More than one in 10 Nevadans are living without health insurance despite overall coverage gains as a result of the Affordable Care Act and the state’s decision to expand its Medicaid program, according to a new report from the Guinn Center released on Wednesday.

The report found that Nevada had the sixth-highest uninsured rate in the nation in 2017 with 14 percent of Nevadans going without insurance coverage that year — a figure that is 3.5 percentage points higher than the national average. All of the states with higher uninsured rates than Nevada’s chose not to expand their state Medicaid programs and fill in historical eligibility gaps for low-income adults, with the exception of Alaska.

That overall uninsured rate represents a decline from 2013 — the year before the Affordable Care Act was implemented — when 21.7 percent of Nevadans lacked health care coverage. But the report notes that while state decisions to opt in to Medicaid expansion tend to loosely correlate with rates of higher insurance coverage, seven states that expanded Medicaid, including Nevada and Alaska, still have uninsured rates that exceed the national average, and 14 non-expansion states have lower uninsured rates than Nevada’s.

Of the uninsured here, more than half, or 55.8 percent, are eligible for the state’s Medicaid program or a tax credit to purchase a plan through the state’s health insurance exchange but are foregoing insurance. The rest, 44.2 percent, are not eligible for any of those options — possibly because they have chosen to decline an employer-sponsored health plan and are thus ineligible for tax credits or because they are undocumented and don’t qualify for government assistance.

“Why are we so high? Let me be careful — I’m not accusing legislators or agencies of anything — but we are high,” said Meredith Levine, director of economic policy at the Guinn Center. “We have a pretty immediate concern in the state. Whether the national solutions will work or whether they won’t are up for grabs, but right now I would say we have something that is undermining the economic health and actual health of Nevada’s residents.”

The report, which is based on the most recently available data from the American Community Survey between 2013 and 2017, sheds additional light on who exactly is living without health insurance in Nevada and what policy solutions might help them gain coverage.

For instance, the state’s uninsured population is commonly thought of as being largely undocumented and, indeed, the report found that while Latinos make up 35.9 percent of the state’s population, they represent 59.1 percent of its uninsured population.

But Levine noted that it isn’t just the issue of legal status that is responsible for high uninsured rates in the Latino community. Other factors, she said, include language barriers in accessing health insurance, socioeconomic status and the relative youth of Latinos.

Another mitigating factor, she said, is citizenship status regardless of legal status. The report found that one in three Nevadans who are uninsured, 32.4 percent, are noncitizens, noting that noncitizens face a five-year waiting period before they can qualify for Medicaid.

Based on national uninsured rates of the undocumented population, the report estimates that roughly 94,500 undocumented immigrants went without insurance coverage in Nevada in 2017, representing only about 23.7 percent of the state’s uninsured population.

“There are a significant number of Latinos that are undocumented, but the question is what is actually going on with the Latino population? I don’t think it has wholly to do with authorization. I think that’s part of it,” Levine said. “My guess is there’s a constellation of items and they coalesce.”

The report also found that the state’s uninsured population is largely concentrated in populous Clark County — which has an uninsured rate of 14.7 percent — though some rural counties do have higher uninsured rates. Those counties include Mineral (15.3 percent), Humboldt (16 percent), Pershing (16.5 percent) and Esmeralda (20.2 percent). Overall, though, the report determined that the uninsured rate in the state’s urban counties, which it counted as Clark, Washoe and Carson City, is 14.2 percent, while the rate of uninsured individuals in rural Nevada is only 12 percent.

“What we found is as Clark goes so Nevada goes,” Levine said. “What we did find is that not only is there no urban-rural divide, but rurals are a little bit lower.”

Employed Nevadans also make up a disproportionate share, 62.9 percent, of the state’s uninsured population. The report notes that those employees may work for companies with 50 or fewer full-time employees — which aren’t required to provide coverage — or work less than 30 hours a week. They also may choose to forego employer coverage if the employee contribution is too pricey.

Of the uninsured, 37.3 percent worked full-time, year round, 35.8 percent worked less than full-time, year round and 26.8 percent did not work.

“The stereotype is if you have employer-sponsored insurance that you’re going to have insurance, but you see there’s a high percentage of unemployed workers,” Levine said. “I think that is notable that in the state we have working folks that are uninsured.”

The report also found that young adults are overrepresented in the state’s uninsured population, making up one-fifth of the state’s uninsured population but only 12.8 percent of the total population. Another group that was overrepresented were those without a high school diploma — who make up 14.1 percent of Nevada’s total population but 29.4 percent of its uninsured — and those in households with an income between $25,000 and $49,999, a category that 22.7 percent of Nevadans fall in but makes up 31.6 percent of the state’s uninsured.