Commonwealth Fund Tool Demonstrates Effects of State Efforts to Expand Coverage and Improve Enrollment

By Sean Miskell

Comparing outcomes across states provides an opportunity to consider how state-specific approaches to administering their health programs provide coverage to their residents and help them stay enrolled. Say Ahhh! readers certainly know that we like our 50-state tables here at CCF. The Commonwealth Fund has updated its interactive tool that allows users to see the gains states could realize by achieving the levels of better-performing states across a variety of metrics.

In addition to highlighting divergent outcomes across states, this useful tool helps us to visualize the number of people that would benefit from state-level improvements in coverage and enrollment. For example, in a post highlighting the updated interactive tool, researchers at the Commonwealth Fund considered how many more adults in states that have not yet expanded Medicaid would gain coverage if their state had insurance levels comparable to those in Kentucky, whose Medicaid expansion and successful state-based marketplace (ahem) helped the state achieve the greatest improvement in coverage for adults from 2013 to 2014. Should this come to pass, this analysis based on Commonwealth’s interactive tool demonstrates that 6.2 million more adults in these states would be insured.

I conducted a similar simulation, this time focused on how many more children would have coverage if states that have not expanded Medicaid had coverage levels comparable to the average in states that have implemented expansion. As my colleagues Joan Alker and Alisa Chester highlighted in their most recent report on children’s health coverage, states that expanded Medicaid in 2014 had an uninsurance rate of 4.6 percent for children while states that had not yet expanded had a higher rate of uninsurance for children at 7.5 percent.

If all non-expansion states had a rate of children’s coverage comparable to states that have expanded, Commonwealth’s interactive tool suggests that at least 1,027,191 more children would have health coverage. (See table below, and note that because Commonwealth’s tool allows adjustments in increments of one percentage point, I rounded up to 5 percent from 4.6 percent.)

Number of Children (ages 0-18) who would gain health coverage if selected states improved children’s coverage to the average level achieved by states that have expanded Medicaid
Percent of Children aged 0-18 insured in 2014 Number of Children Who Would Gain Coverage
Alabama 96 N/A
Florida 90 219,557
Georgia 92 78,438
Idaho 92 14,000
Kansas 94 7,481
Maine 94 2,766
Mississippi 94 7,577
Missouri 93 30,279
Nebraska 95 N/A
North Carolina 94 24,474
Oklahoma 91 40,906
South Carolina 94 11,436
South Dakota 92 6,521
Tennessee 95 N/A
Texas 88 522,659
Utah 91 37,923
Virginia 94 20,308
Wisconsin 95 N/A
Wyoming 93 2,866
Total 1,027,191
Source: The Commonwealth Fund, Scorecard on State Health System Performance, 2015
Notes: Average coverage level rounded to 5 percent from 4.6 percent as reported in Alker and Chester, “Children’s Health Insurance Rates in 2014: ACA Results in Significant Improvements,” Georgetown University Center for Children and Families, October 2015.

Of course, such comparisons are simply a heuristic way to compare insurance levels across states, and cannot tell us how much a particular policy may or may not expand coverage to more people. States have different starting points in terms of insurance rates, as well as various coverage arrangements and ways of administering their health programs.

For example, our recent report with the National Council of La Raza on insurance rates for Hispanic children underscores that a variety of coverage policies including Medicaid and CHIP eligibility levels for children, covering lawful-residing children without a five-year waiting period, and expanding Medicaid to low-income adults all play a role in differences in rates of uninsurance for Hispanic children across states. Diving yet more deeply into state policies, the Kaiser Family Foundation’s 50-state survey of Medicaid and CHIP eligibility and enrollment policies is a useful reminder that along with eligibility levels, enrollment and renewal processes influence the extent to which eligible individuals are enrolled and maintain their coverage.

But in highlighting the number of residents that could gain coverage if their state achieved insurance levels comparable to more high performing states, Commonwealth’s interactive tool nonetheless illustrates that many could benefit from even incremental changes in state eligibility and enrollment policies that have already been adopted by higher-performing states.