Among the many lingering effects of the Great Recession has been stagnant levels of health insurance coverage, as Americans continue to face high levels of unemployment and businesses continue a long-term trend of paring back benefits. Women of reproductive age (15–44) accounted for 13 million, or more than one-quarter, of the 50 million U.S. residents who were uninsured in 2010, according to a Guttmacher Institute analysis of new data from the U.S. Census Bureau.1,2 Put another way, more than one in five (22%) reproductive-age women are uninsured, including 41% among those who have incomes below the federal poverty level ($18,530 for a family of three).1,3

Millions of Americans have turned to Medicaid and the Children's Health Insurance Program (CHIP) as a backstop against the loss of private insurance coverage. Nine million reproductive-age women—15% of that population—rely on these programs, including 38% of those below poverty.1 These numbers reflect the expanded role that Medicaid and CHIP have taken on over the past decade: Between 2000 and 2010, overall enrollment in these public insurance programs increased by nearly 75%, from 28 million to 49 million.2 Even that rapid expansion, however, has not been enough to completely offset losses in employment- based insurance; the ranks of the uninsured grew by 36% over the decade.

Medicaid and CHIP enrollment expansions have not occurred evenly across the country; rather, states vary widely in the eligibility criteria they have set for the programs and in their outreach and enrollment efforts. Enrollment in public—and private—insurance also reflects considerable differences in states' levels of unemployment and poverty, as well as state fiscal difficulties. As a result of these various crosscurrents, the proportion of reproductive-age women enrolled in Medicaid or CHIP ranges from 8% in Nevada, New Hampshire, Utah and Virginia to a high of 28% in Maine, with several other states in the Northeast also surpassing 20% (see table).1 The proportion of uninsured reproductive-age women varies even more widely, from 6% in Massachusetts—reflecting the success of that state's early efforts at health care reform—to 34% in Texas.

The rising number of Americans relying on public insurance programs has also meant escalating costs for the state and federal governments and has made Medicaid a high-priority target for budget hawks (see "Political Tug-of-War Over Medicaid Could Have Major Implications for Reproductive Health Care," Summer 2011). The program continues to be discussed prominently as a potential source of cuts for the Joint Select Committee on Deficit Reduction, the "super committee" tasked by Congress and President Obama in August to recommend at least $1.5 trillion in deficit reduction over 10 years. That committee has until late November to make its recommendations, which would then face a simple up-or-down vote by Congress in late December. Failure to reach an agreement would trigger $1.2 trillion in across-the-board cuts; the president and congressional Democrats succeeded in exempting Medicaid from those triggered cuts.

At the state level, the outlook for Medicaid is similarly mixed. States' revenues remain below prerecession levels, and a temporary federal boost to federal Medicaid reimbursement rates expired in June 2011. According to a survey of state agencies from the Kaiser Commission on Medicaid and the Uninsured, almost every state took steps in FY 2011, and plan to take additional steps in FY 2012, to contain Medicaid costs through such tactics as reducing provider payment rates, setting controls on prescription drug spending, restricting optional benefits or increasing patient copayments.4 Yet, many states are also gearing up for 2014, when the Affordable Care Act requires them to make the most significant expansion to the Medicaid program since it was established in 1965, opening their programs' doors to all Americans with an income below 133% of poverty—far above the eligibility ceilings set by most states today (related article, page 20). The Kaiser Commission survey found that 33 states made enhancements to their eligibility standards or enrollment and renewal processes in FY 2011, and 22 states plan to do so in FY 2012.—Adam Sonfield

COVERAGE VARIES
States differ substantially in the extent of their public and private insurance coverage—and the proportion left uninsured.
Women Aged 15–44, 2009–2010
  Total % on Medicaid or CHIP % privately insured % uninsured
U.S. TOTAL* 61,488,291 14.7 60.0 21.7
Alabama 942,477 11.7 58.7 23.5
Alaska 143,186 9.5 52.8 22.4
Arizona 1,304,486 19.2 54.5 23.2
Arkansas 560,766 14.4 53.7 28.3
California 7,669,775 16.7 56.1 24.5
Colorado 1,033,721 10.3 67.4 17.0
Connecticut 680,800 13.9 71.4 13.3
Delaware 176,008 17.8 62.5 16.2
District of Columbia 153,453 21.5 63.4 14.0
Florida 3,435,803 10.7 54.6 29.6
Georgia 2,072,955 10.6 56.6 26.1
Hawaii 244,566 16.4 61.2 10.6
Idaho 303,585 9.7 61.9 25.1
Illinois 2,638,736 16.9 62.0 18.6
Indiana 1,262,218 16.1 60.6 19.7
Iowa 574,141 12.5 68.5 16.8
Kansas 554,912 10.3 65.9 18.1
Kentucky 856,749 16.7 58.6 21.8
Louisiana 928,497 15.0 56.0 25.6
Maine 240,300 27.7 57.6 10.7
Maryland 1,170,696 10.0 71.1 16.2
Massachusetts 1,358,175 23.8 69.3 6.1
Michigan 1,929,823 17.7 62.1 18.3
Minnesota 1,035,115 15.7 70.4 12.0
Mississippi 593,014 19.0 49.8 27.4
Missouri 1,177,834 13.6 64.3 20.6
Montana 181,129 12.0 59.7 25.1
Nebraska 352,535 9.1 69.1 16.2
Nevada 520,743 7.8 60.4 27.5
New Hampshire 254,838 8.1 75.1 14.4
New Jersey 1,714,486 12.3 67.8 19.1
New Mexico 392,636 18.7 48.4 28.7
New York 3,996,392 22.7 58.5 17.4
North Carolina 1,893,632 14.4 54.9 23.9
North Dakota 126,376 9.6 70.1 16.1
Ohio 2,229,317 16.8 63.1 17.3
Oklahoma 732,716 13.0 54.0 26.0
Oregon 757,288 12.2 63.6 22.4
Pennsylvania 2,402,761 15.2 68.1 14.9
Rhode Island 210,862 20.4 62.5 15.2
South Carolina 905,864 11.6 58.6 26.3
South Dakota 153,190 10.3 67.0 18.0
Tennessee 1,264,103 19.8 55.7 18.3
Texas 5,189,460 9.9 52.9 34.1
Utah 613,127 7.9 70.6 18.1
Vermont 118,629 24.0 59.7 12.8
Virginia 1,605,548 7.7 65.3 17.8
Washington 1,343,441 12.4 62.5 18.2
West Virginia 339,460 17.9 53.8 23.5
Wisconsin 1,101,926 18.7 69.0 10.4
Wyoming 104,809 10.0 62.5 22.6
*2010 data. Source: Reference 1

REFERENCES

1. Jones R, Guttmacher Institute, special tabulations of the 2011 U.S. Census Bureau Current Population Survey.

2. DeNavas-Walt C, Proctor BD and Smith JC, Income, poverty, and health insurance coverage in the United States: 2010, Current Population Reports, 2011, Series P60, No. 239, <http://www.census.gov/prod/ 2011pubs/p60-239.pdf>, accessed Oct. 31, 2011.

3. Department of Health and Human Services, Annual update of the HHS poverty guidelines, Federal Register, 2011, 76(13): 3637–3638, <http://edocket.access.gpo.gov/ 2011/pdf/2011-1237.pdf>, accessed Oct. 31, 2011.

4. Smith VK et al., Moving Ahead Amid Fiscal Challenges: A Look at Medicaid Spending, Coverage and Policy Trends, Washington, DC: Kaiser Commission on Medicaid and the Uninsured, 2011, <http://www.kff.org/ medicaid/upload/8248.pdf>, accessed Oct. 31, 2011.