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States as Innovators in Low-Income Health Coverage

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Document date: June 01, 2002
Released online: June 01, 2002

Assessing the New Federalism is a multiyear Urban Institute project designed to analyze the devolution of responsibility for social programs from the federal government to the states. It focuses primarily on health care, income security, employment and training programs, and social services. Researchers monitor program changes and fiscal developments. Alan Weil is the project director. In collaboration with Child Trends, the project studies changes in family well-being. The project provides timely, nonpartisan information to inform public debate and to help state and local decisionmakers carry out their new responsibilities more effectively.

Key components of the project include a household survey, studies of policies in 13 states, and a database with information on all states and the District of Columbia. Publications and database are available free of charge on the Urban Institute's web site: http://www.urban.org. This paper is one in a series of discussion papers analyzing information from these and other sources.

This paper received special funding from The Robert Wood Johnson Foundation as part of the Urban Institute's Assessing the New Federalism project. The project received additional funding from The Annie E. Casey Foundation, the W.K. Kellogg Foundation, The Henry J. Kaiser Family Foundation, The Ford Foundation, The John D. and Catherine T. MacArthur Foundation, the Charles Stewart Mott Foundation, The David and Lucile Packard Foundation, The McKnight Foundation, The Commonwealth Fund, the Stuart Foundation, the Weingart Foundation, The Fund for New Jersey, The Lynde and Harry Bradley Foundation, the Joyce Foundation, and The Rockefeller Foundation.

The nonpartisan Urban Institute publishes studies, reports, and books on timely topics worthy of public consideration. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders.

Note: This report is available in its entirety in the Portable Document Format (PDF).


I. INTRODUCTION

The majority of nonelderly Americans are covered with health insurance obtained through their own or a family member's employer. Others are insured through solely federally funded programs, such as Medicare or military health programs. A small share purchase private coverage in the individual market. Those remaining without private or fully federally funded insurance must rely on federal-state subsidy, or they are left uninsured. The number of uninsured in a state will depend on, first, how many people are not covered by private insurance or federal health programs and, second, how far states go in developing state-subsidized programs to cover those remaining.

In this paper we examine the extent to which states have been innovative in designing programs to provide health insurance to low-income Americans. Have states functioned as laboratories, with successful innovations being replicated by other states? Or have some states successfully extended coverage while the majority have done little beyond the minimum required to obtain federal matching funds under Medicaid and the State Children's Health Insurance Program (SCHIP)? Can the existing federal-state partnership be relied upon to solve the problem of the uninsured, particularly for those with low incomes?

Following a discussion of the mechanisms available for states to expand coverage, this paper introduces a typology for designating states by the extent of their coverage expansions. The typology divides states into four groups, ranging from most to least innovative. The results show that it is only a minority of states that have seriously attempted to extend coverage beyond what are essentially levels required for Medicaid and SCHIP. These states have used considerable creativity in employing diverse funding streams and have fought many difficult political battles to achieve what they have. In contrast, the majority of states have done relatively little to expand coverage beyond minimum federal requirements.

We then describe the programs developed by the most innovative states. The concluding discussion highlights differences between those states that have chosen to substantially expand coverage and those who have not. We show that coverage innovations are more likely in states that have higher incomes, higher education levels, larger urban populations, and that are less politically conservative. We additionally demonstrate that the thirteen states in the most innovative group have the highest rates of public coverage and the lowest uninsurance rates, but they also have likely reduced some private coverage. Even in these more innovative states, uninsurence rates for low-income populations remain surprisingly high.

Note: This report is available in its entirety in the Portable Document Format (PDF).



Topics/Tags: | Governing | Health/Healthcare | Poverty, Assets and Safety Net


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