026,989 31% Pennsylvania 10,763,884 1,886,148 18% 1,735,473 16% 3,196,369 30% 3,945,894 37% Rhode Island 875,455 168,541 19% 139,981 16% 224,096 26% 342,837 39% South Carolina 3,986,837 853,635 21% 811,863 20% 1,280,171 32% 1,041,168 26% South Dakota 703,440 113,226 16% 130,423 19% 253,647 36% 206,144 29% Tennessee 5,457,678 1,180,358 22% 1,093,560 20% 1,718,875 31% 1,464,885 27% Texas 23,090,586 5,181,634 22% 4,861,552 21% 6,441,780 28% 6,605,620 29% Utah 2,560,747 378,933 15% 585,358 23% 888,436 35% 708,020 28% Vermont 516,488 69,071 13% 85,524 17% 171,626 33% 190,267 37% Virginia 6,927,932 1,022,906 15% 1,058,782 15% 1,964,650 28% 2,881,594 42% Washington 5,971,672 958,359 16% 1,132,048 19% 1,716,827 29% 2,164,438 36% West Virginia 1,542,410 321,374 21% 300,206 19% 505,004 33% 415,826 27% Wisconsin 4,872,659 752,855 15% 721,453 15% 1,653,643 34% 1,744,708 36% Wyoming 498,176 69,404 14% 98,143 20% 151,637 30% 178,992 36% Data source: March 2012–13 Current Population Survey (CPS). 18 America’s Underinsured: A State-by-State Look at Health Insurance Affordability Prior to the New Coverage Expansions Table 3. Uninsured or Underinsured Under Age 65, Total, by State, 2011–2012 a UNINSURED OR UNDERINSURED UNDER AGE 65 EITHER UNINSURED OR a a UNINSURED UNDERINSURED UNDERINSURED State People Percent People Percent People Percent United States (2012) 47,296,988 18% 31,653,855 12% 78,950,843 29% United States (2011–2012) 47,617,535 18% 31,112,183 12% 78,729,718 29% Alabama 660,730 16% 582,071 14% 1,242,801 30% Alaska 129,873 20% 73,672 11% 203,545 32% Arizona 1,140,186 20% 657,244 12% 1,797,430 32% Arkansas 510,383 21% 357,034 15% 867,417 35% California 6,992,371 21% 3,507,450 11% 10,499,821 31% Colorado 736,879 16% 616,371 14% 1,353,250 30% Connecticut 285,748 9% 313,463 10% 599,211 20% Delaware 92,570 12% 79,411 10% 171,981 23% District of Columbia 49,802 9% 46,898 9% 96,700 18% Florida 3,866,688 25% 1,854,797 12% 5,721,485 36% Georgia 1,849,656 22% 1,014,262 12% 2,863,918 33% Hawaii 102,739 9% 145,513 13% 248,252 22% Idaho 257,948 19% 233,806 17% 491,754 36% Illinois 1,772,366 16% 1,315,672 12% 3,088,038 28% Indiana 801,579 15% 709,556 13% 1,511,135 28% Iowa 301,444 12% 293,442 11% 594,886 23% Kansas 368,441 15% 286,847 12% 655,288 27% Kentucky 647,130 17% 459,237 12% 1,106,367 29% Louisiana 866,303 22% 452,581 12% 1,318,884 34% Maine 129,293 12% 139,451 12% 268,744 24% Maryland 755,915 15% 452,051 9% 1,207,966 24% Massachusetts 242,879 4% 531,029 10% 773,908 14% Michigan 1,110,519 13% 921,020 11% 2,031,539 25% Minnesota 462,517 10% 399,529 9% 862,046 19% Mississippi 453,574 18% 408,632 16% 862,206 34% Missouri 834,076 16% 580,551 11% 1,414,627 28% Montana 178,919 22% 102,306 13% 281,225 34% Nebraska 233,282 15% 190,606 12% 423,888 27% Nevada 620,817 26% 257,626 11% 878,443 37% New Hampshire 158,520 14% 93,608 8% 252,128 22% New Jersey 1,250,736 17% 749,402 10% 2,000,138 27% New Mexico 421,705 24% 234,019 13% 655,724 38% New York 2,220,839 13% 1,806,989 11% 4,027,828 24% North Carolina 1,593,276 20% 1,117,065 14% 2,710,341 33% North Dakota 70,031 12% 62,392 10% 132,423 22% Ohio 1,460,837 15% 1,250,465 13% 2,711,302 28% Oklahoma 633,071 20% 381,381 12% 1,014,452 32% Oregon 559,347 17% 480,649 15% 1,039,996 31% Pennsylvania 1,426,872 13% 1,114,294 10% 2,541,166 24% Rhode Island 125,046 14% 87,170 10% 212,216 24% South Carolina 765,291 19% 468,964 12% 1,234,255 31% South Dakota 111,335 16% 79,858 11% 191,193 27% Tennessee 849,557 16% 872,052 16% 1,721,609 32% Texas 6,166,602 27% 2,618,242 11% 8,784,844 38% Utah 406,843 16% 435,507 17% 842,350 33% Vermont 47,759 9% 56,663 11% 104,422 20% Virginia 1,020,551 15% 686,787 10% 1,707,338 25% Washington 947,718 16% 677,634 11% 1,625,352 27% West Virginia 266,650 17% 198,372 13% 465,022 30% Wisconsin 566,533 12% 584,069 12% 1,150,602 24% Wyoming 93,789 19% 74,473 15% 168,262 34% Min 4% 8% 14% Max 27% 17% 38% a Underinsured defined as insured in household that spent 10% or more of income on medical care (excluding premiums) or 5% or more if income under 200% poverty. Note: Percentages of “uninsured” and “underinsured” may not sum to total because of rounding. Data source: March 2012–13 Current Population Survey (CPS). www.commonwealthfund.org19 Table 4. Underinsured Under Age 65, Total and by Federal Poverty Level, by State, 2011–2012 a UNDERINSURED UNDER AGE 65 TOTAL, 2011–2012 LESS THAN 100% POVERTY 100%–199% POVERTY 200%–399% POVERTY 400% POVERTY OR MORE Number of Percent of Number of Percent of Number of Percent of Number of Percent of Number of Percent of State underinsured population underinsured population underinsured population underinsured population underinsured population United States 31,653,855 12% 15,959,850 30% 9,745,342 20% 4,247,733 6% 1,700,930 2% (2012) United States 31,112,183 12% 15,879,464 30% 9,274,283 19% 4,384,403 6% 1,574,033 2% (2011–2012) Alabama 582,071 14% 292,887 34% 230,720 29% 53,258 4% 5,206 0% Alaska 73,672 11% 31,843 33% 19,195 18% 15,073 8% 7,561 3% Arizona 657,244 12% 364,750 27% 160,625 14% 101,649 6% 30,220 2% Arkansas 357,034 15% 186,285 32% 102,599 19% 46,808 6% 21,342 4% California 3,507,450 11% 1,980,504 26% 921,257 14% 415,002 5% 190,687 2% Colorado 616,371 14% 254,776 35% 178,326 27% 113,419 9% 69,850 4% Connecticut 313,463 10% 175,661 41% 91,276 22% 34,221 5% 12,305 1% Delaware 79,411 10% 40,789 28% 23,048 17% 11,393 5% 4,181 2% District of 46,898 9% 32,532 24% 7,888 11% 3,489 4% 2,989 1% Columbia Florida 1,854,797 12% 990,043 30% 491,315 16% 265,017 6% 108,422 2% Georgia 1,014,262 12% 579,540 29% 277,444 18% 113,414 4% 43,864 2% Hawaii 145,513 13% 90,354 37% 43,785 19% 8,312 3% 3,062 1% Idaho 233,806 17% 85,360 34% 88,257 27% 46,656 11% 13,533 4% Illinois 1,315,672 12% 589,774 29% 482,166 23% 186,539 6% 57,193 1% Indiana 709,556 13% 373,260 34% 202,759 19% 101,435 6% 32,102 2% Iowa 293,442 11% 118,536 34% 109,214 23% 56,743 6% 8,949 1% Kansas 286,847 12% 133,027 30% 93,619 21% 49,841 7% 10,360 1% Kentucky 459,237 12% 213,340 27% 159,977 21% 70,482 6% 15,438 1% Louisiana 452,581 12% 252,117 25% 131,117 18% 44,712 4% 24,635 2% Maine 139,451 12% 63,245 37% 43,709 22% 24,961 7% 7,536 2% Maryland 452,051 9% 238,408 33% 105,485 14% 70,831 5% 37,327 2% Massachusetts 531,029 10% 290,415 34% 169,272 23% 54,998 4% 16,344 1% Michigan 921,020 11% 471,835 30% 285,685 20% 137,626 6% 25,874 1% Minnesota 399,529 9% 154,992 27% 138,861 22% 79,528 6% 26,148 1% Mississippi 408,632 16% 220,366 34% 115,955 21% 54,026 7% 18,285 3% Missouri 580,551 11% 292,717 29% 172,317 20% 95,098 6% 20,419 1% Montana 102,306 13% 50,454 32% 33,168 20% 16,225 6% 2,459 1% Nebraska 190,606 12% 72,066 33% 59,457 22% 45,831 9% 13,252 2% Nevada 257,626 11% 134,399 27% 75,318 15% 32,094 4% 15,815 3% New Hampshire 93,608 8% 39,010 34% 30,329 22% 14,017 4% 10,252 2% New Jersey 749,402 10% 405,093 36% 210,377 18% 82,058 4% 51,874 2% New Mexico 234,019 13% 127,717 27% 68,234 20% 23,277 5% 14,791 3% New York 1,806,989 11% 1,132,976 31% 392,553 14% 182,527 4% 98,933 2% North Carolina 1,117,065 14% 521,994 32% 371,415 22% 171,512 7% 52,144 2% North Dakota 62,392 10% 24,403 34% 21,249 26% 14,693 7% 2,047 1% Ohio 1,250,465 13% 581,115 30% 392,229 22% 218,940 7% 58,181 2% Oklahoma 381,381 12% 196,027 30% 117,895 19% 54,788 6% 12,671 1% Oregon 480,649 15% 215,748 35% 166,556 25% 76,239 8% 22,106 2% Pennsylvania 1,114,294 10% 640,618 34% 333,848 19% 110,151 3% 29,677 1% Rhode Island 87,170 10% 45,933 27% 30,928 22% 8,677 4% 1,632 0% South Carolina 468,964 12% 273,015 32% 98,636 12% 78,693 6% 18,620 2% South Dakota 79,858 11% 27,825 25% 28,352 22% 17,789 7% 5,892 3% Tennessee 872,052 16% 430,069 36% 272,693 25% 129,432 8% 39,858 3% Texas 2,618,242 11% 1,275,740 25% 826,537 17% 382,066 6% 133,899 2% Utah 435,507 17% 163,070 43% 196,322 34% 62,787 7% 13,328 2% Vermont 56,663 11% 25,803 37% 16,643 19% 10,152 6% 4,065 2% Virginia 686,787 10% 354,101 35% 192,379 18% 94,350 5% 45,957 2% Washington 677,634 11% 280,232 29% 237,361 21% 102,663 6% 57,378 3% West Virginia 198,372 13% 92,694 29% 65,813 22% 30,079 6% 9,786 2% Wisconsin 584,069 12% 230,779 31% 162,647 23% 152,277 9% 38,366 2% Wyoming 74,473 15% 21,227 31% 27,473 28% 18,555 12% 7,218 4% Min 8% 24% 11% 3% 0% Max 17% 43% 34% 12% 4% a Underinsured defined as insured in household that spent 10% or more of income on medical care (excluding premiums) or 5% or more if income under 200% poverty. Data source: March 2012–13 Current Population Survey (CPS). 20 America’s Underinsured: A State-by-State Look at Health Insurance Affordability Prior to the New Coverage Expansions Table 5. Uninsured Under Age 65, Total and by Federal Poverty Level, by State, 2011–2012 UNINSURED UNDER AGE 65 LESS THAN 100% 400% POVERTY TOTAL, 2011–2012 100%–199% POVERTY 200%–399% POVERTY POVERTY OR MORE State People Percent People Percent People Percent People Percent People Percent United States 47,296,988 18% 17,383,796 33% 13,501,469 27% 11,335,826 15% 5,075,897 6% (2012) United States 47,617,535 18% 17,720,248 33% 13,614,695 28% 11,215,821 15% 5,066,771 6% (2011–2012) Alabama 660,730 16% 294,272 34% 170,281 21% 151,854 12% 44,323 4% Alaska 129,873 20% 33,870 35% 28,868 27% 42,882 23% 24,253 10% Arizona 1,140,186 20% 425,653 32% 364,154 33% 244,817 15% 105,562 6% Arkansas 510,383 21% 209,969 36% 151,972 29% 106,921 14% 41,521 7% California 6,992,371 21% 2,766,547 36% 1,992,080 30% 1,572,094 18% 661,650 6% Colorado 736,879 16% 255,119 35% 187,301 28% 192,995 15% 101,464 6% Connecticut 285,748 9% 92,320 22% 67,440 16% 76,756 10% 49,232 3% Delaware 92,570 12% 30,330 20% 29,460 22% 20,856 10% 11,924 5% District of 49,802 9% 18,405 14% 11,233 16% 10,779 11% 9,385 4% Columbia Florida 3,866,688 25% 1,416,672 43% 1,083,019 35% 917,227 20% 449,770 10% Georgia 1,849,656 22% 792,355 40% 459,228 29% 405,796 16% 192,277 8% Hawaii 102,739 9% 46,323 19% 26,094 11% 21,073 6% 9,249 3% Idaho 257,948 19% 91,238 37% 91,985 28% 58,213 14% 16,512 5% Illinois 1,772,366 16% 668,542 33% 494,737 24% 428,994 14% 180,093 5% Indiana 801,579 15% 291,705 27% 250,850 24% 173,253 11% 85,771 5% Iowa 301,444 12% 92,958 27% 83,807 18% 90,502 10% 34,177 4% Kansas 368,441 15% 141,285 32% 98,102 22% 90,938 12% 38,116 5% Kentucky 647,130 17% 282,728 36% 201,431 26% 115,389 10% 47,582 5% Louisiana 866,303 22% 393,220 39% 221,474 30% 181,163 17% 70,446 7% Maine 129,293 12% 32,761 19% 38,148 19% 42,938 12% 15,446 4% Maryland 755,915 15% 248,343 34% 208,643 28% 209,207 16% 89,722 4% Massachusetts 242,879 4% 66,462 8% 57,086 8% 67,346 5% 51,985 2% Michigan 1,110,519 13% 396,077 26% 311,636 22% 247,770 11% 155,036 5% Minnesota 462,517 10% 151,920 27% 116,106 18% 124,744 9% 69,747 3% Mississippi 453,574 18% 189,123 29% 138,977 26% 88,009 12% 37,465 7% Missouri 834,076 16% 353,336 35% 208,462 24% 198,650 13% 73,628 4% Montana 178,919 22% 58,874 38% 52,604 31% 47,458 17% 19,983 9% Nebraska 233,282 15% 61,555 28% 73,397 27% 67,965 13% 30,365 5% Nevada 620,817 26% 240,693 48% 185,493 37% 148,719 20% 45,912 7% New Hampshire 158,520 14% 40,748 36% 40,570 30% 48,884 15% 28,318 5% New Jersey 1,250,736 17% 411,045 36% 384,962 33% 300,336 16% 154,393 5% New Mexico 421,705 24% 178,039 37% 113,491 34% 90,245 21% 39,930 8% New York 2,220,839 13% 795,554 21% 577,298 20% 553,842 12% 294,145 5% North Carolina 1,593,276 20% 573,311 35% 469,017 27% 382,691 16% 168,257 7% North Dakota 70,031 12% 23,481 33% 16,585 20% 21,356 11% 8,609 4% Ohio 1,460,837 15% 575,183 30% 412,896 24% 336,841 11% 135,917 5% Oklahoma 633,071 20% 199,261 30% 184,567 30% 158,294 16% 90,949 9% Oregon 559,347 17% 194,843 32% 160,539 24% 140,178 14% 63,787 6% Pennsylvania 1,426,872 13% 461,502 24% 431,329 25% 351,121 11% 182,920 5% Rhode Island 125,046 14% 48,022 28% 33,409 24% 30,069 13% 13,546 4% South Carolina 765,291 19% 301,508 35% 203,594 25% 188,196 15% 71,993 7% South Dakota 111,335 16% 39,547 35% 29,013 22% 31,237 12% 11,538 6% Tennessee 849,557 16% 323,619 27% 285,277 26% 172,107 10% 68,554 5% Texas 6,166,602 27% 2,295,143 44% 1,893,761 39% 1,410,012 22% 567,686 9% Utah 406,843 16% 131,185 35% 114,178 20% 107,176 12% 54,304 8% Vermont 47,759 9% 12,859 19% 12,394 14% 16,192 9% 6,314 3% Virginia 1,020,551 15% 340,389 33% 289,533 27% 252,245 13% 138,384 5% Washington 947,718 16% 327,215 34% 319,382 28% 217,453 13% 83,668 4% West Virginia 266,650 17% 90,000 28% 68,336 23% 75,401 15% 32,913 8% Wisconsin 566,533 12% 188,328 25% 147,307 20% 158,167 10% 72,731 4% Wyoming 93,789 19% 26,811 39% 23,189 24% 28,470 19% 15,319 9% Min 4% 8% 8% 5% 2% Max 27% 48% 39% 23% 10% Data source: March 2012–13 Current Population Survey (CPS). www.commonwealthfund.org21 Table 6. Uninsured or Underinsured Under Age 65, Total and by Federal Poverty Level, by State, 2011–2012 a UNINSURED OR UNDERINSURED UNDER AGE 65 400% POVERTY TOTAL, 2011–2012 LESS THAN 100% POVERTY 100%–199% POVERTY 200%–399% POVERTY OR MORE State People Percent People Percent People Percent People Percent People Percent United States 78,950,843 29% 33,343,646 63% 23,246,811 47% 15,583,559 20% 6,776,827 8% (2012) United States 78,729,718 29% 33,599,712 63% 22,888,978 46% 15,600,224 20% 6,640,804 8% (2011–2012) Alabama 1,242,801 30% 587,159 68% 401,001 50% 205,112 17% 49,529 4% Alaska 203,545 32% 65,713 69% 48,063 46% 57,955 30% 31,814 13% Arizona 1,797,430 32% 790,403 59% 524,779 47% 346,466 22% 135,782 8% Arkansas 867,417 35% 396,254 67% 254,571 48% 153,729 21% 62,863 11% California 10,499,821 31% 4,747,051 61% 2,913,337 44% 1,987,096 23% 852,337 8% Colorado 1,353,250 30% 509,895 70% 365,627 54% 306,414 24% 171,314 9% Connecticut 599,211 20% 267,981 63% 158,716 38% 110,977 15% 61,537 4% Delaware 171,981 23% 71,119 48% 52,508 39% 32,249 15% 16,105 6% District of 96,700 18% 50,937 38% 19,121 27% 14,268 14% 12,374 5% Columbia Florida 5,721,485 36% 2,406,715 73% 1,574,334 51% 1,182,244 26% 558,192 12% Georgia 2,863,918 33% 1,371,895 69% 736,672 47% 519,210 20% 236,141 9% Hawaii 248,252 22% 136,677 55% 69,879 30% 29,385 9% 12,311 4% Idaho 491,754 36% 176,598 71% 180,242 55% 104,869 25% 30,045 9% Illinois 3,088,038 28% 1,258,316 62% 976,903 47% 615,533 20% 237,286 6% Indiana 1,511,135 28% 664,965 61% 453,609 44% 274,688 17% 117,873 7% Iowa 594,886 23% 211,494 61% 193,021 41% 147,245 16% 43,126 5% Kansas 655,288 27% 274,312 63% 191,721 43% 140,779 19% 48,476 6% Kentucky 1,106,367 29% 496,068 63% 361,408 47% 185,871 16% 63,020 6% Louisiana 1,318,884 34% 645,337 64% 352,591 47% 225,875 21% 95,081 9% Maine 268,744 24% 96,006 56% 81,857 42% 67,899 19% 22,982 6% Maryland 1,207,966 24% 486,751 67% 314,128 43% 280,038 21% 127,049 6% Massachusetts 773,908 14% 356,877 42% 226,358 30% 122,344 9% 68,329 3% Michigan 2,031,539 25% 867,912 56% 597,321 42% 385,396 17% 180,910 6% Minnesota 862,046 19% 306,912 54% 254,967 39% 204,272 15% 95,895 5% Mississippi 862,206 34% 409,489 63% 254,932 47% 142,035 19% 55,750 10% Missouri 1,414,627 28% 646,053 63% 380,779 44% 293,748 20% 94,047 6% Montana 281,225 34% 109,328 70% 85,772 51% 63,683 23% 22,442 10% Nebraska 423,888 27% 133,621 62% 132,854 49% 113,796 22% 43,617 7% Nevada 878,443 37% 375,092 75% 260,811 52% 180,813 25% 61,727 10% New Hampshire 252,128 22% 79,758 70% 70,899 52% 62,901 19% 38,570 7% New Jersey 2,000,138 27% 816,138 72% 595,339 51% 382,394 20% 206,267 6% New Mexico 655,724 38% 305,756 64% 181,725 54% 113,522 26% 54,721 11% New York 4,027,828 24% 1,928,530 52% 969,851 33% 736,369 16% 393,078 7% North Carolina 2,710,341 33% 1,095,305 66% 840,432 49% 554,203 23% 220,401 9% North Dakota 132,423 22% 47,884 66% 37,834 47% 36,049 18% 10,656 4% Ohio 2,711,302 28% 1,156,298 60% 805,125 46% 555,781 18% 194,098 7% Oklahoma 1,014,452 32% 395,288 60% 302,462 50% 213,082 22% 103,620 11% Oregon 1,039,996 31% 410,591 67% 327,095 48% 216,417 22% 85,893 8% Pennsylvania 2,541,166 24% 1,102,120 58% 765,177 44% 461,272 14% 212,597 5% Rhode Island 212,216 24% 93,955 56% 64,337 46% 38,746 17% 15,178 4% South Carolina 1,234,255 31% 574,523 67% 302,230 37% 266,889 21% 90,613 9% South Dakota 191,193 27% 67,372 60% 57,365 44% 49,026 19% 17,430 8% Tennessee 1,721,609 32% 753,688 64% 557,970 51% 301,539 18% 108,412 7% Texas 8,784,844 38% 3,570,883 69% 2,720,298 56% 1,792,078 28% 701,585 11% Utah 842,350 33% 294,255 78% 310,500 53% 169,963 19% 67,632 10% Vermont 104,422 20% 38,662 56% 29,037 34% 26,344 15% 10,379 5% Virginia 1,707,338 25% 694,490 68% 481,912 46% 346,595 18% 184,341 6% Washington 1,625,352 27% 607,447 63% 556,743 49% 320,116 19% 141,046 7% West Virginia 465,022 30% 182,694 57% 134,149 45% 105,480 21% 42,699 10% Wisconsin 1,150,602 24% 419,107 56% 309,954 43% 310,444 19% 111,097 6% Wyoming 168,262 34% 48,038 69% 50,662 52% 47,025 31% 22,537 13% Min 14% 38% 27% 9% 3% Max 38% 78% 56% 31% 13% a Underinsured defined as insured in household that spent 10% or more of income on medical care (excluding premiums) or 5% or more if income under 200% poverty. Data Source: March 2012–13 Current Population Survey (CPS). 22 America’s Underinsured: A State-by-State Look at Health Insurance Affordability Prior to the New Coverage Expansions Table 7. Average Health Insurance Premiums as Percent of Median Household Income, by State, 2003 and 2012 MEDIAN INCOME PREMIUMS AS A PERCENT OF MEDIAN INCOME Single premiums as Family premiums as Median income percent of median percent of median Average premiums for single-person Median income income for single-person income for family as percent of median household for family household household household household income for State (under age 65) (all under age 65) (under age 65) (all under age 65) under-65 population* 2002–03 2011–12 2002–03 2011–12 2003 2012 2003 2012 2003 2012 United States $24,400 $26,700 $61,000 $70,000 14.3% 20.2% 15.2% 22.1% 14.9% 21.6% Alabama 20,952 22,799 58,000 62,458 15.1% 21.8% 13.9% 20.4% 14.2% 20.8% Alaska 25,082 31,174 66,634 80,000 16.0% 23.8% 15.9% 22.4% 15.9% 22.8% Arizona 20,800 25,003 55,536 60,800 15.4% 20.8% 16.2% 25.1% 16.0% 23.9% Arkansas 19,788 22,000 45,000 53,030 15.8% 20.3% 17.7% 25.1% 17.3% 23.8% California 25,400 26,049 58,548 65,004 13.0% 20.8% 15.5% 24.5% 14.9% 23.4% Colorado 27,540 30,000 65,797 85,739 13.2% 17.6% 14.5% 18.7% 14.1% 18.4% Connecticut 26,520 32,399 80,450 99,000 13.9% 18.3% 12.6% 17.1% 12.9% 17.4% Delaware 26,520 29,000 68,340 71,000 14.5% 19.3% 15.4% 22.0% 15.1% 21.2% District of Columbia 32,464 42,000 50,811 86,870 11.5% 13.3% 21.2% 19.8% 16.5% 16.6% Florida 23,529 25,000 56,770 62,150 15.3% 20.7% 16.4% 24.9% 16.1% 23.6% Georgia 24,024 26,000 58,707 63,000 15.1% 19.8% 14.7% 23.2% 14.8% 22.3% Hawaii 25,000 29,000 63,638 63,038 12.1% 17.5% 12.4% 23.4% 12.3% 21.2% Idaho 21,442 24,176 52,577 62,934 15.5% 18.4% 16.3% 22.3% 16.1% 21.5% Illinois 24,960 28,800 64,276 70,000 14.8% 18.8% 15.1% 22.5% 15.0% 21.5% Indiana 24,000 25,938 65,001 65,788 14.6% 21.2% 14.3% 23.5% 14.4% 23.0% Iowa 24,480 27,601 64,480 74,999 13.4% 18.6% 13.1% 19.1% 13.1% 19.0% Kansas 23,912 28,000 63,775 68,100 14.2% 17.7% 14.0% 20.2% 14.0% 19.6% Kentucky 21,425 22,000 54,078 62,325 16.0% 24.5% 16.9% 25.2% 16.7% 25.1% Louisiana 23,500 24,000 46,257 58,050 14.1% 22.4% 18.9% 26.0% 17.7% 25.0% Maine 23,000 25,000 56,886 72,930 16.7% 22.8% 18.1% 22.2% 17.8% 22.4% Maryland 28,560 32,001 78,044 92,400 12.0% 16.6% 11.8% 16.5% 11.9% 16.5% Massachusetts 28,000 33,000 77,750 97,263 12.5% 18.5% 12.7% 17.6% 12.6% 17.9% Michigan 24,391 24,159 65,514 76,621 15.1% 22.2% 14.4% 18.8% 14.6% 19.7% Minnesota 27,040 31,000 79,272 95,463 13.6% 17.2% 12.7% 16.1% 12.9% 16.4% Mississippi 20,000 21,221 45,103 55,000 16.5% 22.2% 17.9% 25.8% 17.6% 24.9% Missouri 24,480 25,200 64,273 68,000 13.5% 20.4% 14.0% 22.0% 13.9% 21.6% Montana 20,000 25,000 49,552 60,200 17.5% 22.3% 17.2% 24.4% 17.3% 23.9% Nebraska 23,582 28,000 65,607 80,923 14.9% 18.2% 13.9% 17.9% 14.1% 18.0% Nevada 25,000 27,501 55,029 60,000 14.3% 18.0% 16.0% 21.5% 15.6% 20.5% New Hampshire 26,849 31,200 80,910 95,504 13.3% 18.2% 12.1% 17.1% 12.4% 17.4% New Jersey 29,355 30,000 85,000 90,034 13.0% 19.5% 12.0% 18.8% 12.2% 19.0% New Mexico 18,972 23,000 45,000 51,811 17.7% 21.9% 20.7% 30.6% 19.9% 28.4% New York 25,013 30,000 61,380 68,000 14.4% 20.1% 15.4% 24.9% 15.1% 23.4% North Carolina 20,565 24,000 53,043 64,481 16.6% 23.5% 16.0% 24.2% 16.1% 24.0% North Dakota 22,524 29,459 57,144 85,050 13.3% 18.3% 13.8% 16.9% 13.7% 17.2% Ohio 23,970 25,000 63,397 68,842 14.3% 20.3% 14.4% 22.4% 14.4% 21.9% Oklahoma 20,420 25,000 50,150 62,064 16.1% 19.4% 17.4% 21.8% 17.1% 21.3% Oregon 21,846 25,002 57,477 65,070 15.4% 21.8% 15.4% 23.8% 15.4% 23.2% Pennsylvania 24,000 26,499 66,111 79,344 14.4% 20.3% 13.8% 19.4% 14.0% 19.6% Rhode Island 26,000 28,000 65,280 82,153 14.3% 21.0% 14.5% 19.3% 14.4% 19.8% South Carolina 21,000 23,957 55,200 60,000 16.1% 21.3% 16.2% 23.8% 16.1% 23.1% South Dakota 20,617 26,000 58,855 71,169 16.3% 20.8% 14.4% 21.1% 14.9% 21.0% Tennessee 21,624 24,000 52,000 62,000 16.6% 21.1% 17.8% 24.0% 17.5% 23.2% Texas 22,112 26,020 48,000 60,000 15.4% 19.7% 19.9% 24.4% 18.9% 23.2% Utah 22,710 27,000 61,200 74,357 14.8% 19.1% 13.6% 19.6% 13.9% 19.5% Vermont 24,480 30,000 65,740 75,405 14.7% 18.6% 14.4% 20.0% 14.5% 19.6% Virginia 25,149 30,000 75,000 86,029 13.2% 17.7% 12.2% 17.9% 12.5% 17.8% Washington 25,000 30,000 66,788 75,050 14.1% 17.9% 13.8% 21.7% 13.9% 20.6% West Virginia 19,992 23,000 43,860 60,240 19.1% 25.6% 20.9% 26.0% 20.5% 25.9% Wisconsin 25,500 28,000 64,016 78,738 14.7% 20.5% 14.9% 20.6% 14.9% 20.6% Wyoming 23,002 25,000 57,002 77,533 16.1% 23.4% 16.9% 20.1% 16.7% 21.0% * Weighted by single and family household distribution in state. Data source: Median household incomes—2003, 2004, 2012, and 2013 Current Population Surveys (CPS); Total average premiums for employer-based single and family health insurance plans—2003 and 2012 Medical Expenditure Panel Survey—Insurance Component. www.commonwealthfund.org23 Table 8. Insured Individuals Under Age 65 with Premiums That Exceed the Affordable Care Act Threshold, Total and by Federal Poverty Level, by State, 2011–2012 INSURED INDIVIDUALS UNDER AGE 65 WITH PREMIUMS THAT EXCEED THE AFFORDABLE CARE ACT THRESHOLD OR MEDICAIDa TOTAL, 2011–2012 BELOW 100% POVERTY 100%–199% POVERTY 200%–399% POVERTY Percent of Percent of Percent of Percent of Percent of State People insured population People population People population People population United States (2012) 29,241,328 13% 11% 8,109,966 15% 12,124,544 24% 9,006,818 12% United States (2011–2012) 28,671,344 13% 11% 8,011,646 15% 11,886,679 24% 8,773,019 11% Alabama 541,581 16% 13% 148,132 17% 256,306 32% 137,143 11% Alaska 44,375 9% 7% 10,268 11% 23,528 22% 10,579 6% Arizona 637,938 14% 11% 155,576 12% 260,922 23% 221,440 14% Arkansas 263,170 14% 11% 77,490 13% 109,886 21% 75,794 10% California 3,101,895 12% 9% 949,477 12% 1,312,738 20% 839,680 10% Colorado 415,046 11% 9% 94,904 13% 157,358 23% 162,784 13% Connecticut 299,193 11% 10% 72,896 17% 119,760 29% 106,537 14% Delaware 80,211 12% 11% 23,884 16% 32,701 24% 23,626 11% District of Columbia 37,721 8% 7% 18,508 14% 13,637 19% 5,576 6% Florida 1,863,735 16% 12% 512,044 16% 719,212 23% 632,479 14% Georgia 912,873 14% 11% 311,996 16% 369,522 23% 231,355 9% Hawaii 141,374 14% 12% 56,521 23% 55,807 24% 29,046 9% Idaho 174,912 16% 13% 30,533 12% 89,889 27% 54,490 13% Illinois 1,192,392 13% 11% 284,092 14% 572,828 27% 335,472 11% Indiana 619,136 13% 11% 185,281 17% 252,360 24% 181,495 12% Iowa 324,510 14% 12% 57,869 17% 156,713 34% 109,928 12% Kansas 300,254 15% 12% 78,393 18% 121,439 27% 100,422 13% Kentucky 487,602 16% 13% 105,896 13% 221,883 29% 159,823 14% Louisiana 416,901 14% 11% 144,044 14% 150,357 20% 122,500 11% Maine 119,664 12% 11% 20,450 12% 46,294 23% 52,920 14% Maryland 418,841 10% 8% 123,495 17% 153,023 21% 142,323 11% Massachusetts 617,587 12% 11% 170,288 20% 217,961 29% 229,338 17% Michigan 815,945 11% 10% 261,177 17% 328,406 23% 226,362 10% Minnesota 509,954 12% 11% 101,747 18% 229,687 36% 178,520 13% Mississippi 346,831 17% 14% 140,990 22% 136,182 25% 69,659 9% Missouri 639,600 15% 13% 182,075 18% 252,590 29% 204,935 14% Montana 86,507 14% 11% 25,299 16% 30,354 18% 30,854 11% Nebraska 199,470 15% 13% 51,361 24% 86,547 32% 61,562 12% Nevada 255,514 15% 11% 80,459 16% 103,588 21% 71,467 10% New Hampshire 114,553 12% 10% 22,631 20% 38,053 28% 53,869 16% New Jersey 530,268 9% 7% 148,329 13% 227,181 19% 154,758 8% New Mexico 227,013 17% 13% 67,578 14% 86,683 26% 72,752 17% New York 1,579,069 11% 10% 545,168 15% 574,081 20% 459,820 10% North Carolina 985,457 15% 12% 236,451 14% 437,122 25% 311,884 13% North Dakota 64,847 12% 11% 11,252 16% 27,096 33% 26,499 13% Ohio 1,121,196 14% 12% 303,019 16% 494,242 28% 323,935 11% Oklahoma 326,930 13% 10% 123,473 19% 126,667 21% 76,790 8% Oregon 432,213 16% 13% 99,201 16% 210,641 31% 122,371 12% Pennsylvania 1,158,531 12% 11% 349,669 19% 452,716 26% 356,146 11% Rhode Island 90,933 12% 10% 23,496 14% 42,826 31% 24,611 11% South Carolina 557,412 17% 14% 189,977 22% 241,624 30% 125,811 10% South Dakota 85,440 14% 12% 15,357 14% 37,036 28% 33,047 13% Tennessee 783,506 17% 14% 197,551 17% 332,476 30% 253,479 15% Texas 2,257,083 13% 10% 625,379 12% 931,148 19% 700,556 11% Utah 352,791 16% 14% 83,147 22% 176,223 30% 93,421 11% Vermont 67,036 14% 13% 19,728 29% 29,773 35% 17,535 10% Virginia 706,953 12% 10% 146,489 14% 256,138 24% 304,326 15% Washington 552,268 11% 9% 142,259 15% 236,991 21% 173,018 10% West Virginia 167,329 13% 11% 42,809 13% 82,191 27% 42,329 8% Wisconsin 593,949 14% 12% 134,946 18% 237,408 33% 221,595 13% Wyoming 51,835 13% 10% 8,592 12% 26,885 27% 16,358 11% Min 8% 7% 11% 18% 6% Max 17% 14% 29% 36% 17% a Affordable Care Act thresholds refers to the maximum premium contribution as a share of income in marketplaces or Medicaid if eligible to participate. Data source: March 2012–13 Current Population Survey (CPS). 24 America’s Underinsured: A State-by-State Look at Health Insurance Affordability Prior to the New Coverage Expansions Table 9. Distribution of Insured Population Under Age 65 with High Out-of-Pocket Medical Costs or High Premiums, by Federal Poverty Level, 2012 UNDER-65 POPULATION POVERTY GROUP (PERCENT OF FEDERAL POVERTY LEVEL) 100%– 138%– 200%– 250%– 400% OR TOTAL <100% 137% 199% 249% 399% MORE Total insured population 220.5 35.5 14.2 22.0 17.4 47.4 84.1 Employer-sponsored insurance 153.2 8.8 5.7 12.5 12.3 39.0 75.3 Medicare 8.7 3.1 1.4 1.4 0.7 1.1 0.9 Medicaid 37.0 19.3 5.2 5.3 2.4 3.1 1.6 Military 4.4 0.7 0.3 0.5 0.4 1.0 1.4 Individual 17.3 3.7 1.4 2.2 1.6 3.6 4.8 Total insured population who a 31.7 16.0 4.1 5.7 1.4 2.8 1.7 are underinsured Employer-sponsored insurance 16.0 5.5 2.1 3.7 1.0 2.3 1.4 Medicare 2.4 1.2 0.5 0.4 0.09 0.1 0.05 Medicaid 8.6 6.5 1.0 0.9 0.1 0.09 0.02 Military 0.6 0.4 0.04 0.09 0.01 0.02 0.02 Individual 4.0 2.3 0.4 0.6 0.2 0.3 0.2 Total insured population with premiums that exceed 29.2 8.1 5.6 6.5 3.7 5.3 0 Affordable Care Act threshold b or Medicaid Employer-sponsored insurance 18.4 3.4 3.3 4.6 2.9 4.2 0 Medicare 1.6 0.6 0.4 0.3 0.1 0.1 0 Medicaid 4.6 2.5 1.1 0.7 0.2 0.1 0 Military 0.4 0.2 0.09 0.05 0.03 0.04 0 Individual 4.3 1.5 0.6 0.8 0.5 0.8 0 Note: Columns may not sum to total because of rounding. a Underinsured defined as insured in household that spent 10% or more of income on medical care (excluding premiums) or 5% or more if income under 200% poverty. b Affordable Care Act thresholds refers to the maximum premium contribution as a share of income in marketplaces or Medicaid if eligible to participate. Data source: Analysis of March 2013 Current Population Survey (CPS). www.commonwealthfund.org25 Table 10. Poor Under Age 65 Who Are Uninsured, Underinsured, or Paying High Premiums in States Not Yet Expanding Medicaid, 2011–2012 UNDER AGE 65 BELOW 100% POVERTY, COUNT OF PEOPLE Premiums that exceed State not currently Total uninsured or ACA threshold or expanding Medicaid Uninsured Underinsureda underinsureda Medicaidb 24 states not expanding 8,610,116 6,969,782 15,579,898 3,624,859 Alabama 294,272 292,887 587,159 148,132 Alaska 33,870 31,843 65,713 10,268 Florida 1,416,672 990,043 2,406,715 512,044 Georgia 792,355 579,540 1,371,895 311,996 Idaho 91,238 85,360 176,598 30,533 Indiana 291,705 373,260 664,965 185,281 Kansas 141,285 133,027 274,312 78,393 Louisiana 393,220 252,117 645,337 144,044 Maine 32,761 63,245 96,006 20,450 Mississippi 189,123 220,366 409,489 140,990 Missouri 353,336 292,717 646,053 182,075 Montana 58,874 50,454 109,328 25,299 Nebraska 61,555 72,066 133,621 51,361 New Hampshire 40,748 39,010 79,758 22,631 North Carolina 573,311 521,994 1,095,305 236,451 Oklahoma 199,261 196,027 395,288 123,473 South Carolina 301,508 273,015 574,523 189,977 South Dakota 39,547 27,825 67,372 15,357 Tennessee 323,619 430,069 753,688 197,551 Texas 2,295,143 1,275,740 3,570,883 625,379 Utah 131,185 163,070 294,255 83,147 Virginia 340,389 354,101 694,490 146,489 c Wisconsin 188,328 230,779 419,107 134,946 Wyoming 26,811 21,227 48,038 8,592 a Underinsured defined as insured in household that spent 10% or more of income on medical care (excluding premiums) or 5% or more if income under 200% poverty. b Affordable Care Act (ACA) thresholds refers to the maximum premium contribution as a share of income in marketplaces or Medicaid if eligible to participate. c Wisconsin will provide Medicaid to parents and childless adults with incomes up to 100 percent of poverty as of April 2014. Data source: March 2012–13 Current Population Survey (CPS). 26 America’s Underinsured: A State-by-State Look at Health Insurance Affordability Prior to the New Coverage Expansions www.commonwealthfund.org