The 2020 census shows that the U.S. states with the fastest-growing population score the worse when it comes to the quality of their residents’ health and access to care. They have large numbers of uninsured adults, high levels of premature death from treatable conditions, less investment in public health, too many people with mental illness unable to get the care they need, and residents facing mounting insurance costs. There are things state and federal policymakers and private sector leaders can do to significantly improve health at the state level.
The 2020 census revealed trends in the geographic distribution of Americans that may be bad news for their health unless policymakers and private sector leaders act to correct marked deficiencies in the health and health systems where more and more Americans are dwelling.
The fastest-growing states in terms of population over the last decade, including Texas, Florida, and Georgia, consistently rank last when it comes to health and health care. This is because these states have large numbers of uninsured adults, high levels of premature death from treatable conditions, less investment in public health, too many people with mental illness unable to get the care they need, and residents facing mounting insurance costs that make health care less affordable than in many other parts of the country, according to the Commonwealth Fund.
Take Texas, which added 4 million people, the most of any state, over the past decade. Texas ranked 42nd overall in our measure of health system performance — in large part because of how hard it is for people in the state to get and afford the health care they need. It has the highest uninsured rate in the country, and fewer of its residents report having a regular source of health care — an important marker of how well the health system is working. Texas also has the largest number of residents who said they skipped health care they needed because of cost, and health insurance costs take a bigger share of people’s incomes in Texas than in almost any other state. Texas is also one of 14 states that still have not expanded Medicaid under provisions of the Affordable Care Act, leaving millions of working people uninsured.
Florida, which grew by nearly 3 million people, has a similar story. It ranks 41st overall and its residents face many of the same health care access and affordability challenges as people living in Texas, with many uninsured and high insurance costs. Another fast-growing state, Georgia, ranks 46th overall. Georgians face similar health care access problems as Texans and Floridians, but what stands out is its preventable mortality: Georgia has one of the highest rates of premature (before age 75) death from treatable conditions and one of the highest rates of infant mortality — ranking 42nd on both measures. All three of these states rank poorly in other areas of health care too.
Overall, the states that rank at the bottom of the scorecard accounted for half of the aggregate population growth in the United States from 2010 to 2020.
So, what does all of this mean for Americans’ health? Geography does not have to be destiny. There are things state and federal policymakers and private sector leaders can do to significantly improve health at the state level.
Recently, the Biden administration and Congress made more people eligible for assistance with their Affordable Care Act marketplace health insurance premiums. Right now, these more generous subsidies will last for two years. Making them permanent would make health insurance more affordable for millions, including the 3.7 million people in Texas and Florida, who have enrolled in insurance plans through ACA marketplaces. States could also expand their Medicaid programs under the Affordable Care Act. Doing so in Texas, Florida, and Georgia would extend health insurance coverage to 2.7 million people.
Health insurance coverage has a ripple effect. It is the most important determinant of access to health care, and assuring more people have it is also likely to lead to improvements in other health measures.
Similarly, investments in public health made possible by the $350 billion allocated to states and local governments under the American Rescue Plan, which President Biden signed into law in March, could improve the capacity of low-performing states to address preventable causes of illness and death such as excess maternal mortality, heart attack, stroke, cancer and more.
Finally, it is possible that people from healthier states may bring their better health and commitment to collective health improvement with them to less healthy states. Migrants from states with more robust governmental health programs, included expanded Medicaid, may support such investments at the voting booth in their new home states. This could mean that states that have been reluctant to invest in health care coverage and improvements may be more likely to do so in the future. Business leaders, who depend on a healthy workforce, can assist by letting state and local officials know how important it is prioritize public health and coverage expansion.
Of course, in an ideal world, our health system would be good enough that people in every state would have affordable, high quality health care. Getting there will require investing in state and federal policies that we know work to get people the health care they need, no matter where they live.