Deteriorating Health Insurance Coverage from 2000 to 2010: Coverage Takes the Biggest Hit in the South and Midwest

Quantitative Analysis Report

The Congressional Budget Office projects that full implementation of the Patient Protection and Affordable Care Act (ACA) will lead to substantial increases in health insurance coverage across the United States, as individuals gain subsidized coverage through Medicaid and newly created health insurance exchanges, beginning in 2014. Even with full implementation, however, the effects of the ACA are expected to vary across regions of the country due to pre-reform differences across states: enrollment in the exchanges will depend on state income distributions and current employer-sponsored insurance (ESI) eligibility rates, while new Medicaid enrollment will vary across states due to differences in current Medicaid eligibility thresholds for adults.

This brief compares changes in health insurance coverage from 2000 to 2010 across regions in the United States. By focusing on coverage trends among the nonelderly in the Midwest, Northeast, South and West, this analysis expands on a prior brief that documented declines in coverage nationally among various sub-populations that are targeted by the ACA. These researchers examine trends for children, parents, and adults without dependent children by income within regions, using the "ACA-relevant" income measure—modified-adjusted gross income (MAGI)—to categorize individuals: those below 138 percent of the federal poverty level (FPL) who could become newly eligible for Medicaid, individuals with income between 138 and 400 percent of FPL who could become eligible for subsidies in the newly established health insurance exchanges, and individuals at or above 400 percent of FPL.

In summary, implementation of the ACA would result in the greatest gains of coverage among residents in regions with the lowest coverage rates in 2010—the South and the West of the United States. However, failure to implement the Medicaid expansion and slow progress in implementing exchanges would mean that the benefits of the ACA would not be felt in these regions as intended.

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