Framework highlights states’ different circumstances both before the ACA and four years after implementation.
Previous data released in 2018 provided analysis on changes in coverage from the year immediately preceding the Affordable Care Act’s (ACA) main coverage reforms. Following earlier research, this brief summarizes the state variation in coverage changes using a typology that groups states according to their pre-ACA uninsurance levels and their subsequent policy decisions around Medicaid expansion and efforts to encourage marketplace enrollment.
Researchers examined the insurance landscape before and after implementation of the ACA and created a framework that grouped states into five categories, based on similar attributes: high or low uninsured rate prior to the ACA, whether the state expanded Medicaid or not, and marketplace enrollment by subsidy-eligible individuals. Changes in the employer-sponsored insurance market, average incomes, and other factors were also considered. Among the groupings:
In Delaware, the uninsured rate declined by 5.4 percent since 2013.
In California, the uninsured rate declined by 11.6 percent since 2013.
In Connecticut, the uninsured rate declined by 4.5 percent since 2013.
In Florida, the uninsured rate declined by 8.8 percent since 2013.
In Alabama, the uninsured rate declined by 5.1 percent since 2013
The state typology developed here highlights states’ different circumstances both before the ACA and four years after implementation. States that already had high coverage levels before the ACA and expanded Medicaid made additional progress, but their percentage-point advances tended to be smaller than other states’ because they began the reform process in a better position. Many remaining states that did not expand Medicaid and did not have robust subsidized marketplace enrollment experienced much smaller reductions in their uninsurance rates.
About the Urban Institute
The nonprofit Urban Institute is dedicated to elevating the debate on social and economic policy. For nearly five decades, Urban scholars have conducted research and offered evidence-based solutions that improve lives and strengthen communities across a rapidly urbanizing world. Their objective research helps expand opportunities for all, reduce hardship among the most vulnerable, and strengthen the effectiveness of the public sector. Visit the Urban Institute’s Health Policy Center for more information specific to its staff and its recent research.
States Seek Greater Control, Cost-Savings by Converting to State-based Marketplaces
The Urban Institute finds that 11 states and D.C. currently operate their own health insurance marketplace eligibility and enrollment websites under the ACA, but that number is slated to grow.