2016 has been a chaotic and unpredictable year for President Obama's signature health reform law. Most of the major health insurers announced they were leaving the individual marketplace, some premiums are being hiked by 10 percent or more, and a majority of the co-ops created by the Affordable Care Act (ACA) are closing their doors.
But one thing remains certain: The number of uninsured Americans continues to drop.
On Tuesday, a new U.S. Census Bureau report found that only 9.1 percent of Americans in 2015 lacked health insurance -- down from 10.4 percent in 2014 and 13.4 percent in 2013, the year before the ACA marketplaces opened.
For a number of reasons -- the biggest being whether a state adopted one of the ACA's biggest provisions and agreed to make more people eligible for Medicaid -- the uninsured rate in states ranges from 2.8 percent to 17.1 percent. The five states with the lowest uninsured rate all chose to expand Medicaid, while just one of the five states with the highest uninsured rate took the federal funding to do so.
Here are the states with the lowest and highest uninsured rates.
Rate of uninsured: 2.8 percent
No surprise here. The state's landmark legislation that provides near-universal health care became a roadmap for the Affordable Care Act.
While the state leads the nation in rates of insured, there are some troubling spots on the horizon: Health-care costs have been rising fast in the state, which can be attributed to a mix of soaring drug prices, more expensive health-care services and implementation of the ACA.
Rate of uninsured: 3.8 percent
Like Massachusetts, Vermont boasted higher-than-average insured rates before the Affordable Care Act was penned. There are many reasons for this, including a generous Medicaid program, low unemployment and proactive prevention programs. Prior to the ACA, the state had a law that didn't allow insurance companies to discriminate based on a person's medical history.
The state planned for years to implement a single-payer system, which would have been the first in the country. But state lawmakers suddenly lost their enthusiasm for it once they realized how much taxes would need to increase for both businesses and residents.
Rate of uninsured: 4 percent
Hawaii has been one of the success stories of Medicaid expansion. The state was one of the first to immediately agree to it, and the expansion covered about half of the state’s previously uninsured population.
The state also has a strict employer coverage law, passed in 1976, that requires employers to provide insurance to all employees working more than 20 hours a week. The ACA, by contrast, only requires employers to offer health care to employees who work more than 30 hours a week.
Rate of uninsured: 4.5 percent
Lawmakers in Minnesota point to a couple of different reasons that the state has a lower-than-average uninsured rate: The state immediately expanded Medicaid, and MinnesotaCare -- the state’s Medicaid program -- is a relatively robust program, offering the working poor a more generous subsidy than most states.
Rate of uninsured: 5 percent
Iowa’s uninsured population was lower than average before the Affordable Care Act was enacted: around 9 percent in 2010. The state expanded Medicaid in 2013 and as a result, covered about half of the uninsured population in 2014.
Rate of uninsured: 13.3 percent
Florida is in a unique position.
Like Texas, a large immigrant population likely contributes to its high uninsured population. But the state also has one of the highest rates of uninsured children -- hovering at 9 percent. That can be attributed to a strict Medicaid program. Unlike most states, Florida requires families earning between 133 to 200 percent of the federal poverty line to pay a premium, and rates went up last year.
The state Senate approved a plan to expand Medicaid last year, but Republican Gov. Rick Scott rejected the measure.
Rate of uninsured: 13.9 percent
GOP Gov. Mary Fallin was among the class of governors who immediately declined Medicaid expansion, and she hasn’t revisited the issue since. A Senate bill that would more or less expand Medicaid -- called the Medicaid Rebalancing Act of 2020 -- died earlier this year.
Rate of uninsured: 13.9 percent
If Georgians want to bring down the rate of uninsured, they’ll have to find a way other than Medicaid expansion. Republican Gov. Nathan Deal has made it clear that option is off the table. In fact, there’s a state policy in place that forbids state employees from even publicly advocating for Medicaid expansion.
The state also has a pretty limited Medicaid program for children, likely contributing to the high number of uninsured. It only covers parents who are 40 percent above the federal poverty line. Even in states that also chose not to expand Medicaid, parents are eligible, on average, if they're 47 percent above the poverty line.
Rate of uninsured: 14.9 percent
Alaska’s uninsured rate will likely be the one to watch in the coming years. Last summer, newly-elected independent Gov. Bill Walker adopted Medicaid expansion. It went into effect last September, meaning the effect of expanded Medicaid won't be seen until next year's census release of uninsured rates.
Rate of uninsured: 17.1 percent
Texas blows the other states out of the water when it comes to the population of uninsured -- it’s a full four percentages higher than Alaska, the second-highest uninsured state.
There are several reasons for this: The state has a large immigrant population, a limited Medicaid program and a lower-than-average rate of employer-sponsored health coverage.
And yes, Medicaid expansion would likely drive down the number of uninsured, but that proposition is unlikely. Republican Rick Perry, the former governor, immediately declined to expand Medicaid, and his GOP successor, Greg Abbott, has also refused.