A Typology for Analyzing Coverage Gains by State: 2013-2017

A medical assistant checks a patient's blood pressure.

Framework highlights states’ different circumstances both before the ACA and four years after implementation.



The Issue

Previous data released in 2018 provided analysis on changes in coverage from the year immediately preceding the Affordable Care Act’s (ACA) main coverage reforms. Following earlier research, this brief summarizes the state variation in coverage changes using a typology that groups states according to their pre-ACA uninsurance levels and their subsequent policy decisions around Medicaid expansion and efforts to encourage marketplace enrollment.

Key Findings

Researchers examined the insurance landscape before and after implementation of the ACA and created a framework that grouped states into five categories, based on similar attributes: high or low uninsured rate prior to the ACA, whether the state expanded Medicaid or not, and marketplace enrollment by subsidy-eligible individuals. Changes in the employer-sponsored insurance market, average incomes, and other factors were also considered. Among the groupings:

  • In Delaware, the uninsured rate declined by 5.4 percent since 2013.

  • In California, the uninsured rate declined by 11.6 percent since 2013.

  • In Connecticut, the uninsured rate declined by 4.5 percent since 2013.

  • In Florida, the uninsured rate declined by 8.8 percent since 2013.

  • In Alabama, the uninsured rate declined by 5.1 percent since 2013.


The state typology developed here highlights states’ different circumstances both before the ACA and four years after implementation. States that already had high coverage levels before the ACA and expanded Medicaid made additional progress, but their percentage-point advances tended to be smaller than other states’ because they began the reform process in a better position. Many remaining states that did not expand Medicaid and did not have robust subsidized marketplace enrollment experienced much smaller reductions in their uninsurance rates.

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