Don't forget about us: The millions of Americans who will be left uninsured

Left out of the ACA's expansion, left without coverage

The Affordable Care Act won't lead to health coverage for all: About two-thirds of low-income blacks and single mothers and more than half of low-wage workers who lack health coverage are expected to be left uninsured despite the ACA's implementation, the New York Times reports.

For the most part, these uninsured Americans live in states that have declined to expand Medicaid and have incomes too high to qualify for federal subsidies to purchase coverage in the ACA's insurance exchanges, a Times analysis of U.S. Census data found.

  • How does the Medicaid expansion work? Check out the Daily Briefing's primer on the ACA provision to learn how it works, who's paying, and who will be eligible under the rules.

Where the uninsured will (likely) live

According to the Times, the 26 states that have opted out of Medicaid expansion are home to:

  • About 50% of the U.S. population;
  • About 68% of low-income and uninsured blacks and single mothers; and
  • About 60% of low-income working residents who are uninsured.

Black Americans will be disproportionately affected by states' decisions to reject the expansion because about six in 10 black U.S. residents live in such states, which are mostly in the South.

"You got to be almost dead before you can get Medicaid in Mississippi."
- One uninsured Miss. resident

In Mississippi—which has the highest percentage of low-income and uninsured residents, at 13%—56% of low-income and uninsured residents are black, even though they account for just 38% of the total state population. Barring a change in policy, some uninsured residents are pessimistic that they will be able to obtain health coverage. "You got to be almost dead before you can get Medicaid in Mississippi," one uninsured 53-year-old told the Times.

According to H. Jack Geiger, who helped create the community health center model, "The irony is that these states that are rejecting Medicaid expansion—many of them Southern—are the very places where the concentration of poverty and lack of health insurance are the most acute." He added, "It is their populations that have the highest burden of illness and costs to the entire health care system."

Most Republican leaders and lawmakers in those states have said their decision to opt out of the Medicaid expansion is largely based on economic concerns, according to the Times (Tavernise/Gebeloff, New York Times, 10/2).

See the states with the most uninsured post-ACA 

In June, the Daily Briefing's Juliette Mullin and Rich Van Haste examined which states would have the most uninsured residents after the ACA's implementation.


Editor's Note: Since this analysis was conducted, governors in several states have clarified their position on coverage expansion, which means that expected uninsurance rates will change. For the most up-to-date version of this tracker, check out our interactive Medicaid expansion map.

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