Monday, December 19, 2016

The wealth and health of states, cont.

In my most recent post at healthinsurance.org, I noted that the five states highlighted by the Kaiser Family Foundation as those with the highest percentages of residents with "declinable pre-existing conditions" under pre-ACA rules were also the five poorest states in the nation as measured by median household income. That is, by these broad measures, the sickest states are the poorest states. (Those with "declinable pre-existing conditions" are those who, according to Kaiser, would likely have been unable to obtain health insurance in the individual market prior to ACA enactment. Kaiser conservatively estimates that 27% of U.S. adults under age 65 have DPCs.)

The correlation between state wealth and health carries pretty well through the fifty states. The chart below plots the percentage of residents in each state with declinable pre-existing conditions (DPC, y-axis) against 2015 median household income, according to the Census Bureau.



Here are the state-by state figures for median household income and percentage of population with DPCs, along with a third measure: the percentage of population in each state with incomes under twice the Federal Poverty Level, according to the Kaiser Family Foundation (based on the Census Bureau's March 2016 Current Population Survey). The states are sorted by DPC percentage, sandwiched for easy comparison between the two measures of income.

State
2015 Median
income
Percent DPC
% under 200% FPL
West Virginia
42,824
36%
0.38
Mississippi
40,037
34%
0.44
Alabama
44,509
33%
0.37
Kentucky
42,387
33%
0.40
Tennessee
47,330
32%
0.35
Arkansas
42,798
32%
0.39
Oklahoma
47,077
31%
0.39
Missouri
59,196
30%
0.28
Kansas
54,865
30%
0.31
Indiana
51,983
30%
0.32
Louisiana
45,922
30%
0.37
D.C.
70,071
29%
0.27
Maine
50,756
29%
0.30
Georgia
50,768
29%
0.37
Michigan
54,203
28%
0.29
Ohio
53,301
28%
0.32
South Carolina
46,360
28%
0.35
Wyoming
60,925
27%
0.25
Penn
60,389
27%
0.28
Oregon
60,834
27%
0.31
N. Carolina
50,797
27%
0.35
Texas
56,473
27%
0.35
New Mexico
45,119
27%
0.41
Maryland
73,594
26%
0.23
Illinois
60,413
26%
0.28
Virginia
61,486
26%
0.28
Florida
48,825
26%
0.37
Arizona
52,248
26%
0.38
Vermont
59,494
25%
0.27
Nebraska
60,474
25%
0.28
Washington
67,243
25%
0.28
Rhode Island
55,701
25%
0.29
Wisconsin
55,425
25%
0.29
New York
58,005
25%
0.31
South Dakota
55,065
25%
0.32
Idaho
51,624
25%
0.33
Montana
51,395
25%
0.33
Nevada
52,008
25%
0.35
New Hampshire
75,675
24%
0.19
Connecticut
72,889
24%
0.23
Hawaii
64,514
24%
0.25
Mass.
67,861
24%
0.26
Iowa
60,855
24%
0.27
North Dakota
57,415
24%
0.28
California
63,636
24%
0.33
Alaska
75,112
23%
0.24
New Jersey
68,357
23%
0.24
Utah
66,258
23%
0.28
Delaware
57,756
23%
0.31
Minnesota
68,730
22%
0.22
Colorado
66,596
22%
0.25

The relationship holds well in the top and bottom quarters of of the chart. The 13 states with the lowest percentage of residents with declinable pre-existing conditions are all above median income, and, with the exception of California, below median percentage of residents under 200% FPL. The reverse is true for the 13 states (plus DC)  with the highest DPC percentage, with the exceptions of DC and Missouri for income and Indiana (barely) and Missouri for percentage of pop under 200% FPL. Twelve of the thirteen lowest-DPC states have incomes above $60,000, and ten of thirteen highest-DPC states have incomes under $52,000.

The thirteen highest-DPC states-plus-DC, with the exception of DC, are all red states, but six of them have accepted the ACA Medicaid expansion. Of the three that did so before 2015, the last year for which uninsurance rates are available, West Virginia cut its uninsurance rate by 8.6 percentage points from 2010 to 2015 , Kentucky by 9.3, and Arkansas by 8.0, according to HHS tracking released this month. (DC provided Medicaid eligibility up to 200% FPL prior to ACA enactment, so its drop has been small. Indian's expansion began in Feb. 2015, and Louisiana's in July of this year). The seven nonexpansion states among the thirteen, in contrast, cut their uninsurance rates by an average of just 4.1 percentage points.

Here are the uninsured rate drops for these thirteen states, as tabulated by HHS. Those that adopted the ACA's Medicaid eligibility in 2014 are marked in blue, those that refused the expansion in red, and those for which the expansion would not show full impact in 2015 are in yellow.


The takeaway here is pretty much the same, I think, as in the healthinsurance.org post:
The ACA not only makes individual market health insurance available to people without regard to medical condition, it also provides relatively income-appropriate coverage to the 32 percent of the population living in households with incomes under 200% FPL – compared at least to Republican replacement alternatives, which will do most harm if they repeal or radically scale back the ACA Medicaid expansion. The populations in states with the worst health will suffer most under ACA repeal -- and also under Tom Price's skimpy ACA replacement plan.
Update, 12/21: Eyeballing the DPC rates this morning, it occurred to me that all 11 states with over 30% DPC voted for Trump.

P.S.  Back in November 2014 I noted the correlations between state incomes, state public health measures, and silver plan selection in the ACA marketplace. Low income marketplace enrollees are eligible for Cost Sharing Reduction subsidies if they buy silver plans, and enrollment data shows tht where the poor and sick are concentrated, CSR takeup is high.

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