Health Care Reform and the Geography of the Uninsured

Last night at his 100-Day press conference, President Obama again promised that health care reform would be a high priority, right behind the economy in the first year. This raised a question in my mind; is there a geographic constituency for health care reform? What might it look like?

In 2005, the U.S. Census estimated the size of the uninsured population for every county in the nation. The result is mapped below as the percentage of each county’s population (under age 65, since the elderly are covered by Medicare) that has no health care coverage:


Clearly the South and Southwest stand out on this map as areas where the uninsured are highly concentrated. In the Deep South states, across counties, the percentage uninsured runs 5.5 percent higher, on average, than everywhere else in the nation. In Texas and Oklahoma, the percentage uninsured runs 10 percentage points higher than elsewhere.

In the Southwest and Western U.S. the percentage of uninsured residents is also very high, partly due to large uninsured immigrant populations (both legal and illegal). Immigrants are about 2.5 times more likely to be uninsured than natives. An estimated one-third of Latinos are without health insurance, the highest rate for any ethnic group. Californians and Arizonans are, by now, very familiar with the health care and general fiscal impact of high levels of immigration—a reminder that health care reform and immigration reform are linked. Immigration is a challenge for policymakers who are trying to reduce the size of the uninsured population.

The president was much less clear in his remarks about when he might take on the immigration issue. But does an expansive new health care plan for the uninsured make sense as long as the immigrant inflow is as large as it is?

The geographic concentration of the uninsured seems a bit ironic, given that the South and Southwest are not known for being Democratic strongholds agitating for a universal-coverage-single-payer system. But most of the uninsured fall heavily among the ranks of non-voters. The Republican congressional delegations from these states have little political incentive to work on this issue with President Obama. But the President doesn’t look like he needs them, either.

Republicans, for their part, will rightly be focused on the bottom line—emphasizing the fiscal and tax implications of a generous new health care plan in the presence of what is among the world’s most generous and lenient of immigration policies.

13 Responses to Health Care Reform and the Geography of the Uninsured

  1. Brian Arbour May 1, 2009 at 8:57 am #

    What’s most interesting to me looking at this map is how sharp the lines are at state borders. As Jim’s in-box shows, I’ve been looking at maps of Obama & Clinton vote as well as ethnic patterns. These mpas bleed heavily across state lines, and show more cultural and ethnic boundaries. Those exist much less in these maps (compare the darker West Virginia to the lighter Pennsylvania & Kentucky).

    This visual assessment indicates that state policies are an important factor in insurance rates in a state. What are the implications for the health care debate? In the implementation state (should the White House successfully make it there), politics between Washington and the states will still matter. And it means an important question in the writing of any health care bill is the mandates on state government.

  2. Bill Harshaw May 1, 2009 at 9:47 am #

    On the local level, though, I’m struck that Delta counties in MS and AR have low rates of uninsured. I would have expected very high rates. Maybe it’s Medicaid?

  3. Scott P. May 3, 2009 at 11:03 pm #

    It’s not at all clear from this map that the uninsured are concentrated in the south and southwest. Most of those counties in Texas, New Mexico, and Oklahoma are pretty empty.

  4. John May 3, 2009 at 11:11 pm #

    TX is one of the most populous states in the union, and so’s FL. Both are also colored quite dark on this map. OK is middle of the pack, pop-wise. CA is #1, of course.

    So that seems a fair generalization.

  5. sherifffruitfly May 3, 2009 at 11:17 pm #

    Now overlay this map with a map of union labor concentration, and I betcha you’ll have something interesting.

  6. Scott P. May 3, 2009 at 11:30 pm #

    Yes, Texas is populous, but looking at the map, Dallas and the Austin area are considerably lighter than the rest of the state. That’s a good chunk of the population right there. A state-level instead of county-level map would be more illuminating, I think.

  7. Kaitlin Duck Sherwood May 4, 2009 at 3:23 am #

    Brian Arbour, I have been doing a lot with maps lately, and I’m actually not surprised at the visibility of state boundaries.

    You can see state boundaries pretty clearly in the difference in unemployment 2007 and 2008 especially WI:

    and in differences between one presidential election to the next:

    You can look at the population density, racial makeup, election results, and unemployment graphs at

    I am working on getting census-tract-level maps up; stay tuned!

  8. Jim Gimpel May 4, 2009 at 12:56 pm #

    Maps can be misleading because they are always better at representing where the land is better than they represent where the people are. So Scott’s point is well taken.

    Aggregating to the state level, the states with the largest percentage of uninsured residents are, in order:

    New Mexico

    In terms of sheer numbers, California, Texas and Florida are at the top.

  9. Mike In Texas May 4, 2009 at 1:16 pm #

    The texas counties that are lighter do not include dallas or austin. The light county in the center of the state is williamson, an affluent county with a large military population that is directly north of austin. The light county in the north is denton, with a large university population.

    Texas, like Cali and AZ, has problems largely due to immigration, but also because of aweful insurance regulation. However, it is quite easy to see most doctors here for a relatively moderate price, without insurance (they have made adjustments because of the state of uninsured people).

  10. Anon May 4, 2009 at 4:09 pm #

    Why use percentages?

    Is 90% uninsured (population 10) a bigger problem than 25% uninsured (population 10,000)?

  11. Stan Ulrich May 4, 2009 at 4:59 pm #

    “The Republican congressional delegations from these states” — well, NM is 100% dem (2+3), so the generalization doesn’t apply here.

  12. Jim Gimpel May 4, 2009 at 5:48 pm #

    No evil conspiracy here, folks. It’s just one way of presenting the data. There are other ways, of course.

    Percentages or proportions capture one meaning of ‘concentration’ (as a share of a county’s or state’s population) that’s worth mapping. Raw numbers will follow population — so no need for map — but with Florida, Texas and California at the top, as indicated in the previous post.

  13. folson May 6, 2009 at 2:22 pm #

    More elaboration data visualization can be done here. Dig into that census data and pull out ethnicity and income levels. More maps! More maps!