While the uninsured rate for all Americans dipped to a historic low of 8.6 percent in the first three months of 2016 – thanks in great part to the Affordable Care Act — rates across states and cities vary widely, according to WalletHub’s 2017 ranking of Cities & States with the Highest & Lowest Uninsured Rates.

Using U.S. Census data, WalletHub compared overall insurance rates across states, as well as state rates based on age, race and income (it did the same for cities in a separate table). The changes in the overall uninsured rate for each state refer to the difference between the percentages of uninsured in 2016 and 2010.

“A small change in the absolute difference does not necessarily indicate a negative outcome, as the percentage of uninsured people pre-Obamacare may have already been low to start with,” the website writes.

The following Benefits Pro slideshow has a bit more color on the five states with the lowest overall ranking for uninsured residents, and the five states with the highest overall ranking.

FIVE STATES WITH THE LOWEST UNINSURED RATES>>>

Iowa

No. 5: Iowa

2016 uninsured rate: 4.26%

The Hawkeye State in June submitted an application for an ACA waiver to create a stopgap measure plan – which would be the only plan offered in the ACA marketplace, according to the Kaiser Family Foundation. The state is also seeking to replace advanced premium tax credits with flat premium subsidies based on age and income and eliminate cost-sharing subsidies, and establish a reinsurance program. Federal pass through funds would finance the new premium subsidies and the reinsurance program.

Modern Healthcare writes that Iowa hopes the Centers for Medicare & Medicaid Services will approve the waiver on an emergency basis because only one insurer, Medica, has offered to sell ACA-compliant plans in the state for 2018. Moreover, Medica has proposed raising its rates by 57 percent. “I wouldn’t be surprised in other states aren’t already developing similar waiver requests,” Keith Mueller, interim dean of the University of Iowa College of Public Health, tells Modern Healthcare. “How quickly other states would jump in depends on what whether Congress moves fairly quickly on market reforms.”

  • Change in uninsured rate between 2010 and 2016: -5.05%

  • Children’s uninsured rate (state rank): 2.5% (9)

  • Adults’ uninsured rate (state rank): 4.78% (5)

  • Whites’ uninsured rate (state rank): 3.30% (5)

  • Blacks’ uninsured rate (state rank): 8.4% (25)

  • Hispanics’ uninsured rate (state rank): 15.1% (15)

  • Low-income households’ uninsured rate (state rank): 6.73% (6)

  • High-income households’ uninsured rate (state rank): 2.1% (4)

Minnesota

No. 4: Minnesota

2016 uninsured rate: 4.12%

In addition to immediately expanding Medicaid after the passage of the ACA, the North Star State also has more generous Medicaid benefits, Governing.com writes. Moreover, state lawmakers last year passed a bill that offered anyone who didn’t qualify for subsides a 25 percent discount on their plans, after premiums jumped by 60 percent.

In May, Minnesota submitted an application for an ACA waiver to create a new state reinsurance program, to be funded with a combination of federal pass through funds and state appropriations, according to the Kaiser Family Foundation.

“The waiver requests that funds the federal government would have paid in premium tax credits and cost-sharing reductions to eligible marketplace enrollees had the reinsurance program not been in place be provided directly to the state to be used to finance the program,” the foundation writes.

  • Change in uninsured rate between 2010 and 2016: -4.95%

  • Children’s uninsured rate (state rank): 3.4% (20)

  • Adults’ uninsured rate (state rank): 4.35% (4)

  • Whites’ uninsured rate (state rank): 2.8% (2)

  • Blacks’ uninsured rate (state rank): 7.20% (16)

  • Hispanics’ uninsured rate (state rank): 17.6% (25)

  • Low-income households’ uninsured rate (state rank): 7.07% (7)

  • High-income households’ uninsured rate (state rank): 1.8% (2)

Vermont

No. 3: Vermont

2016 uninsured rate: 3.72%

 In 2014, former Vermont Gov. Peter Shumlin, a Democrat, dropped his plan to enact a single-payer health care system in the Granite State, saying at the time that the additional taxes and premiums it called for would be “detrimental to Vermonters.”

The model called for businesses to take on a double-digit payroll tax, while individuals would face up to a 9.5 percent premium assessment. Big businesses, in particular, didn’t want to pay for Shumlin’s plan while maintaining their own employee health plans, according to Politico.

“These are simply not tax rates that I can responsibly support or urge the Legislature to pass,” Shumlin said at the time. “In my judgment, the potential economic disruption and risks would be too great to small businesses, working families and the state’s economy.”

Aside from that experiment, Vermont “has been tinkering” with its health-care system for years, trying to get the number of uninsured as close to zero as possible, Governing.com writes, In addition to expanding Medicaid, the state also has maintained its historically robust Medicaid offerings and preventative health programs, and the number of insured people is also high due to Vermont’s low unemployment rate.

  • Change in uninsured rate between 2010 and 2016: -4.33%

  • Children’s uninsured rate (state rank): 1.6% (2)

  • Adults’ uninsured rate (state rank): 4.22% (3)

  • Whites’ uninsured rate (state rank): 3.6% (8)

  • Blacks’ uninsured rate (state rank): 8% (22)

  • Hispanics’ uninsured rate (state rank): 5.5% (3)

  • Low-income households’ uninsured rate (state rank): 4.42% (2)

  • High-income households’ uninsured rate (state rank): 2.1% (4)

  

Hawaii

No. 2: Hawaii

2016 uninsured rate: 3.53%

Of the six states that have submitted ACA 1332 waiver applications to the federal government, only Hawaii’s waiver has been approved so far, according to the Kaiser Family Foundation. The Aloha State received the right to retain the employer coverage provisions currently in place through Hawaii’s 1974 Prepaid Health Care Act, which requires employers to provide more generous coverage than is required under the ACA. Moreover, the state is allowed now allowed to waive the ACA requirement that the small business tax credits only be available through the ACA’s Small Business Health Options Program (SHOP) marketplace.

Governing.com writes that Medicaid expansion “had a huge hand” in Hawaii being one of the states with the lowest uninsured population, as roughly half of those previously uninsured have become covered under the law.

Hawaii in 2016 also had the lowest average deductible for single plans, at $988, compared to a high of $2,434 in New Hampshire, according to University of Minnesota research funded by the Robert Wood Foundation. Hawaii also had the lowest percentage of workers enrolled in high-deductible health plans (about 12 percent), compared to New Hampshire, which had the highest percentage (69 percent).

  • Change in uninsured rate between 2010 and 2016: -4.36%

  • Children’s uninsured rate (state rank): 2.2% (5)

  • Adults’ uninsured rate (state rank): 3.9% (2)

  • Whites’ uninsured rate (state rank): 3.4% (6)

  • Blacks’ uninsured rate (state rank): 7.3% (18)

  • Hispanics’ uninsured rate (state rank): 4.8% (1)

  • Low-income households’ uninsured rate (state rank): 5.95% (3)

  • High-income households’ uninsured rate (state rank): 2.6% (10)

 

Massechusetts

No. 1: Massachusetts

 

2016 uninsured rate: 2.54%

According to Governing.com, Massachusetts has had record low numbers of uninsured residents ever since it passed its own version of universal health care in 2006, which served as a roadmap for the ACA. Moreover, the Bay State’s uninsured rate continues to fall because Massachusetts expanded Medicaid further under the ACA and has its lowest unemployment rate in 15 years.

The number of people in Massachusetts buying individual insurance plans last year rose by 34.5 percent, and premiums for individuals who buy insurance on their own declined by 3.4 percent, according to the state’s annual report. “The point we have figured out here in Massachusetts is that we can raise coverage standards and still stabilize that market because we promise we’re going to be here today and the next day,” Sen. Elizabeth Warren tells MassLive. While that has also made health care more affordable in Massachusetts than in other states, bipartisan adjustments are still needed, Warren adds.

  • Change in uninsured rate between 2010 and 2016: -1.87%

  • Children’s uninsured rate (state rank): 0.9% (1)

  • Adults’ uninsured rate (state rank): 2.95% (1)

  • Whites’ uninsured rate (state rank): 1.9% (1)

  • Blacks’ uninsured rate (state rank): 3.8% (1)

  • Hispanics’ uninsured rate (state rank): 5.4% (2)

  • Low-income households’ uninsured rate (state rank): 3.6% (1)

  • High-income households’ uninsured rate (state rank): 1.5% (1)

FIVE STATES WITH THE HIGHEST UNINSURED RATES

 Florida

No. 46: Florida

2016 uninsured rate: 12.54%

The Sunshine State’s high uninsured rate is due in part to its large immigrant population as well as a strict Medicaid program: families with incomes between 133 and 200 percent of the federal poverty line have to pay a premium — something other states don’t require, according to Governing.com. The state Senate passed a bill in 2015 to expand Medicaid, but Republican Gov. Rick Scott rejected it.

Louisa McQueeney, spokeswoman for Florida Voices for Health tells FloridaWatchdog.org that expanding the Medicaid program in Florida would have helped to insure 800,000 more people in the state.

Paul Duncan, a professor and health services researcher at the University of Florida, tells the website that the state’s high uninsured rate is also due to the make-up of Florida’s major industry clusters — tourism, agriculture, aquaculture and a large number of small firms that cater to the needs of retirees and the elderly in the state.

“These are precisely the employers that are least likely to offer or significantly support health insurance for their employees,” Duncan says.

State lawmakers should find ways to encourage employers to provide health coverage to their workers, he says.

  • Change in uninsured rate between 2010 and 2016: -8.73%

  • Children’s uninsured rate (state rank): 6.2% (42)

  • Adults’ uninsured rate (state rank): 14.16% (45)

  • Whites’ uninsured rate (state rank): 9% (44)

  • Blacks’ uninsured rate (state rank): 14.3% (42)

  • Hispanics’ uninsured rate (state rank): 19.4% (27)

  • Low-income Households’ uninsured rate (state rank): 17.09% (45)

  • High-income Households’ uninsured rate (state rank): 5.9% (47)

Georgia

No. 47: Georgia

2016 uninsured rate: 12.94%

Georgia’s Republican leaders not only refused to expand Medicaid under the ACA, but the Peach State has maintained it strict Medicaid program, only allowing parents with incomes of 40 percent below the poverty line to qualify, according to Governing.com.

“In fact, GOP Gov. Nathan Deal signed a bill that made it illegal for state employees to even advocate publicly for Medicaid expansion,” the website writes. “Buthis tune might be changing. After Congress failed to repeal the ACA this summer, Deal said his cabinet was “exploring” new health-care options.”

The Atlanta Journal-Constitution’s Politically Georgia interviewed a number of prominent leaders about how health care can be improved in the state:

“Georgia should expand Medicaid to cover everyone under 138 percent of the poverty line — that’s about $16,000 per year in income for an individual,” says Laura Colbert, executive director, Georgians for a Healthy Future. “We have about a million and a half Georgians that are uninsured. And by expanding Medicaid we would cover about a third of those people. It’s the biggest step that our state can take to covering the remaining uninsured. And also to fully implementing the Affordable Care Act in the way that other states have.”

However, Mercy Care president Tom Andrews tells Politically Georgia that state leaders “need to get away from the whole focus around, we’re not going to expand Medicaid.”

“But we can talk about some transformational ways that we can bring some of the federal dollars down through things, like 1115 waivers and other special grant opportunities, that would allow us to expand access to people that are poor and underserved and do not currently qualify for Medicaid, but don’t put them in the Medicaid system,” Andrews says.

  • Change in uninsured rate between 2010 and 2016: -6.76%

  • Children’s uninsured rate (state rank): 6.5% (43)

  • Adults’ uninsured rate (state rank): 15.06% (47)

  • Whites’ uninsured rate (state rank): 9.8% (48)

  • Blacks’ uninsured rate (state rank): 13.1% (39)

  • Hispanics’ uninsured rate (state rank): 32.5% (50)

  • Low-income households’ uninsured rate (state rank): 19.74% (49)

  • High-income households’ uninsured rate (state rank): 4.8% (42)

 

 Oklahoma

No. 48: Oklahoma

2016 uninsured rate: 13.77%

The Sooner State saw premiums jump 76 percent last year – more so than in any other state, Governing.com writes.

“Although most people who take advantage of the ACA pay little to nothing in premiums, the large increase might have discouraged some from shopping on the marketplace at all,” the website writes. “Republican Gov. Mary Fallin doesn’t support Medicaid expansion, and the issue hasn’t been revisited by the state legislature since a bill died last year.” Oklahoma last month filed an ACA waiver request to use federal subsidy money to fund a new reinsurance program, as the first step in a broader reform of the ACA coverage system, according to Modern Healthcare.

“Like Iowa, Oklahoma wants to replace the federal insurance exchange with its own purchasing platform and modify income eligibility for premium subsidies,” the website writes. “Unlike Iowa, it also wants to revise the ACA’s essential benefits requirements. Oklahoma also has only one insurer currently selling ACA-compliant plans.”

  • Change in uninsured rate between 2010 and 2016: -5.09%

  • Children’s uninsured rate (state rank): 7.3% (45)

  • 2016 Adults’ uninsured rate (state rank): 15.92% (49)

  • Whites’ uninsured rate (state rank): 9.7% (47)

  • Blacks’ uninsured rate (state rank): 15.3% (46)

  • Hispanics’ uninsured rate (state rank): 26.9% (44)

  • Low-income households’ uninsured rate (state rank): 19% (48)

  • High-income households’ uninsured rate (state rank): 6.1% (48)

Alaska

No. 49: Alaska

2016 uninsured rate: 14.01%

The Last Frontier State in June submitted an application for an ACA waiver to allow federal pass through funding to partially finance the state’s reinsurance program, according to the Kaiser Family Foundation. The waiver, currently under review, requests that funds the federal government would have paid in premium tax credits and cost -sharing reductions to eligible marketplace enrollees had the reinsurance program not been in place be provided directly to the state to be used to finance the program.

Access to affordable health care coverage should not be a partisan issue, Alaska Gov. Bill Walker writes in The Arctic Sounder. Walker, a Republican turned independent, in 2014 joined with Democrat Byron Mallott to form the unity ticket. They serve as the country’s only nonpartisan governor and lieutenant governor.

Walker last week joined seven other governors in urging Congress “to take action right away to make health care coverage more stable and affordable — without shifting the costs to states and without jeopardizing the resources and care for our most vulnerable.”

“Two years ago, I chose to expand Medicaid coverage,” he writes. “Since then, more than 36,000 Alaskans have received life-saving care — and peace of mind knowing they have health care coverage. That should be protected.”

  • Change in uninsured rate between 2010 and 2016: -5.85%

  • Children’s uninsured rate (state rank): 10% (50)

  • Adults’ uninsured rate (state rank): 15.43% (48)

  • Whites’ uninsured rate (state rank): 9.3% (45)

  • Blacks’ uninsured rate (state rank): 9.8% (29)

  • Hispanics’ uninsured rate (state rank): 16% (19)

  • Low-income households’ uninsured rate (state rank): 18.44% (47)

  • High-income households’ uninsured rate (state rank): 9.2% (50)

Texas

No. 50: Texas

2016 uninsured rate: 16.6%

The Lone Star State’s uninsured rate is not only the highest in the country – it’s also double the national average, Governing.com writes. Still, it’s a big improvement from the years before the ACA became law, when nearly a quarter of Texans lacked health insurance.

“The Lone Star State has always had historically high numbers of uninsured, partially attributed to a large immigrant population, a limited Medicaid program and a lower-than-average rate of employers who offer health coverage,” the website writes.

Neither Gov. Greg Abbott nor the legislature have considered expanding Medicaid, Governing.com adds.

Of the 10 highest uninsured cities in the U.S. in 2016, eight of them were in Texas, including Dallas, Laredo, and Baytown, according to WalletHub. Dallas had the highest rate of the cities with more than 300,000 (22.24 percent), with Houston right above it (22.16 percent).

Because the devastation from Hurricane Harvey is now occupying the attention of many residents, many Texas families making too much to qualify for Medicaid might not be able to receive help from the federal Children’s Health Insurance Program (CHIP), according to The Dallas Morning News. The Centers for Medicare & Medicaid Services waived several application and renewal requirements in counties declared disaster areas to streamline access to care, but that still might not give distressed people enough time to submit applications – and for the federal government to process them.

“As CHIP’s Sept. 30 expiration date approaches and the system absorbs new applicants made eligible by Harvey, some experts fear that between rising demand for care and unpredictable reauthorization, these families will have nowhere to turn for health insurance,” the publication writes.

  • Change in uninsured rate between 2010 and 2016: -7.11%

  • Children’s uninsured rate (state rank): 9.2% (49)

  • Adults’ uninsured rate (state rank): 19.27% (50)

  • Whites’ uninsured rate (state rank): 9.3% (45)

  • Blacks’ uninsured rate (state rank): 13.8% (41)

  • Hispanics’ uninsured rate (state rank): 26.3% (43)

  • Low-income households’ uninsured rate (state rank): 24.63% (50)

  • High-income households’ uninsured rate (state rank): 6.9% (49)