ASPE ISSUE BRIEF Affordable Care Act Has Led to Historic, Widespread Increase in Health Insurance Coverage September 29, 2016 By Kelsey Avery, Kenneth Finegold, and Amelia Whitman Historic gains in health insurance coverage have been achieved since the implementation of the Affordable Care Act (ACA). Individuals and families of all income levels, age groups, races and ethnicities, and urban and rural areas have seen substantial reductions in uninsured rates. Coverage expansion provisions of the ACA (i.e., the Health Insurance Marketplace and Medicaid expansion) and reforms in the private market, such as allowing young adults to remain on their parents’ plan until age 26 and requiring insurers to cover individuals with pre-existing health conditions, have worked in concert to reduce the national uninsured rate to a historic low of 8.6 percent.1 To date, 20 million individuals have gained health coverage as a result of the ACA.2 In this brief, we use new and previously published estimates from the National Health Interview Survey to examine gains in health insurance coverage for non-elderly adults from 2010 to 2015. We provide estimates of the uninsured rate over time by income, race, state Medicaid expansion status, age, and urban and rural residence (see Appendix Table 2 for additional demographic categories). 1 Cohen, R. A., Martinez, M. E., & Zammitti, E. P. (7 September, 2016). “Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January – March 2016.” National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201609.pdf. 2 Uberioi, N., Finegold, K., & Gee, E. (3 March 2016). “Health Insurance Coverage and the Affordable Care Act, 2010-2016.” Office of the Assistant Secretary for Planning and Evaluation. Retrieved from https://aspe.hhs.gov/sites/default/files/pdf/187551/ACA2010-2016.pdf. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation http://aspe.hhs.gov ASPE Issue Brief Page 2 Key Highlights  Gains in health coverage have occurred across all income groups, races and ethnic groups, ages, and geographies between 2010 and 2015, with groups with the highest uninsured rates in 2010 generally seeing the largest percentage point reductions.  The declines in the uninsured rate from 2010 to 2015 have been similar in size across most income, racial, ethnic, and geographic groups, measured in percentage terms. For example, the percent reductions in the uninsured rate by income group were as follows: o Less than 100 percent of FPL: Percent reduction of 39 percent (from 42 percent to 26 percent). o 100-125 percent of FPL: Percent reduction of 48 percent (from 46 percent to 24 percent). o 125-250 percent of FPL: Percent reduction of 41 percent (from 38 percent to 22 percent). o 250-400 percent of FPL: Percent reduction of 37 percent (from 19 percent to 12 percent). o Greater than 400 percent of FPL: Percent reduction of 42 percent (from 6 percent to 4 percent). GAINS IN HEALTH COVERAGE, 2010-early 2016 Data from the National Health Interview Survey (NHIS) indicate that the uninsured rate has continued to drop to a historic low of 8.6 percent (Figure 1).3 Using data from the Gallup Healthways Well-Being Index, we have previously estimated that 20 million adults gained coverage through early 2016.4 3 Cohen, R. A., Martinez, M. E., & Zammitti, E. P. (7 September, 2016). “Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January – March 2016.” National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201609.pdf. 4 Uberioi, N., Finegold, K., & Gee, E. (3 March 2016). “Health Insurance Coverage and the Affordable Care Act, 2010-2016.” Office of the Assistant Secretary for Planning and Evaluation. Retrieved from https://aspe.hhs.gov/sites/default/files/pdf/187551/ACA2010-2016.pdf. ASPE Office of Health Policy September 2016 ASPE Issue Brief Page 3 Figure 1. Uninsured Rate for Persons of All Ages, National Health Interview Survey, 2010- Early 2016 18% 16.0% 16% 15.1% 14.7% 14.4% 14% 11.5% 12% 10% 9.1% 8.6% 8% 6% 4% 2% 0% 2010 2011 2012 2013 2014 2015 Q1 2016 Source: Cohen, R. A., Martinez, M. E., & Zammitti, E. P. (7 September, 2016). “Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January – March 2016.” National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201609.pdf. Importantly, our analyses of NHIS data demonstrate that since the implementation of the ACA began, a substantial convergence in coverage rates has occurred. Rates of health insurance coverage have improved across a wide range of demographic categories – including income, age, race and ethnicity, and urban and rural residence – and groups with the highest pre-ACA uninsured rates have often experienced the largest increases in coverage. Demographic groups with low pre-ACA uninsured rates have also seen improvements, bringing their uninsured rates to exceptionally low levels. Uninsured Rates by Income, 2010-2015 All income groups have seen gains in coverage (Appendix Table 1). Income groups that had the highest uninsured rate at the time the ACA was passed have experienced the largest reduction in their uninsured rates (Appendix Table 1). Non-elderly adults with incomes below 250 percent of the Federal Poverty Level (FPL) experienced a larger decrease in the proportion of uninsured compared to higher income groups (Appendix Table 1) – a decrease of 41 percent, declining from 40.4 percent in 2010 to 23.7 percent in 2015. Figure 2, below, shows changes in the uninsured rate for this population by income. Between 2010 and 2015, the uninsured rate among non-elderly adults with incomes from 100 to 125 percent of the FPL decreased from 45.9 percent to 24.0 percent (a nearly 48 percent decline). Non-elderly adults between 125 and 250 percent of the FPL have also seen a large reduction in the percentage of uninsured, decreasing from 37.9 percent in 2010 to 22.4 percent in 2015 (a nearly 41 percent decline). The uninsured rate for non-elderly adults with incomes below 100 percent of the FPL decreased from 42.4 percent to 25.9 percent (a nearly 39 percent decline). ASPE Office of Health Policy September 2016 ASPE Issue Brief Page 4 Figure 2. Uninsured Rate for Non-Elderly Adults Below 250% FPL, National Health Interview Survey, 2010-2015 2010 2011 2012 2013 2014 2015 48% reduction 39% reduction 50% 46% 41% reduction 45% 42% 43% 42% 40% 40% 40% 40% 40% 38% 35% 35% 35% 35% 33% 33% 30% 28% 26% 24% 25% 22% 20% 15% 10% 5% 0% < 100% FPL 100-125% FPL 125%-250% FPL Source: ASPE analysis of National Health Interview Survey data, 2010-2015. Although non-elderly adults with incomes above 400 percent of the FPL historically have had a low rate of uninsurance, this income group has also seen improvements in health care coverage under the ACA, with the uninsured rate dropping by nearly 42 percent, from 6.2 percent in 2010 to 3.6 percent in 2015. Similarly, middle-income non-elderly adults, who already had lower uninsured rates than low-income individuals, have also seen improvements in coverage. Non- elderly adults with incomes between 250 and 400 percent of the FPL experienced a 37 percent decrease in the uninsured rate from 18.7 percent in 2010 to 11.7 percent in 2015. (See Figure 3.) ASPE Office of Health Policy September 2016 ASPE Issue Brief Page 5 Figure 3. Uninsured Rate for Non-Elderly Adults Above 250% FPL, National Health Interview Survey, 2010-2015 2010 2011 2012 2013 2014 2015 37% reduction 20% 19% 18% 18% 17% 18% 16% 14% 13% 12% 12% 42% reduction 10% 8% 6% 6% 5% 5% 6% 4% 4% 4% 2% 0% 250%-400% FPL > 400% FPL Source: ASPE analysis of National Health Interview Survey data, 2010-2015. Medicaid Expansion and Coverage Gains by Income Expansion states have realized a greater reduction in the uninsured rate than non-expansion states, as shown in Appendix Table 1 and discussed in the ASPE issue brief “Impacts of the Affordable Care Act’s Medicaid Expansion on Insurance Coverage and Access to Care.”5 Between 2010 and 2015, the overall uninsured rate decreased from 19.9 percent to 10.0 percent in expansion states (a decline of nearly 50 percent) and from 25.9 percent to 17.7 percent in non- expansion states (a decline of nearly 32 percent). As expected, the decrease in the uninsured rate for non-elderly adults with incomes in the Medicaid-eligible income range is larger in expansion states than in non-expansion states. In expansion states, the uninsured rate among non-elderly adults with incomes below 100 percent of the FPL has decreased from 37.2 percent to 17.1 percent between 2010 and 2015 (a 54 percent drop), compared to a decline from 49.5 percent to 40.0 percent in non-expansion states (a 19 percent decrease). States that have not expanded Medicaid also have seen a drop in the uninsured rate for those with incomes below 100 percent of the FPL, largely due to higher enrollment by populations that were eligible for Medicaid under pre-ACA eligibility rules. 5 Office of the Assistant Secretary for Planning and Evaluation. (20 June, 2016). “Impacts of the Affordable Care Act’s Medicaid Expansion on Insurance Coverage and Access to Care.” Retrieved from https://aspe.hhs.gov/pdf- report/impacts-affordable-care-acts-medicaid-expansion-insurance-coverage-and-access-care. ASPE Office of Health Policy September 2016 ASPE Issue Brief Page 6 Uninsured Rates by Race and Ethnicity, 2010-2015 As with income, coverage gains have been broadly shared across racial and ethnic groups (see Appendix Table 1 and Figure 4). The uninsured rate among non-elderly non-Hispanic Asians decreased the most precipitously, down from 19.4 percent in 2010 to 8.0 percent in 2015 (a nearly 59 percent decline). The uninsured rate for non-elderly non-Hispanic Blacks also dropped dramatically, from 27.1 percent in 2010 to 14.5 percent in 2015 (a nearly 47 percent reduction). Non-Hispanic Whites, who have historically had a lower uninsured rate compared to other racial and ethnic groups, experienced strong gains in coverage as well, with their uninsured rate decreasing from 16.3 percent in 2010 to 8.8 percent in 2015 (a 46 percent decrease). Finally, the uninsured rate among non-elderly Hispanics declined from 43.3 percent in 2010 to 28.1 percent in 2015 (a decrease of 35 percent). Figure 4. Uninsured Rate for Non-Elderly Adults by Race and Ethnicity, National Health Interview Suvey, 2010-2015 2010 2011 2012 2013 2014 2015 35% reduction 50% 45% 43% 42%41% 41% 40% 47% reduction 34% 35% 30% 27% 28% 59% reduction 25% 25% 25% 24% 46% reduction 19% 19% 20% 19% 18% 16% 16%16% 15% 15%15% 15% 12% 12% 10% 8% 9% 5% 0% Non-Hispanic Asian Non-Hispanic Black Non-Hispanic White Hispanic Source: ASPE analysis of National Health Interview Survey data, 2010-2015. Medicaid Expansion and Coverage Gains by Race and Ethnicity Improvements in health care coverage among racial and ethnic minority groups are even more dramatic in states that have expanded Medicaid compared to states that have not expanded Medicaid. For example, the uninsured rate among non-elderly Hispanics in expansion states decreased from 39.6 percent to 22.7 percent between 2010 and 2015 (a drop of nearly 43 percent), compared to a decline from 49.5 percent to 36.6 percent in non-expansion states (a 26 percent decrease). Similarly, the uninsured rate among non-Hispanic Blacks declined from 24.0 ASPE Office of Health Policy September 2016 ASPE Issue Brief Page 7 percent in 2010 to 9.9 percent in 2015 in expansion states (a nearly 59 percent decrease), versus a decrease from 29.8 percent to 18.8 percent in non-expansion states (a decline of nearly 37 percent). In expansion states, the decline in the uninsured rate for non-Hispanic Whites and non-Hispanic Asians also was larger than the decline for those groups in non-expansion states. The uninsured rate among non-Hispanic whites decreased from 14.5 percent to 6.8 percent in expansion states (a reduction of 53 percent) between 2010 and 2015, and from 19.3 percent to 12.0 percent in non-expansion states (a nearly 38 percent decline). Similarly, the uninsured rate among non- Hispanic Asians in expansion states decreased from 18.3 percent in 2010 to 6.9 percent in 2015 (a drop of 62 percent), compared to declining from 23.3 percent to 11.3 percent in non-expansion states (a nearly 52 percent decrease). Uninsured Rates by Age, 2010-2015 The primary focus of the ACA’s coverage provisions was on increasing health insurance coverage among non-elderly adults. Children and the elderly have had high rates of coverage before and after the passage of the ACA. Since 2010, non-elderly adults of all ages have seen substantial decreases in the uninsured rate. (See Figure 5 and Appendix Table 2.) The expansion of dependent coverage eligibility up to age 26, which took effect in 2010, has increased coverage substantially among 18 to 25 year olds. 6 This age group had the highest uninsured rate among non-elderly adults in 2010 (31.5 percent). By 2015, the uninsured rate had dropped to second highest among the age groups illustrated below, at 15.1 percent (a decline of 52 percent) – most likely due to access to dependent coverage on the parents’ health plans. Individuals aged 55 to 64 years old, who have historically had higher levels of coverage, also experienced a large decrease in the uninsured rate from 12.8 percent to 7.7 percent between 2010 and 2015 (a nearly 40 percent decline). The uninsured rate among 35 to 54 year olds decreased from 20.1 percent in 2010 to 12.3 percent in 2015 (a drop of nearly 39 percent), and 26 to 34 year olds had a similar decrease in their uninsured rate, dropping from 27.8 percent to 17.9 percent from 2010 to 2015 (a nearly 36 percent decline). 6 Uberioi, N., Finegold, K., & Gee, E. (3 March 2016). “Health Insurance Coverage and the Affordable Care Act, 2010-2016.” Office of the Assistant Secretary for Planning and Evaluation. Retrieved from https://aspe.hhs.gov/sites/default/files/pdf/187551/ACA2010-2016.pdf. ASPE Office of Health Policy September 2016 ASPE Issue Brief Page 8 Figure 5. Uninsured Rates for Non-Elderly Adults by Age, National Health Interview Survey, 2010-2015 2010 2011 2012 2013 2014 2015 52% reduction 35% 36% reduction 32% 30% 28%28% 28% 27% 26% 25% 39% reduction 25% 25% 23% 20%20% 20% 20% 19% 18% 19% 40% reduction 15% 16% 15% 13%14% 12% 13%13% 10% 10% 8% 5% 0% 18-25 26-34 35-54 55-64 Source: ASPE analysis of National Health Interview Survey data, 2010-2015. Uninsured Rates by Metropolitan Status 2010-2015 The uninsured rate has decreased similarly among non-elderly adults in both urban and rural areas.7 In 2010, the uninsured rate among non-elderly adults in metropolitan areas was 21.8 percent, compared to 25.1 percent in non-metropolitan areas. In 2015, the uninsured rate among non-elderly adults dropped to 12.6 percent in urban areas and 15.4 percent in rural areas (declines of 42 percent and nearly 39 percent, respectively). (See Figure 6 and Appendix Table 2.) 7 Avery, K., Finegold, K., & Xiao, X. (10 June 2016). “Impact of the Affordable Care Act Coverage Expansion on Rural and Urban Populations.” Office of the Assistant Secretary for Planning and Evaluation. Retrieved from https://aspe.hhs.gov/pdf-report/impact-affordable-care-act-coverage-expansion-rural-and-urban-populations. ASPE Office of Health Policy September 2016 ASPE Issue Brief Page 9 Figure 6. Uninsured Rates for Non-Elderly Adults by Metropolitan Status, National Health Interview Survey, 2010-2015 2010 2011 2012 2013 2014 2015 39% reduction 30% 42% reduction 25% 24% 25% 25% 24% 22% 21% 20% 20% 20% 18% 16% 15% 15% 13% 10% 5% 0% Metropolitan Non-metropolitan Source: ASPE analysis of National Health Interview Survey data, 2010-2015. CONCLUSION One of the primary goals of the ACA was to improve access to health coverage. The results of this analysis demonstrate that health coverage has consistently improved across a wide range of demographic categories from 2010 to 2015. There have been substantially larger improvements in coverage in states that have expanded Medicaid as opposed to states that have not yet expanded Medicaid, particularly for low-income individuals and racial and ethnic minorities. ASPE Office of Health Policy September 2016 ASPE Issue Brief Page 10 APPENDIX Appendix Table 1. Uninsured Rates Among Non-Elderly Adults by Income, Race, and State Medicaid Expansion Status, National Health Interview Survey, 2010-2015 2010 2011 2012 2013 2014 2015 All States Non-Elderly Adults All 22.2% 21.0% 20.7% 20.4% 16.5% 13.0% Income < 100% FPL 42.4% 40.1% 40.3% 39.6% 32.9% 25.9% 100-125% FPL 45.9% 42.7% 41.6% 40.1% 32.8% 24.0% 125%-250% FPL 37.9% 35.4% 34.7% 34.8% 27.9% 22.4% <250% FPL 40.4% 38.0% 37.5% 37.1% 30.2% 23.7% 250%-400% FPL 18.7% 17.5% 17.6% 16.9% 13.0% 11.7% > 400% FPL 6.2% 5.7% 5.2% 5.3% 4.0% 3.6% Race and Ethnicity Non-Hispanic White 16.3% 15.6% 15.1% 14.5% 11.5% 8.8% Non-Hispanic Black 27.1% 24.6% 23.6% 24.7% 17.6% 14.5% Non-Hispanic Asian 19.4% 18.8% 19.1% 16.1% 12.1% 8.0% Hispanic 43.3% 42.1% 41.3% 41.1% 34.1% 28.1% Non-Hispanic Other Races & Multiple 33.1% 27.6% 24.8% 23.7% 19.4% 16.3% Races Expansion States Non-Elderly Adults All 19.9% 18.6% 18.1% 18.3% 13.6% 10.0% Income < 100% FPL 37.2% 34.1% 34.2% 34.3% 25.9% 17.1% 100-125% FPL 40.9% 38.1% 38.2% 36.3% 28.7% 19.5% 125%-250% FPL 35.8% 33.9% 32.2% 33.0% 24.2% 18.7% 250%-400% FPL 17.8% 16.2% 16.8% 16.6% 11.0% 10.0% Above 400% FPL 6.0% 5.3% 5.0% 5.0% 3.8% 3.0% Race and Ethnicity Non-Hispanic White 14.5% 13.9% 13.2% 13.3% 9.4% 6.8% Non-Hispanic Black 24.0% 19.8% 20.2% 21.4% 13.8% 9.9% Non-Hispanic Asian 18.3% 18.3% 17.4% 14.5% 10.8% 6.9% Hispanic 39.6% 38.6% 37.5% 37.5% 29.5% 22.7% Non-Hispanic Other Races & Multiple 31.8% 23.7% 19.9% 21.4% 16.5% 10.9% Races ASPE Office of Health Policy September 2016 ASPE Issue Brief Page 11 Non-Expansion States Non-Elderly Adults All 25.9% 24.9% 24.7% 23.5% 20.8% 17.7% Income < 100% FPL 49.5% 48.2% 48.2% 47.0% 42.6% 40.0% 100-125% FPL 52.4% 49.1% 45.8% 45.6% 38.3% 29.9% 125%-250% FPL 40.8% 37.5% 38.1% 37.1% 32.9% 27.3% 250%-400% FPL 20.1% 19.4% 18.8% 17.3% 15.9% 14.0% > 400% FPL 6.6% 6.5% 5.6% 5.9% 4.3% 4.7% Race and Ethnicity Non-Hispanic White 19.3% 18.3% 18.3% 16.5% 14.9% 12.0% Non-Hispanic Black 29.8% 29.3% 26.6% 27.8% 21.0% 18.8% Non-Hispanic Asian 23.3% 20.6% 24.5% 21.1% 16.0% 11.3% Hispanic 49.5% 47.9% 47.7% 46.6% 41.0% 36.6% Non-Hispanic Other Races & Multiple 35.3% 35.0% 32.6% 27.6% 24.3% 25.8% Races Source: ASPE analysis of National Health Interview Survey data, 2010-2015. Note: States are defined as Medicaid expansion states if they expanded Medicaid at any point between March 23, 2010 and December 31, 2015. The analyses here use final NHIS public use files merged with restricted identifiers, which include various edits not in the preliminary microdata used for NHIS early release reports produced by the National Center for Health Statistics (NCHS). Estimates in this brief may vary slightly from those in NCHS’s published reports for this reason. ASPE Office of Health Policy September 2016 ASPE Issue Brief Page 12 Appendix Table 2. Non-Elderly Adult Uninsured Rates by Demographic Category, National Health Interview Survey, 2010 – 2015 2010 2011 2012 2013 2014 2015 Age 18-25 31.5% 26.3% 24.7% 25.0% 18.5% 15.1% 26-34 27.8% 27.9% 28.3% 27.0% 22.7% 17.9% 35-54 20.1% 19.7% 19.6% 19.0% 15.6% 12.3% 55-64 12.8% 13.0% 13.2% 13.5% 9.7% 7.7% Gender Men 25.3% 23.6% 23.3% 22.6% 18.3% 15.0% Women 19.3% 18.8% 18.6% 18.4% 14.4% 11.0% Education Level Less than High School 44.7% 41.5% 42.1% 41.7% 34.4% 30.5% High School/GED 28.1% 27.6% 26.8% 26.2% 22.1% 17.3% Post-High School 14.4% 13.7% 13.5% 13.6% 10.0% 7.7% Metropolitan Status Metropolitan 21.8% 20.6% 20.2% 19.9% 16.0% 12.6% Nonmetropolitan 25.1% 24.3% 24.6% 23.7% 18.4% 15.4% Health Status Excellent 18.2% 17.5% 18.3% 17.8% 14.0% 11.8% Very Good 19.1% 18.2% 18.1% 17.8% 14.6% 11.8% Good 26.7% 26.6% 24.1% 24.8% 20.5% 14.9% Fair/Poor 24.9% 24.1% 25.2% 23.4% 18.6% 13.8% Region Northeast 15.2% 14.8% 14.1% 13.8% 11.2% 8.2% Midwest 17.8% 16.7% 16.7% 16.2% 12.9% 10.1% South 26.7% 25.3% 25.0% 24.5% 20.7% 17.4% West 25.0% 24.1% 23.7% 23.1% 16.4% 12.1% State Marketplace Type Federally-Facilitated 23.5% 22.3% 22.1% 21.5% 17.6% 14.7% State-Based 19.6% 18.9% 18.4% 18.4% 13.5% 9.2% Source: ASPE analysis of National Health Interview Survey data, 2010-2015. Note: States are considered to have Federally-Facilitated Marketplaces if they used the HealthCare.gov platform for the third Open Enrollment Period, from November 1, 2015 to January 31st, 2016. The analyses here use final NHIS public use files merged with restricted identifiers, which include various edits not in the preliminary microdata used for NHIS early release reports produced by the National Center for Health Statistics (NCHS). Estimates in this brief may vary slightly from those in NCHS’s published reports for this reason. ASPE Office of Health Policy September 2016 ASPE Issue Brief Page 13 Appendix Table 3. Nonelderly Adult Uninsured Rate by State, National Health Interview Survey, 2010 – 2015 2010 2011 2012 2013 2014 2015 All States 22.3% 21.3% 20.9% 20.4% 16.3% 12.8% Alabama -- 23.0% 18.5% 17.3% 14.8% 14.3% Alaska -- -- -- v 24.6% 21.0% Arizona 31.5% 22.9% 26.8% 23.4% 19.5% 13.8% Arkansas -- 26.3% 27.9% 27.5% 15.6% 15.7% California 25.8% 25.2% 24.4% 23.7% 16.7% 11.1% Colorado -- 20.8% 16.7% 18.3% 13.3% 8.5% Connecticut -- 11.9% 28.9% 13.2% 10.0% 7.6% Delaware -- -- -- 13.8% *6.0% 8.3% District of Columbia -- -- -- *4.7% ** 4.5% Florida 29.0% 28.1% 28.9% 29.1% 23.0% 18.7% Georgia 27.8% 26.0% 25.6% 27.2% 20.2% 15.9% Hawaii -- -- *9.5% ** ** 6.1% Idaho -- -- 26.7% 24.3% 21.9% 18.2% Illinois 19.5% 19.8% 18.3% 17.8% 15.0% 9.9% Indiana 20.2% 20.1% 17.3% 19.0% 18.3% 14.8% Iowa -- 10.2% 13.0% 11.3% 8.4% 7.1% Kansas -- 21.1% 19.3% 19.5% 13.9% 13.0% Kentucky -- -- 22.2% 24.1% 15.6% 8.4% Louisiana -- 25.1% 21.2% 19.8% 18.9% 15.5% Maine -- -- 11.2% 15.9% 16.9% 13.3% Maryland 16.6% 13.4% 12.4% 16.4% 12.3% 9.3% Massachusetts *5.4% *5.6% *6.6% *6.0% *3.8% *3.0% Michigan 17.5% 16.9% 16.1% 15.8% 11.6% 8.4% Minnesota -- 10.8% 9.7% 9.7% 8.0% 6.4% Mississippi -- -- 27.3% 24.2% 22.4% 16.2% Missouri 24.3% 20.5% 22.0% 20.1% 16.9% 13.9% Montana -- -- -- ** 18.0% 16.7% Nebraska -- -- 17.1% 18.5% 16.9% 16.1% Nevada -- 27.3% 24.7% 29.3% 20.4% 15.1% New Hampshire -- -- 20.5% 16.1% 11.6% 8.3% New Jersey 20.3% 17.5% 16.4% 17.5% 12.9% 10.2% New Mexico -- -- 27.5% ** 18.7% 15.7% New York 15.4% 16.2% 14.7% 13.6% 12.9% 7.0% North Carolina 26.8% 29.5% 27.1% 25.6% 22.5% 19.5% North Dakota -- -- -- ** 9.3% 9.7% Ohio 19.0% 14.9% 16.6% 16.3% 10.9% 9.3% Oklahoma -- 28.8% 30.9% 28.3% 26.6% 21.5% Oregon -- 22.7% 22.7% 20.4% 13.3% 11.7% Pennsylvania 16.3% 17.2% 15.9% 16.4% 11.9% 10.9% Rhode Island -- -- 15.6% 13.1% 9.0% 6.3% ASPE Office of Health Policy September 2016 ASPE Issue Brief Page 14 South Carolina -- 24.5% 28.6% 23.2% 21.0% 19.7% South Dakota -- -- -- ** 13.4% 11.9% Tennessee 24.7% 19.2% 22.3% 16.2% 14.8% 13.7% Texas 30.8% 29.5% 28.6% 28.4% 25.7% 22.5% Utah -- -- 22.1% 20.7% 16.2% 13.2% Vermont -- -- -- ** 9.1% *4.2% Virginia 18.0% 19.3% 16.8% 16.0% 15.2% 12.4% Washington 20.7% 21.3% 22.6% 23.4% 13.3% 11.1% West Virginia -- -- 23.2% 28.8% 12.2% 8.9% Wisconsin 13.5% 12.9% 17.1% 11.1% 8.7% 6.0% Wyoming -- -- -- ** 15.2% 17.5% Source: National Health Interview Survey Early Release Reports on Detailed Estimates of Health Insurance Coverage: 2010, 2011, 2012, 2013, 2014 & 2015. Retrieved from: http://www.cdc.gov/nchs/nhis/releases.htm. Note: In some years, estimates are presented for fewer than 50 states and the District of Columbia due to considerations of sample size and precision * Estimates are considered unreliable. Data preceded by an asterisk have a relative standard error (RSE) greater than 30% and less than or equal to 50% and should be used with caution. Data not shown have an RSE greater than 50%. ** Data have an RSE greater than 50% or could not be shown due to considerations of sample size. -- Estimates are presented for fewer than 50 states and the District of Columbia due to considerations of sample size and precision. ASPE Office of Health Policy September 2016 ASPE Issue Brief Page 15 ACKNOWLEDGEMENTS ASPE appreciates the assistance of the Centers for Disease Control and Prevention National Center for Health Statistics Research Data Center in facilitating our access to and analysis of the restricted NHIS geocodes. The findings and conclusions in this brief are those of the authors and do not necessarily represent the views of the Research Data Center, the National Center for Health Statistics, or the Centers for Disease Control and Prevention. ASPE Office of Health Policy September 2016