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How Would States Be Affected by Health Reform?

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Document date: January 25, 2010
Released online: January 25, 2010


In this paper we examine various pathways through which individuals could gain coverage through the Senate and House health reform proposals. We show that large shares of the population, particularly the uninsured, could potentially gain coverage under health reform through one pathway or another, depending on income and employment status. The number of individuals who would gain coverage and how they would gain coverage varies considerably among states. The benefits of the reform would be disproportionately in southern and western states due to their current low levels of coverage and low incomes.

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In this paper, we examine how different states would be affected by health reform legislation. States enter health reform in very different situations. Some states have high rates of employer coverage and low uninsured rates. For others, the opposite is true. Some have much larger low- and moderate-income populations who would need financial assistance. Some states have already taken steps to expand eligibility for public health insurance programs to larger segments of their populations than have other states. Because coverage and need vary across states in the current system, the reforms being considered would affect states differently. This paper shows how the effects of these reforms are likely to vary across states.

We did not tie our analysis to one specific proposal, though we generally follow the provisions of the Senate bill. There are enough common features between the House and Senate bills to allow us to provide insight into the size of the subpopulations in each state that would have new coverage options or financial support. For example, both the House and Senate proposals would extend eligibility for the Medicaid program, with the Senate proposal expanding to all individuals with incomes up to 133 percent of the federal poverty level (FPL) and the House expanding to 150 percent of the FPL. Both would provide subsidies to help low- and middle-income families purchasing coverage through new health insurance “exchanges” to those between Medicaid eligibility levels and 400 percent of the FPL. Both would allow small employers to contribute toward the cost of health insurance for their workers through the exchanges as well. Both bills include a requirement for individuals to enroll in health insurance coverage (an individual mandate), and this is expected to increase enrollment in Medicaid, subsidized coverage, and unsubsidized coverage.

We examine the distribution of current eligibility for Medicaid and simulate the numbers of people who would be newly eligible for Medicaid and for income-related subsidies under reform. We do not make estimates of the costs that would be borne by states or of the dollars that would flow into states as a consequence of reform. Rather, we focus on the numbers of people who would be affected. The estimates are derived as if health reform was fully implemented in 2009.

First, we provide a brief overview of our methodological approach. Next, we provide the state-specific distributions of health insurance coverage under current law. We then delineate the subpopulations in each state that would be affected by different provisions of the reform proposals. We estimate the number of those currently and newly eligible for the Medicaid program; this is important because the share of Medicaid expenditures paid by the federal government (i.e., the federal matching rates) under reform would be very different for those currently and newly eligible.1 We then show the numbers with incomes in the range of eligibility for subsidized coverage through the exchange, and those with family incomes above 400 percent of the poverty level who would not be eligible for financial assistance with coverage. Finally, we summarize the potential impacts of reform on the uninsured populations in each state.

(End of excerpt. The entire paper is available in PDF format.)

Topics/Tags: | Health/Healthcare

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