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.