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Which states have the most uninsured people left, and why?

There was a lot of good news in the Census report released this week on health coverage in the U.S. in 2015. For example, the report told us that 90.9 percent of people in our country had health insurance coverage for all or part of last year.

Where did we get our health insurance? A little more than half of us (55.7 percent) had coverage from our employers. In other words, the prediction pre-ACA that the law would prompt employers to drop employee health insurance coverage has not turned out to be true. Medicaid covered 19.6 percent of us, followed by Medicare (16.3 percent), direct-purchase health plans (16.3 percent) and military coverage (4.7 percent). More people had directly purchased their own coverage last year than in the previous year (when it was 14.6 percent), no doubt reflecting the continuing success of the health insurance marketplaces created under the Affordable Care Act.

The biggest percentage drops in uninsured people were in these states: California (down 8.6 percent), Nevada (down 8.4 percent), Kentucky (down 8.3 percent), West Virginia (down 8 percent) and New Mexico (down 7.7 percent). All of these states expanded their Medicaid programs (although Kentucky’s governor is now trying to make some controversial changes to its Medicaid program that Raising Women’s Voices opposes.) These states also established their own ACA health insurance marketplaces (although Nevada and New Mexico are using the federal website for enrollment and West Virginia ultimately chose a state/federal partnership model).

But where are there still the most numbers of uninsured people? A Census table showed the percentage of uninsured people in each state, from 2013 to 2015. Guess which state was No. 1 for uninsured people? We bet you won’t be surprised to learn it was Texas, a state that has refused to expand its Medicaid program and defaulted to a federally-facilitated marketplace when state officials refused to create their own. The estimated number of uninsured people in Texas in 2015 was a whopping 4,615,000.

Our RWV regional coordinators in Texas – the Lesbian Health Initiative in Houston and The Afiya Center in Dallas have been working hard to improve their state’s coverage numbers by advocating for Medicaid expansion and helping to reach and enroll uninsured people who qualify for the available coverage options in Texas.

Other states with the largest number of uninsured people are California, No. 2 with 3,317,000 still uninsured; Florida, No. 3 with 2,662,000 uninsured people; Georgia, No. 4 with 1,388,000; and New York with 1,381,000 still uninsured. The listings for Florida and Georgia are not surprising because both states have politicians who have been refusing to cooperate with ACA implementation, including expanding Medicaid. In recent months, there have been some signs of possible movement in Georgia in 2017.

But what about California and New York – two progressive states with their own ACA marketplaces, Medicaid expansion and records of dramatically reducing uninsured rates? One of the key factors in both states is their large populations of immigrants who do not qualify for any of the various ACA coverage options. What can be done about this problem, which stems from the ACA’s restrictions on coverage for immigrants?

California is asking the federal government  to approve a plan that would allow undocumented immigrants to buy health insurance on California’s ACA marketplace. State officials estimate that up to 30 percent of California’s two million undocumented immigrants could be eligible for this program. No federal dollars would be used for this expanded coverage. The state already took a first step toward covering more immigrants this year with a new law that allows undocumented children to sign up for Medi-Cal, California’s Medicaid program. California Latinas for Reproductive Health (CLRJ) has been active in educating policymakers about the need for these coverage expansions, and Raising Women’s Voices submitted comments supporting the state’s request to the federal government.

In New York, some immigrants have already been covered through the new Essential Plan, which is that state’s version of the Basic Health Program option allowed under the ACA. But an estimated 450,000 New Yorkers remain uninsured because of their immigration status. The Health Care for All New York coalition – in which Raising Women’s Voices-NY serves as a steering committee member – is advocating for additional expansions of coverage to groups of immigrants through participation in a Coverage4 All campaign led by the New York Immigration Coalition and Make the Road New York.

Historic drop in uninsured rate, but still more work to do!

Six years after the Affordable Care Act (ACA) was signed into law and three years after the ACA insurance marketplaces opened, the nation’s uninsured rate has dropped to the lowest level ever recorded.

Between 2010 and 2016, the percentage of people without health insurance fell by nearly half, from 16 percent to 8.6 percent. The sharp decline is illustrated in this chart from Vox. The previous low of 9.1 percent was recorded in 2015.
The new numbers were released this week by the National Center for Health Statistics, and are based on the National Interview Survey conducted during the first quarter of 2016. The survey uncovered some important variations among population groups when it comes to health insurance. For example:
  • Only 5 percent of children 17 and younger are now uninsured. Of those, 42.1 percent had public coverage and 54.9 percent had private coverage.
  • Hispanic adults had the greatest decline in un-insurance, going from 40.6 percent in 2013 to 24.5 percent in 2016. But that reduced rate was still much higher than the 2016 rates for non-Hispanic blacks (13 percent), whites (8.4 percent) and Asians (6.7 percent).
There was no gender breakdown in the survey report.
Uninsured Rates Higher in States Resisting the ACA
The national survey data also reveal striking disparities between rates of un-insurance between states that have fully implemented the ACA – by expanding their Medicaid programs and creating their own health insurance exchanges, or marketplaces – and those that have refused to do so because of conservative political opposition.
First, let’s look at the impact of a state’s decision to expand Medicaid. In the expansion states, the percentage of uninsured adults (ages 18 to 64) dropped by half -- from 18.4 percent in 2013 to 9.2 percent in 2016. By contrast, in non-expansion states, the uninsured rate fell somewhat – from 22.7 percent in 2013 to 16.7 percent in 2016 -- but still remained high.
Next, let’s look at the difference in uninsured rates between states that opened their own marketplace (or partnered with the federal government to create a marketplace) and those states that refused to do so, and instead defaulted to having a federally-run marketplace. There have been significant declines in uninsured rates in states with their own marketplaces (from 18.7 percent in 2013 to 9.1 percent in 2016) and in partnership marketplace states (from 17.9 percent in 2013 to 8.2 percent this year). 
The survey found a different story in the states with federally-run marketplaces. Although even those states experienced a drop in the uninsured rate (from 22 percent to 14.5 percent), the 2016 percentage of residents who remain uninsured is much higher than in the other states.
Signing up enrollees in a state that recently expanded Medicaid
Some of the states that initially refused to expand Medicaid have agreed to expansion over the last year or so. Louisiana, for example, has just started Medicaid enrollment over the summer. Montana’s Legislature narrowly approved expansion last year and it went into effect on January 1 of this year. RWV regional coordinator Montana Women Vote (MWC) was busy over the summer getting out the word about Medicaid expansion among a diverse group of residents, including LGBTQ people, rural people, low-income residents and Native-American women.
MWV had 779 conversations and handed out close to 630 pieces of literature on Medicaid expansion and the ACA by tabling at the Missoula Food Bank, at grocery stores, homeless shelters, free lunch days at the public library and schools, and other free community events. MWV worked with Healthy Montana Coalition partners to push stories that have kept the ACA and Medicaid expansion as part of the conversation in the news during election season. The stories included coverage of the overwhelming number of signups for Medicaid Expansion and the significant drop in state’s uninsured rate. By July of this year, more than 47,000 low-income Montana residents had gained Medicaid coverage.

We’re making progress in the South and Southwest!

Summer is coming to an end, but the work of RWV’s regional coordinators is as hot as ever. This week we’re highlighting some of the work being done by our RCs in conservative states in the South and Southwest. The coordinators are organizing health forums, tabling at community events, highlighting the ACA’s benefits for women and LGBTQ people, deepening relationships within coalitions and recruiting, training, and bringing on promotoras (health workers). To learn more about any of these groups, visit their websites or contact Cecilia Sáenz Becerra, RWV Regional Field Manager by email at

Arizona: Trans Queer Pueblo

This summer, the newly-consolidated Trans Queer Pueblo (TQP) created a training series for promotor@s. (They use @ to be gender inclusive in their terminology.) Now the first two graduates from the program -- Crystal Zaragoza, at left in photo, and Cyntia Domenzain, right --are ready to take on community health forums to help reach the broader LGBT, migrant and Latino community, with a specific focus on trans migrant women, undocumented LGBTQ+ people, and LGBTQ+ migrant women. TQP also held four health-related events, reaching more than 100 people, where they shared health literacy materials and talked to community members.  

They continue to lay the groundwork in Arizona for a health care system that is inclusive of undocumented and LGBTQ people. Trans Queer Pueblo recently joined the Health Improvement Partnership of Maricopa County to move health institutions that are part of this coalition toward a health justice framing that is more closely aligned with TQP’s vision of health care.

Georgia: Feminist Women’s Health Center

Feminist Women’s Health Center (FWHC) canvassed at more than 20 sites around metro Atlanta and had conversations with more than 60 individuals about the benefits the ACA has had in their lives. FWHC also held six Black Women’s Wellness discussion groups to hear directly from the community. Common frustrations included: “It’s very challenging to find information on insurance companies’ pages. It’s a research project that often has a lot of dead ends.” Using RWV’s My Health, My Voice health literacy guide, FWHC staff have been able to help women effectively use their new health insurance to access the care they need.

FWHC staff also creatively engaged people at festivals by playing a variation of a game from the RWV Medicaid Expansion Community Organizing & Advocacy Toolkit. People who walked up to the table rolled a die, the number rolled pointed to a specific scenario read aloud by FWHC staff and volunteers, and participants had to quickly determine how that person qualified for coverage. Way to make folks think on their feet!

Louisiana: Women With A Vision

In Louisiana, Women With A Vision (WWAV) hosted three sessions this summer, reaching a total of 100 women, where they discussed the importance of obtaining health insurance, learning how to effectively use your new coverage and receiving yearly well-woman health check-ups. WWAV took this opportunity to inform participants about the state’s new Medicaid expansion that went into effect on July 1, 2016, and help them enroll!

Pushing the boundaries of their traditional base, WWAV worked with two local Latin@ organizations to educate them on RWV’s health insurance guide and distributed more than 250 Spanish health literacy fact sheets to the Latin@ community.

This summer, WWAV conducted research on five insurance companies that cover Medicaid enrollees to learn about their contraceptive coverage, family planning services and OB/GYN providers in Louisiana. The results were mixed, with three of the insurance companies refusing to answer questions without the caller having a plan. As a result, WWAV decided to create a few flyers directing people to where they can access HIV testing, birth control, pregnancy testing, and other women’s health care services.

Texas: Lesbian Health Initiative 
 RWV’s regional coordinator in Houston, the Lesbian Health Initiative (LHI), reached 230 people at 12 events varying from their own bi-annual health fair, to a Medicaid Expansion Advocacy Day, trainings and festivals.
Using RWV’s Medicaid Expansion Organizing Toolkit, LHI organized a house party in partnership with Young Invincibles. The event (shown in photo at right) was called “Dialogue: TX Millennials Left Out of Healthcare.” It attracted about 30 people, most of whom were of people of color between the ages of 18-34, and a handful of participants identified as LGBTQ.
In other exciting news, LHI Executive Director Aurora Harris became a steering committee member of Cover Texas Now, the coalition leading the efforts to expand Medicaid in Texas!



Is the ACA working? These women say yes!

The 2016 election cycle has generated plenty of debate on health reform’s next steps. Opponents are once again calling for repeal of the Affordable Care Act (ACA). Supporters of the ACA want to improve it, such as by adding a public option and strengthening provider networks. On the ground, meanwhile, the law is working for many people, including women, LGBT people and our families. 
Raising Women’s Voices regional coordinators have been gathering and employing stories to document how women and LGBT people have benefited from the ACA. Here are a few stories from the different corners of the country: Texas, Montana and Maine.
Mia Morin, Texas
This story was gathered by the Lesbian Health Initiative, the RWV regional coordinator in Houston.
“I’m from San Antonio and I’ve recently moved to Houston,” says 23-year-old Mia Morin. “I’m ready to branch out on my own and make my mark on the world as a dancer and visual specialist. As a freelancer, I was on my own when it came to health insurance. I was concerned about the process and I didn't really know where to start.”
“When I reached out to a friend about it, Mia recalls, “she told me she had heard about a health fair being put on by the Lesbian Health Initiative from a post she saw on Facebook. I went because I wanted to be responsible and to be informed about my health coverage options and LGBTQ-specific resources. I feel like a part of living an adult life is making sure you're healthy and leading a healthy lifestyle.”
Mia’s story has a happy ending: “I ended up enrolling in health insurance through this year because I wanted full coverage. For me, living well is a physical, mental and spiritual journey. No matter what stage you’re in, your body and who you are is always adjusting to life. As a young adult you have a lot of first time experiences that can be scary, exciting or amazing. Either way, you need to be covered at every step.”
Lauren T. Cullen-Paulson, Maine
This story was gathered by Consumers for Affordable Health Care, the RWV regional coordinator for Maine.
Sometimes, a diagnosis can be a relief. That was the case for Lauren, who, after years of struggling with misdiagnoses and confusion, could finally put a name to her condition: Ehlers-Danlos syndrome, a chronic disorder that affects the body’s connective tissue. Also a relief? Being able to keep her coverage when she cut back on her work hours to take care of herself.
“When the Affordable Care Act came along, the place I was working started giving us all stipends to purchase our own silver plans,” Lauren recently explained. “Looking back, I’m very grateful, because once I left that job it meant I could keep that coverage without having to scramble to find any kind of health care.”
Lauren is grateful that the portability of her ACA coverage means no longer having to stick with a job just for the benefits. All it took was a phone call to the Marketplace to update her income, and her plan kept going with new, lower premiums. Continuing her existing coverage meant she didn’t have to find a new plan and contend with starting again to satisfy new deductible requirements or out-of-pocket expenditure maximums. That’s huge for somebody with chronic health needs. Plus, thanks to patient protections under the ACA, Lauren now has the comfort of knowing that she can never be denied coverage in the future or charged more simply because of a pre-existing condition.
Lauren appreciates being able to get health coverage without having to rely on a partner. When she was trying to find the right kind of birth control, mandated coverage under the ACA meant she could explore her options at no cost until she found what worked best for her. “It’s been so nice to be able to do this when your circumstances change,” Lauren says.
Sara, Montana
This story was gathered by Montana Women Vote, the RWV regional coordinator for Montana.
“I am 20 years old and from Shepherd, MT,” says Sara, who describes herself as bisexual. “I currently live in Missoula and work as a waitress 30 to 35 hours a week. I had been without health insurance since I was 18. I feel lucky that I have not gotten injured or majorly ill, and used to worry what that will look like if that were to happen.”
“My job offers health insurance to employees that work 40 hours a week, but it is rare that anyone is scheduled to work the 40 it would take to qualify,” she explains. “I have looked into buying health insurance, but all of the plans were out of my price range. I would have to go without car insurance, groceries, or paying utilities to be able to afford a health insurance plan. I already live tightly, and there is no way I could afford even the cheapest plan on my own.”
“The Montana Legislature expanding Medicaid gave me good health insurance and peace of mind through The HELP Act,” Sara says. “It gave me a safety net if something awful were to happen and will keep me healthy so I can continue to work to support myself. I work hard to pay my bills, and I think I deserve to have quality health insurance, just like someone with a higher paying job.”
Do you have a story of how the Affordable Care Act has helped you gain coverage? Share it with us at


Contraceptive Mandate: After Zubik, the Fight Goes On

Following the Supreme Court’s surprise decision in May to punt final resolution of the contraceptive coverage fight in Zubik v. Burwell, the federal government has called for public comments on how—if at all—the “accommodation” given to religious employers could be further modified without sacrificing the critical contraception coverage guaranteed by the Affordable Care Act.
The ACA requires insurance plans to provide birth control coverage without cost-sharing to employees. But under the accommodation, religiously-affiliated non-profits and closely-held for-profits who object to contraception on religious grounds can opt out by signing a short form stating their objections. The form then shifts responsibility for payment onto to the insurer. While not ideal, the accommodation is a compromise that allows women to access seamless birth control coverage at no cost, but also accommodates the religious objections of employers.
But in the consolidated cases included in Zubik, religious employers argued that the accommodation represented a violation of their rights in two distinct ways: first, filling out the form was a burden, they claimed, and second, the accommodation allowed the government to “hijack” their health plans when, they felt, entirely separate plans should be required.
In its May statement remanding Zubik back to the lower courts, the Court (at least in the near-term) implicitly rejected the “hijack” framework that contraception coverage must be provided through a separate policy, and gave the government explicit authority to move ahead with providing seamless coverage to the employees of the employers in the suit. At the end of July, the government began to build off of that partial win by publicly committing to providing coverage to those employees—even if the organizations don’t fill out their form.
Now, with its request for public comment, the government has acknowledged that “the issues addressed in the supplemental briefing in Zubik affect a wide variety of stakeholders, including many who are not parties to the cases that were before the Supreme Court.” The request for information (RFI) seeks input on a number of scenarios, including one proposed by the Court itself after oral arguments in March that insurers could move forward without formal notification from employers. The RFI also seeks input on two proposals raised by religious employers in Zubik: that women enroll in contraception-only plans, and that instead of automatic enrollment, they take “affirmative steps” to enroll. Critically for women’s health, the RFI asks: “What impact would [separate policies] have on the ability of women enrolled in group health plans established by objecting employers to receive seamless coverage for contraceptive services?”
At RWV, we remain strongly concerned that these kinds of alternate proposals are not just unworkable, putting affordable preventive care out of reach for women nationwide, but suggest a deeper reality: ultimately, no amount of compromise will satisfy coverage opponents. We see this in the host of related lawsuits led by individuals (versus employers) attacking the contraceptive mandate that are working their way through the courts, including the case of Missouri state legislator Paul Wieland who cited religious objections to the inclusion of contraception in his state health plan. In a similar case, Real Alternatives v. Burwell, Judge John Jones III gets to the heart of what a victory for the objectors would mean:

Many with religious objections to a wide variety of services covered by insurance plans are similarly situated to Plaintiffs. As the Seventh Circuit notes in Grote v. Sebelius, “contraceptive care is by no means the sole form of heath care that implicates religious concerns.” Grote v. Sebelius, 708 F.3d 850, 866 (7th Cir. 2013). Rather, “artificial insemination and other reproductive technologies; genetic screening; counseling and gene therapy; preventative and remedial treatment for sexually transmitted diseases; sex reassignment; vaccination; organ transplant from deceased donors;” blood transfusions; and, in some religions, virtually all conventional medical treatments, are objectionable. Id. Coverage for many of these services is required by the ACA. Yet no court has as of yet permitted an individual to demand a health plan tailored to his or her exact religious beliefs, and no insurance provider supplies one. A finding that coverage for one set of objectionable services constitutes a substantial burden would imply that coverage for all such services imposes a substantial burden. Then, by Plaintiffs’ interpretation, only by allowing all such objectors to opt out of the objectionable coverage would RFRA be satisfied. This would render the health care system totally unworkable.1

The fight here is both the long-standing battle for women’s health and autonomy, well within the framework of reproductive rights, health, and justice. But it is also a broader, more opaque fight by groups interested in dismantling the regulatory system and the consumer, safety, and environmental protections it provides.
RWV has been actively involved in getting the word out about what Zubik means for women’s health. We will be submitting comments and sharing information so that you can make your voice heard. To learn more about how you can engage, email Sarah Christopherson, Policy Advocacy Director for the National Women’s Health Network
To learn more about the comment period, click here. Comments are dueSeptember 20.



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