Health Coverage Varies Widely by State

When it comes to state residents’ health insurance coverage, Utah and New Mexico are polar opposites.

Sixty percent of Utah residents are covered at work – the most nationwide. New Mexico employers cover only 36 percent – the lowest coverage rate.

It follows that their Medicaid populations also differ. In Utah, the federal-state health insurance program covers the nation’s smallest share (10 percent) of poor and low-income workers. New Mexico’s Medicaid population is triple that (31 percent of residents), and its poverty rate is among the highest nationwide.

“Where you live can play an important role in what coverage options are available to you and how affordable they are,” said Rachel Garfield, the Henry J. Kaiser Family Foundation’s senior researcher and associate director of its Medicaid and uninsured program. The Kaiser data are from 2016.

The factors driving the two indicators – employer vs. Medicaid coverage – are intertwined. A larger presence of big, successful companies ensures more employer coverage, raising the standard of living and reducing the need for federal aid. These are, in turn, influenced by other cross-currents in each state, Garfield said: the nature of its industry, whether retail, industrial, high-tech, or agricultural; population demographics, such as the number of immigrants; whether the state expanded Medicaid eligibility under the Affordable Care Act (ACA); and the ebbs and flows of regional recessions and recoveries.

Take Utah. Despite being a primarily rural state with its “Mighty Five” national parks, it is chock full of major employers. Utah’s three largest have 20,000-plus workers each: Intermountain Healthcare, the University of Utah, and state government. Many more employ at least 5,000. Utah’s relatively slim Medicaid population is no doubt influenced by both its employer base and the state’s decision not to participate in the ACA’s Medicaid expansion, which increased the program’s income limits to make more workers eligible.

New Mexico has low employer coverage: only five employers have 5,000-plus workers. They include the University of New Mexico (12,000) and Los Alamos National Laboratory (11,000). Medicaid participation is boosted by the state’s expansion program for its many poor and low-income residents.

California has crazy-quilt coverage. Apple, Cisco eBay, Microsoft, Stanford University – Silicon Valley is densely packed with high-paying employers that invariably offer health insurance. So why do fewer than half of California residents have employer coverage?  The state’s outsized Medicaid coverage reaches into its large immigrant population and workers in the nation’s single biggest state agricultural sector.

New York’s story is an East Coast version roughly similar to California’s. “Both states have high-income and low-income areas that play into what coverage looks like,” Garfield said.

Finally, union presence still matters, even as membership dwindles nationwide. Florida, a non-unionized “right-to-work” state, has low employer coverage.  One possible explanation: Disney World is an international tourist destination, but the small restaurants, bars, and low-cost motels that cater to tourists typically do not offer insurance.

Immigrants also play a role in the Sunshine State, which has the third-largest Latino population. Garfield explained that undocumented immigrants “can’t purchase insurance” through their state’s ACA marketplace. “And people who do have documents are generally barred from Medicaid coverage for the first five years they’re here.”

Only 16 percent of Florida residents are covered by Medicaid benefits, because the state declined the additional coverage through the Medicaid expansion.

Kaiser’s interactive coverage chart can be found here.

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