Health Insurance

Five years after the enactment of Massachusetts health reform initiative, gains in insurance coverage and access to care have been sustained. This report provides an update on trends in the Bay State since fall 2006, just prior to the implementation of the state's health reform initiative, along with a more in-depth overview of the circumstances of working-age adults in 2010, as the state begins implementation of the Affordable Care Act.

Massachusetts is in its sixth year of a reform initiative that provided the template for the federal Affordable Care Act of 2010. This Health Affairs article reports on the status of health reform in Massachusetts as of 2010, providing an early indication of potential gains and challenges under national reform.

San Mateo County is one of a small number of innovative local jurisdictions that is expanding coverage for uninsured adults and at the same time undertaking a reform of its safety net primary care system. We evaluated the impact of the systems redesign by comparing outcomes for a group of people served at the largest county safety net clinic prior to systems redesign (2006) to those served at the clinic after systems redesign (2009). Use of any preventive care services in a year climbed from 25.9 percent to 33.3 percent. Continuity of care also rose significantly, and emergency room use declined. The county's experience provides an example for other communities to follow as they improve the efficiency of health care services for the most vulnerable members of society.

We use the Health Insurance Policy Simulation Model to explore the correlations between a state's progress toward implementing the Affordable Care Act and the anticipated benefits of the reform for state residents, as measured by the expected state gains in insurance coverage and federal subsidies. We group states in three categories based on the status of legislative action and the receipt of level 1 federal establishment grants. We find that states that have made the least progress in establishing health insurance exchanges are in general those that have the largest potential gains in coverage and federal subsidy dollars per capita.

The federal requirement for most Americans to have health insurance-the individual mandate-is an important part of how the ACA would reduce the number of uninsured. We use the Health Insurance Policy Simulation Model to estimate the effects of health reform with and without the mandate. With the mandate, the number of uninsured would decrease from 50 million to 26 million. Without a mandate, about 40 million would remain uninsured. Depending on the effectiveness of the health benefit exchanges in enrolling those eligible for subsidized coverage, exchange premiums would be 10 to 25 percent higher without a mandate.

John Holahan and Vicki Chen use the Current Population Survey to examine trends in health insurance coverage during the "Great Recession" of 2007-2010, as well as over the past decade. The uninsured have increased since 2000 with nonelderly adults shouldering the entire burden. Generous Medicaid coverage for children was able to offset falling ESI coverage, which caused the overall uninsured number of children to decrease. 2010 saw the continuation of many trends from 2007; ESI rates continued to fall, the share and number people who are low-income continued to grow, and unemployment continued to rise. Patterns of insurance coverage were similar across groups of all race/ethnicity, citizens and non-citizens, and all geographic areas. The one exception to recent trends in private coverage is coverage for young adults (ages 19-25). This group had an increase in private coverage while all other age groups experienced a decline in private coverage.

The growth in U.S. health care spending has become a focal point in debates over federal and state health care reform. While the problem is easy to quantify, strategies for slowing rising expenditures are controversial, and evidence of their effectiveness is often elusive. Our full report provides background that describes the problem and reviews the cost containment provisions of the Affordable Care Act (ACA). It also presents estimates of cost savings from several policies that go beyond those included in the ACA. In this appendix, we provide more detail on the methods used to generate these cost savings estimates.

Asthma is one of the most common chronic conditions among children in the United States, affecting nearly 10 percent of children in 2008. Medicaid and CHIP are covering a growing number of asthmatic children; by 2008, two-thirds of low-income asthmatic children were covered by Medicaid/CHIP. Our findings suggest that over the last decade, there has been a trend towards improvement in asthma-related outcomes and receipt of parental asthma management training for asthmatic children with Medicaid/CHIP coverage. Further expansions in health insurance coverage could lead to reductions in negative asthma outcomes and their associated costs, but other changes to the service delivery system would be needed as well.