by Dr. Patrick Jones
By many measures, Spokane County doesn’t place high nationally. This is especially true of economic indicators, such as median household income or poverty. Yet, Spokane has outpaced the U.S., and for that matter Washington state, on a key measure of community well-being: health insurance.
Spokane Trends indicator 5.4.1, tracking the overall rate of the uninsured, clearly shows the county rate to be far below the national and slightly below the state rates. For the most recent year of data, 2019, those shares were 5.8%, 9.2% and 6.6%, respectively.
Another Trends indicator, 5.4.2, breaks down that overall rate into two age-related components: the 19-64 group and those under 19 years. (The rate for the group of residents 65+ has been so low that it is not included in the indicator graph; the data, however, are available in the “Download Data” section.) The age breakdown helps us understand why the overall rate of the uninsured is not closer to zero.
The Affordable Care Act (ACA) ushered in a much wider health safety net for Americans. For the first time, low-income, non-disabled adults qualified for Medicaid. The ACA also introduced government subsidies to the self-employed and those working in small businesses unable to provide classic employer programs. And children’s eligibility to stay on their parents’ plans was extended to 26 years.
Washington state has traditionally offered Medicaid coverage to nearly all children. As the graph shows, the estimated rate in 2019 for the under-19 residents in the county was 2.1%. In 2009, the rate was 3.6%. So, some decline is noticeable, but not a large drop. Nonetheless, the rate for youth is considerably lower than the overall rate in 2019, at 5.8%.
Pushing the average up has been the rate for young and working adults. Indicator 5.4.2 shows that the 2019 estimate was 8.5%. This age group makes up, of course, the bulk of the population. As indicator 0.1.3 displays, these ages counted for 60% of the county’s population in 2019.
Why is the 19-64 rate this high? While the ACA greatly increased the options for non-elderly adults to secure health care insurance, it didn’t create universal coverage. True, Medicaid allowed non-disabled, non-pregnant adults whose incomes were below the 138% multiple of the Federal Poverty Level (FPL) to access this program. In fact, the bulk of the drop in the insured can be attributed to a more generous Medicaid policy. Between 2013, that is pre-ACA, and 2015, the first full year of the ACA’s implementation, about 46,000 county residents gained insurance coverage. The Trends indicator that tracks Medicaid coverage, 5.4.4, shows that the rolls of county residents jumped by about 42,000 over that two-year period.
Much of the success in enrolling thousands of local residents can be attributed to the good work of Better Health Together. But for a couple reasons, this organization has not been able to enroll everyone. According to a recent (November, 2020) summary published by the Kaiser Family Foundation, the primary reason that adults remained without coverage was cost. Not everyone who was uninsured have been eligible for Medicaid, as their incomes lie above the 138% of the FPL threshold. Hence, the importance of the health exchanges.
Yet, the cost argument may be a bit misleading. In another recent national study of the uninsured, the Commonwealth Fund (2019) found that two thirds of uninsured adults had not even checked their state’s health exchange options.
Another reason lies in certain citizenship requirements demanded by Medicaid. Permanent resident immigrants, or green card holders, are eligible, but only after five years of residency. Nonqualified non-citizens (aliens) are eligible only for emergency Medicaid services. This group includes the undocumented.
Unlike some counties, Spokane County is unlikely to be home to many undocumented residents. The economy here doesn’t rely on immigrant labor, as many agricultural local economies do. But the county still might have a significant percentage of non-qualified aliens. In 2019, as Trends indicator 0.2.2 reveals, there were an estimated 10,337 non-citizens in the county, or about 2% of the overall population. Not all of this group are likely to be green card holders with five years of residency.
In the end, an uninsured rate among the 0-64 population is unlikely to drop close to zero, as it has for the 65+ segment. The latter group enjoys Medicare coverage, although it is also restricted to those with permanent residency who have been in the U.S. at least five years. (The very low uninsured rates for the 65+ population may tell us about the age of the recently-arrived immigrant population.)
Since 2015, the rate of the uninsured for the young adult and adult age groups hasn’t budged much. Is it possible to reduce it further? Perhaps.
The same two national studies cited earlier point to higher rates of the uninsured among the adults under 35 years and to the Latine population generally. As seen in indicator 0.1.3, the share of the population 19-34 in Spokane County was most recently estimated at 23.3%. This is higher than the state share by 2.5 percentage points. Many in this group are the “invincibles,” when health is referenced. Perhaps our collective experience with covid-19 may convince those in this camp otherwise.
The Hispanic/Latino population in the county is much smaller than national and state benchmarks, as seen in indicator 0.2.3. But at approximately 6% most recently, it is not negligible. Perhaps language barriers and a general unawareness of government programs are at play with this group.
For now, Spokane should rightly celebrate its outperformance in its residents’ health insurance status. And then ask the question: can we do better?