What’s at Stake: States’ Progress on Health Coverage and Access to Care, 2013–2016


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  • Issue: Given uncertainty about the future of the Affordable Care Act, it is useful to examine the progress in coverage and access made under the law.
  • Goal: Compare state trends in access to affordable health care between 2013 and 2016.
  • Methods: Analysis of recent data from the U.S. Census Bureau and the Behavioral Risk Factor Surveillance System.
  • Findings and Conclusions: Between 2013 and 2016, the uninsured rate for adults ages 19 to 64 declined in all states and the District of Columbia, and fell by at least 5 percentage points in 47 states. Among children, uninsured rates declined by at least 2 percentage points in 33 states. There were reductions of at least 2 percentage points in the share of adults age 18 and older who reported skipping care because of costs in the past year in 36 states and D.C., with greater declines, on average, in Medicaid expansion states. The share of at-risk adults without a recent routine checkup, and of nonelderly individuals who spent a high portion of income on medical care, declined in at least of half of states and D.C. These findings offer evidence that the ACA has improved access to health care for millions of Americans. However, actions at the federal level — including a shortened open enrollment period for marketplace coverage, a failure to extend CHIP funding, and a potential repeal of the individual mandate’s penalties — could jeopardize the gains made to date.


The year 2017 marked a turning point in the implementation of the Affordable Care Act. Republicans in Congress attempted to repeal and replace the Affordable Care Act numerous times, ultimately failing but promising to try again. In addition, the Trump administration significantly cut funding for outreach and enrollment activities during 2018’s open enrollment period for the marketplaces, and disrupted markets by declining to pay insurers money owed to them for providing cost-reduced plans for lower-income enrollees. In December, Senate Republicans passed a tax bill that included a provision to repeal the ACA’s individual mandate penalties, paid by most people who do not have health insurance. Given these developments, many Americans are confused about the ACA’s status, which could reduce the number of people who enroll in health plans for the coming year, despite strong enrollment thus far.

It is useful to assess the changes in coverage and access that happened across states under the law before this tumultuous year. Between 2013, the year before the ACA’s major coverage expansions took effect, and the end of 2016, the number of uninsured Americans under age 65 fell by an estimated 17.8 million.1 Uninsured rates declined in every state and the District of Columbia (Exhibit 1).

In this issue brief, we examine the extent to which health care access and affordability improved from 2013 to 2016 for residents in each of the 50 states and D.C. We use six indicators: uninsured rates for working-age adults and for children, three measures of adults’ access to care, and the percentage of individuals under age 65 with high out-of-pocket medical costs relative to their income (Exhibit 2). These measures align with those reported in the Commonwealth Fund’s ongoing series of Health System Performance Scorecards.


After three years of the ACA’s major coverage expansions, the number of uninsured working-age adults and children in the United States had fallen to a record low. This historic decline was accompanied by widespread reductions in cost-related access problems and improvements in access to routine care for at-risk adults, particularly in states that expanded Medicaid. If the 19 states that have not yet expanded Medicaid decided to expand, they could see similar positive effects for their residents.

There is no deadline for adopting the Medicaid expansion. In November, Maine residents voted to expand Medicaid under a citizen-initiated ballot referendum, indicating that popular support for expanding the program may exist in states where elected officials have rejected it. While implementation in Maine could face hurdles because of opposition from the state’s governor, similar efforts are now under way in other nonexpansion states.

Actions at the federal level could, however, jeopardize the gains made under the ACA. Recent actions by the Trump administration, including a shortened open enrollment period for marketplace coverage and deep cuts in advertising and outreach, could reduce enrollment for 2018.10 In addition, Congress has yet to extend funding for the Children’s Health Insurance Program, which expired at the end of September. In the absence of an extension, more than half of states are projected to run out of federal CHIP dollars by March 2018.11 The result could be a loss of coverage for millions of children.12

Further, the tax bill passed by Senate Republicans included a repeal of the ACA’s individual mandate penalties, which would mean a cancellation of the penalties owed by people who do not take up insurance. The Congressional Budget Office estimated that repealing the penalties would reduce the number of Americans with health insurance by 13 million by 2027 and significantly increase premiums for plans purchased in the individual market. This is because healthy individuals would be the most likely to forgo coverage, leaving sicker people (who are more expensive to insure) in the risk pool.13

People who buy their own coverage on the individual market and who have incomes above 400 percent of the federal poverty level (about $48,200 for an individual and $98,400 for a family of four) — the threshold for ACA premium subsidies — would face the brunt of the premium increase.14 A recent Commonwealth Fund analysis estimates that a 40-year-old buying unsubsidized individual market coverage in one of the 39 states that uses the federally facilitated marketplace would face an average dollar increase in premiums ranging from $556 in North Dakota to $1,264 in Nebraska (Exhibit 10).15

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