Across states, levels and types of health insurance coverage change over time because of economic conditions, the demographic composition of the population, and state and federal policies.

The 2018 American Community Survey (ACS) 1-year estimates show trends in health insurance coverage rates in each of the 50 states and the District of Columbia.

In 2018, 91.1% of people in the United States had health insurance to help cover their medical expenses but coverage varied by state.

In 2018, for example, health coverage rates ranged from 82.3% of people in Texas to 97.2% of people in Massachusetts.

The large sample size of the ACS allows for an examination of types of coverage, including private coverage (employment-based, direct-purchase and TRICARE), public coverage (Medicare, Medicaid, CHAMPVA and VACARE) and the overall insured rate over time at the state level.

Some of the state-by-state findings using data from the 2013, 2017 and 2018 ACS 1-year estimates:

• In 2018, private coverage rates across states ranged from 54.3% to 79.7% (Figure 1).
• Between 2017 and 2018, the percentage of people with private health insurance coverage increased in four states and decreased in four states (Figure 2).
• Public coverage rates in 2018 ranged from 21.3% to 49.4% across states. (Figure 1).
• Between 2017 and 2018, the percentage of people with public health insurance coverage increased in 11 states and declined in two states (Figure 2).
• Medicaid coverage varied 22.6 percentage points across states, ranging from 10.3% to 32.9% (Figure 3).
• Compared with 2013, the year before several key provisions of the Affordable Care Act went into effect, uninsured rates were lower in all 50 states and the District of Columbia in 2018.
• Private coverage increased in 31 states, and public coverage rates increased in 46 states between 2013 and 2018 (Figure 2).

In 2018, most people (67.5%) in the United States had private health insurance coverage, such as coverage through an employer, coverage purchased directly (including through a state or federal marketplace), and/or coverage through TRICARE.

While the majority of people in each state had private coverage, the percentage of people with private coverage varied.

New Mexico had among the lowest rate of private health insurance coverage at 54.3%. North Dakota had among the highest rates at 79.7% in 2018, a 25.4 percentage-point difference.

Two states had private coverage rates of 60.0% or less.

In 2018, about 35.6% of people in the United States had public coverage.

Utah had the lowest public coverage rate at less than one-quarter (21.3%), while New Mexico had the highest at about one-half (49.4%).

Public coverage rates may vary depending on whether a state expanded Medicaid eligibility. In states that chose to do so, a higher percentage of people have public coverage.

Public coverage rates may be related to whether or not a state expanded Medicaid eligibility as part of the ACA. Thirty-one states and the District of Columbia elected to expand Medicaid eligibility on or before January 31, 2018 (“expansion states”), and 19 states did not (“non-expansion states”).

In 2018, 37.4% of people in expansion states had public coverage, which was 4.6 percentage points higher than the percentage of people with public coverage in non-expansion states (32.8%).

The uninsured rate in expansion states was also lower (6.6%) than the uninsured rate in non-expansion states (12.4%).