Health Coverage and Care in the South: A Chartbook

Over 115 million individuals live in the American South today, and together, they account for over one-third (37%) of the total U.S. population. The South is racially and ethnically diverse and home to a large share of the nation’s people of color. As such, efforts to improve health in the South have significant implications for the advancement of health and health equity nationwide.

The South has faced longstanding disparities in health and health care, although significant variation exists between southern states. As a group, compared to those in other regions, Southerners are more likely to be uninsured, less likely to have access to needed health services, and more likely to experience a number of chronic health conditions. Yet, many southern states have also adopted innovative approaches to improve their health systems, particularly in the delivery of care, that provide key lessons for improving access to health coverage in the South more broadly.

Health Coverage and Care in the South: A Chartbook provides key data on the demographic and economic characteristics of the southern population as well as their health status, health insurance coverage, and access to care today.

Together, these data offer a snapshot of health care in the South, highlighting both opportunities for advancement and challenges relating to improving health care and health equity looking forward.

Section 1: Demographics

Section 2: The Southern Economy

Section 3: Health Status

Section 4: Health Insurance Coverage

Section 5: Access to Care, Delivery Systems, and the Safety Net

Section 6: Medicaid’s Broader Role

Over one third of the total U.S. population resides in the 17 southern states, and the population has been growing over time. The southern population is racially and ethnically diverse, although the racial and ethnic composition varies by state. Overall, over four in ten of all people of color in the U.S. reside in the South, including over half of Blacks in the United States. The region is also diverse across a number of factors including citizenship status, age, urban-rural composition, and income.

The southern states play an important role in the national economy, contributing 35 percent of the total U.S. gross domestic product. Work patterns in the South are similar to those in other regions, although Southerners are less likely than those in other regions to be unemployed. Overall, Southerners earn less per capita than individuals in other regions of the U.S. However, income varies significantly by state, and, in four states, per capita earnings are higher than the national average. Earnings also vary widely within states, and several southern states have among the highest levels of income inequality in the country.

While measures of health status vary by state, Southerners as a group are generally more likely than those in other regions to have a number of chronic illnesses and experience worse health outcomes. For example, most of the states with the highest rates of obesity and diabetes are in the South, and many southern states are among those with the highest infant mortality rates and cancer death rates in the country. As in other regions, health status within the South also varies by race and ethnicity, and Blacks in particular, are more likely than Whites to report having fair or poor health.

While a broad array of factors contribute to the relatively high chronic disease rates and poor health outcomes in the South, a first step in addressing these disparities is ensuring that individuals have health coverage that enables them to access preventive and primary care and ongoing treatment to meet their health needs. Health insurance coverage facilitates timely access to health services, and being uninsured affects people’s ability to obtain needed medical care as well as their financial security. Compared to individuals in other regions, Southerners are more likely to be uninsured. Further, within the South, people of color are more likely than Whites to be uninsured. Coverage rates in the South vary by state, however, reflecting variation in demographics and the availability of health coverage options.The Affordable Care Act has the potential to extend health coverage to many currently uninsured Southerners through an expansion of Medicaid to low-income individuals and the creation of new health insurance Marketplaces with financial assistance to help moderate-income individuals purchase private coverage. Because many southern states are not implementing the Medicaid expansion, many uninsured adults in the South will not gain a new coverage option. However, nearly half of uninsured individuals are eligible for some financial assistance to obtain coverage in 2014, largely through the Marketplace, and millions of eligible individuals have already enrolled.

To improve health outcomes in the long term, it will be important to ensure that all individuals are able to obtain needed primary and specialty health care services. Southerners have historically been more likely than those in other regions to report difficulty accessing and paying for needed care.

States are increasingly relying on a number of tools to improve provider capacity and reform the delivery of care including expanding the use of Medicaid managed care, increasing payment to providers, and revising scope of practice laws to allow nurse practitioners to treat patients with fewer restrictions. Even with improvements to the delivery and coordination of care, however, community health centers and other safety net providers in the South will likely continue to serve an important role in providing care to some of the region’s most vulnerable low-income populations including the uninsured, people of color, homeless individuals, and those with limited English proficiency.

Medicaid is both an expenditure and a source of federal revenue in state budgets. The program is funded jointly by states and the federal government through a matching formula based on a state’s personal income, and in many southern states, where per capita personal income is less than the national average, the federal government pays at least two dollars for every dollar states spend on their programs. Overall, the federal government funds the majority of Medicaid costs in the South, although the way in which states finance their share of spending on Medicaid and its impact on their budgets varies by state.

As in other regions and in the United States generally, Medicaid spending in the South is concentrated among a small number of high-need enrollees. Children and adults in the South account for a large majority of Medicaid enrollees but less than 40 percent of expenditures. The elderly and disabled, who make up only about one quarter of Medicaid enrollees, account for nearly two-thirds of spending. Looking forward, efforts to improve care and control costs in Medicaid will likely focus on these high-need, high-cost beneficiaries.

Given the growing and diverse population in the South, changing patterns of health coverage and care in the region have important implications nationally and for people of color. As such, continued attention to health coverage and care in the South for those gaining coverage and those remaining uninsured will be important for understanding the impact of the ACA and implications for longstanding efforts to reduce disparities in coverage, care, and health outcomes.