Changes in Health Insurance Coverage 2013–2016:
Medicaid Expansion States Lead the Way

The primary health insurance coverage reforms of the Affordable Care Act began to take effect on January 1, 2014. Between 2013 and 2016, the most recent year of American Community Survey data available, the share of nonelderly Americans from birth to age 64 without health insurance fell from 17 percent to 10 percent, meaning 18.5 million more Americans had health insurance coverage. These gains were broadly distributed across the groups studied. The report provides detailed estimates of changes in health insurance coverage types between 2013 and 2016 by demographic, socioeconomic, and geographic characteristics. In addition, state fact sheets detail coverage changes by income group in all 50 states and the District of Columbia.

Characteristics of the Uninsured in Texas

Every state has seen coverage growth since the implementation of the Affordable Care Act’s coverage reforms in 2014, but states that expanded Medicaid eligibility have seen the largest increases in coverage. Texas has the country’s highest uninsurance rate, with 4.7 million people younger than 65 estimated to be uninsured in 2018. We estimate that 19 percent of people in that age group are uninsured in 2018, more than 70 percent higher than the national rate of 11 percent. Though the Texas uninsurance rate remains high, it represents a significant increase in coverage across a diverse group of residents since ACA implementation. Urban Institute researchers have analyzed the characteristics of people who are uninsured in Texas both statewide and in local areas.

COVID-19 Resource Tracker: A Guide to State and Local Responses

We compiled resources that monitor state and local COVID-19 responses related to health care, food, housing, income supports, and more.

Dual Medicare-Medicaid Enrollees

Urban Institute staff contribute to a wide variety of research to help policymakers and administrators understand dual enrollees. This body of research spans descriptive studies, quantitative evaluation work, technical data issues, and policy analyses aimed at improving the financing and delivery of care for dual enrollees.

EHR Reporting Program

The 21st Century Cures Act, or Cures Act, directed the US Department of Health and Human Services to establish a new Electronic Health Record (EHR) Reporting Program. The Office of the National Coordinator for Health IT (ONC) contracted with the Urban Institute, and its subcontractor, HealthTech Solutions, to develop the program. The EHR Reporting Program will provide publicly available, comparative information on certified health IT based on input from developers and voluntary input from end users.

Emerging Strategies for Integrating Health and Housing

Funded by the Urban Institute Policies for Action research program, this study examines emerging interventions that integrate housing and health services for low-income people, with a focus on interventions where health care organizations have taken a significant leadership role.

Evidence-Based Strategies for Prevention, Screening, and Treatment of Adolescent Opioid Use Disorder

Opioid use disorder is a serious national crisis and often originates with substance use in adolescence. The Addiction Policy Forum has been supporting the efforts of three Ohio counties to address opioid use disorder in their adolescent populations.  To inform efforts in these counties, we systematically reviewed literature and other resources to identify promising interventions aimed at addressing adolescent opioid use disorder. We summarize the identified interventions in a report and three fact sheets that we hope will help counties across the United States make decisions about how to prevent and treat adolescent OUD. 

Fostering Collaboration in Housing and Health

This series of reports, derived from a literature review and extensive discussions with policy and program experts, examines the current state of housing and health care collaborations, identifies common features and factors that make collaborations successful, and offers guidance to those interested in integrating housing and health care.

From Safety Net to Solid Ground

From Safety Net to Solid Ground offers local, state, and federal policymakers, advocates, practitioners, and philanthropic leaders several resources, including timely, rigorous analyses of potential changes to federal safety net programs. The initiative provides insights into how states manage change and employ administrative flexibility, evidence on how policy changes are implemented in communities, and an assessment of Americans' health and well-being. 

Health Care Reform in Massachusetts

This body of research includes numerous studies of Massachusetts's ambitious effort to transform its health care system, reforms which later became the template for the Affordable Care Act.

Health Care Stewardship Case Studies

In early 2015, Urban conducted case studies examining health care stewardship in Colorado, Minnesota, Ohio, Oregon, and Vermont. Through interviews, we examined the unique ways each of the five states has leveraged its authority to improve the quality and efficiency of the state’s health care system.

Health Reform Modeling Capacity

The Health Insurance Policy Simulation Model (HIPSM) is a sophisticated microsimulation model used to estimate the impacts of health reforms and to inform state and national policy design choices. HIPSM has been used to assist with implementation of the Affordable Care Act and analysis of policy options under the Affordable Care Act.

Health Reform Monitoring Survey

The Health Reform Monitoring Survey (HRMS) provides timely insights into the Affordable Care Act. Including information on coverage, access, and affordability, the HRMS delivers critical data before federal government surveys are available.

Impacts of the ACA and Implications for Its Repeal

Through this body of research, we have analyzed the implications of partial repeal of the Affordable Care Act through budget reconciliation, along with the changes proposed by the American Health Care Act and the Better Care Reconciliation Act. 

Interactive Map: Poor Uninsured Americans Eligible for Medicaid under ACA Expansion

The number of poor, uninsured Americans who would be eligible for Medicaid under Affordable Care Act expansion varies widely by locality.

Labor and Delivery Unit Closures in Rural New Hampshire

As part of the Robert Wood Johnson Foundation Interdisciplinary Research Leaders program, we have explored what leads to rural labor and delivery unit closures, how such closures may affect maternal and infant outcomes, and how the community responds to such losses. This mixed-method study provides critical information for providers and policymakers focused on maintaining access to high-quality maternity care services for a rural population.

Medicaid Areas of Flexibility to Provide Coverage and Care to Justice-Involved Populations

Given the high prevalence of mental health issues, substance use, and chronic health conditions among people involved with the criminal justice system, providing them with better health care services could improve public health and safety outcomes. This series of briefs highlights areas of flexibility within Medicaid that can facilitate enrollment in health coverage and access to care in the community for those involved in the criminal justice system.

Payment Methods and Benefit Designs

All payment methods have strengths and weaknesses, and how they affect the behavior of health care providers depends on their operational design features and how they interact with benefit design.

Reproductive Health and Access

This body of research includes analyses of how access to contraception affects the lives of women and their families and an examination of progress, threats, and opportunities related to reproductive health care access.

State-by-State Employer-Sponsored Insurance Access, Affordability, and Enrollment in 2018

These 51 state appendices document the employer-sponsored insurance landscape in 2018 for employees in private-sector firms

State-by-State Health Insurance Coverage among Women of Reproductive Age in 2017

Despite large declines in the uninsurance rate under the Affordable Care Act, 7.5 million women of reproductive age (15–44) remained uninsured in 2017. Using data from the 2017 American Community Survey, we created state fact sheets that detail the demographic and socioeconomic characteristics of women with the highest uninsurance rates in each state and the District of Columbia. In 40 states, the fact sheets also provide the state-specific breakdown of uninsured womens' potential eligibility for financial assistance obtaining health insurance coverage.

States and the Affordable Care Act 

This comprehensive monitoring and tracking project examines the implementation and effects of the Affordable Care Act in 10 states. The accompanying reports document each state’s progress in establishing a health insurance Marketplace, implementing insurance reforms, and preparing for Medicaid expansion.

Strong Start for Mothers and Newborns

The Strong Start for Mothers and Newborns initiative, funded under the Affordable Care Act, aimed to improve maternal and infant outcomes for women covered by Medicaid and the Children’s Health Insurance Program during pregnancy. The Center for Medicare and Medicaid Innovation contracted with the Urban Institute to conduct an independent, five-year evaluation of Strong Start implementation and the program’s impacts on maternal and infant health outcomes, health care delivery, and cost of care.

The Growing Opioid Crisis

The opioid epidemic is a public health emergency and part of a larger problem of untreated substance use disorder in the United States. Drawing on Urban experts from the health, justice, and safety net fields, we detect emerging problems and risks, monitor policy changes, and identify and evaluate innovative solutions to this growing crisis.  

The Well-Being and Basic Needs Survey

The Well-Being and Basic Needs Survey was launched in December 2017 to track individual and family well-being at a time when policymakers are considering significant changes to the safety net. By assessing the ability of adults and their families to meet basic needs, the survey can provide a broader understanding of material well-being than income-based poverty indicators.

Tracking Medicaid-Covered Prescriptions to Treat Opioid Use Disorder

Making effective opioid use disorder (OUD) treatment more widely available is essential to staunching the opioid epidemic. Access to these treatments is particularly important in Medicaid, because the program covers a disproportionately large share of people with OUD. In this project, we examine prescriptions and spending on three medications approved for OUD and overdose treatment: buprenorphine, naltrexone, and naloxone. We update these data regularly to show long-term trends and up-to-date Medicaid prescribing and spending patterns.

Tracking Progress on Health Insurance Marketplace Enrollment

By the end of the 2014 open enrollment period, about 8 million people had chosen plans in the newly established health insurance Marketplaces. As of April 8, 2015, 11.7 million had selected plans during the second annual open enrollment, an increase of 46 percent. This page contains data on subsidized and unsubsidized plan selections for each state and is updated with the latest enrollment figures as they are released.

Trends in Family Health Insurance Premiums and Contributions for Employer Coverage, 2001–16

This analysis uses data from the Medical Expenditure Panel Survey–Insurance Component to examine the premiums families could face to maintain coverage for their children should children's eligibility for Medicaid and the Children's Health Insurance Program be retrenched.

Understanding Hospital Bed Capacities Nationwide amid COVID-19

As confirmed cases of COVID-19 increase across the United States each day, hospital bed capacities are becoming strained. The US had an estimated 2.2 hospital beds per 1,000 people in 2018, but those numbers varied by region. This interactive county-level map shows which parts of the country have the most and least available hospital beds, indicating which areas may need additional resources amid COVID-19.

Understanding the Consequences of Current Immigration Policy

The Trump administration has proposed sweeping changes to federal immigration policy, including a proposal that would penalize immigrant families for participating in safety net programs. Advocates, policymakers, service providers, and the research community are concerned that current immigration policy could lead immigrant families to disengage with critical public services and forgo assistance that helps them meet their basic needs. Urban Institute researchers are investigating the short- and long-term consequences of evolving immigration policy for the well-being of immigrant families and the communities where they live.

What Lies Ahead for Children's Health Coverage?

This new interactive tool shows the impact of changes to children’s eligibility for Medicaid and the Children’s Health Insurance Program and federal subsidies for marketplace coverage. 

Work Requirements in Safety Net Programs

In April 2018, the administration released an executive order calling for federal agencies to add or strengthen work requirements for federal aid programs such as Medicaid, cash assistance, and nutrition assistance. For Medicaid, work requirements are a major policy shift for the 50-year-old health insurance program. Many other programs, like Temporary Assistance for Needy Families, already mandate work. What we already know about existing work requirements can inform states and agencies as they respond to this policy change. We explore lessons from research about work requirements, estimating who could be affected by these policy changes and studying implementation and impacts.