Florida and Texas should be ashamed, but what about New York and California?

Health Care Coverage and Access in the Nation's Four Largest States

By Petra W. Rasmussen, Sara R. Collins, Michelle M. Doty, Sophie Beutel
The Commonwealth Fund, April 10, 2015

In this brief we use data from the Biennial Survey to examine differences in health insurance coverage, cost-related problems getting needed care, and medical bill problems and debt among adults ages 19 to 64 in the nation’s four largest states.

The four largest states in the U.S.—California, Florida, New York, and Texas—fall into two distinct categories. The first group is represented by California and New York, both of which are operating their own health insurance marketplaces and have expanded eligibility for Medicaid to adults who earn at or below 138 percent of the federal poverty level—about $16,000 for an individual or $32,000 for a family of four.3 Florida and Texas, the second group, are using the federal marketplace to enroll residents in health plans and have declined to expand Medicaid eligibility. In this new analysis of data from the Commonwealth Fund Biennial Health Insurance Survey, we find that, in 2014, there were larger shares of uninsured adults in Florida and Texas compared with California and New York. In addition, adults in Florida and Texas were more likely to report not getting needed care because of cost and to report having problems paying medical bills.

Percent of adults ages 19-64 who are uninsured

12% - New York
17% - California
21% - Florida
30% - Texas

Percent of adults ages 19-64 who experienced cost-related access problems

30% - New York
31% - California
43% - Florida
43% - Texas

Percent of adults 19-64 reporting medical bill problems or medical debt

29% - New York
24% - California
42% - Florida
41% - Texas


The analysis suggests that the health policy decisions made by state leaders matter. Of the four states studied, New York has had the longest history of legislation aimed at enhancing the availability of affordable coverage. California also implemented an early expansion of Medicaid eligibility and, based on federal survey data, both states began achieving declines in their adult uninsured rate earlier than other states. Both have taken advantage of opportunities granted by the Affordable Care Act to further expand the reach of coverage and access. Alternatively, Florida and Texas, while experiencing robust enrollment in private plans through the federal health insurance marketplace, have not expanded Medicaid eligibility and have made less headway in reducing their uninsured populations.

While there have been significant declines in the number and share of uninsured adults since the major provisions of the Affordable Care Act went into effect in 2014, coverage gaps are leaving millions uninsured and without access to affordable coverage. An estimated 3.7 million people have fallen into the Medicaid coverage gap in states that have not yet expanded eligibility for Medicaid.

In addition, the law does not provide access to any new coverage options for unauthorized immigrants. They are ineligible for Medicaid coverage and cannot purchase private plans through the marketplace, either subsidized or unsubsidized. The Congressional Budget Office estimates that by 2020, 30 percent of the remaining uninsured will be unauthorized immigrants, or about 9 million people. Another part of the law that is leaving people uninsured is the so-called “family coverage glitch,” which defines affordability—and eligibility for subsidies—based on the cost of individual, rather than family, coverage. Currently, an estimated 2 million to 4 million people are uninsured because of this issue.

The analysis also indicates that expanded coverage is necessary to improve access to care and reduce medical financial burdens among U.S. families. But the quality and comprehensiveness of coverage across all sources of insurance (marketplace plans, individual plans, employer-provided coverage, and Medicaid), will ultimately determine the degree to which these problems are lessened for U.S. families.



By Don McCanne, MD

New York and California have fully implemented the provisions of the Affordable Care Act whereas Florida and Texas have not. As a result, Florida and Texas have more people who are uninsured, more people who experience cost-related access problems, and more people with medical bill problems or medical debt.

Although the leaderships of Florida and Texas should be ashamed for failing to implement the programs that would ensure that more residents receive the health care that they need, the leaderships of New York and California should be ashamed as well for not demanding changes in our health care financing system that would ensure health care for everyone. The numbers in the tables above for these two “exemplary” states are disgraceful and would not be tolerated by any other wealthy nation.

Incremental patches are grossly inadequate. We need a single payer national health program.