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The Effect of HIFA Waiver Expansions on Uninsurance Rates in Adult


Address correspondence to Adam Atherly, Ph.D., Associate Professor, Department of Health Systems, Management and Policy, Colorado School of Public Health, Mailstop B119, Building 500, 13001 E. 17th Place, Aurora, CO 80045; e-mail:


Research Objective

To evaluate the effect of the Health Insurance Flexibility and Accountability (HIFA) demonstrations on the rate of uninsured. The policy purpose of the HIFA demonstrations is to encourage “new comprehensive state approaches” that will increase the number of insured. HIFA interventions include changes in benefit packages, eligibility rules for public programs, and state subsidization of private health insurance premiums. Some states emphasized private insurance (premium assistance), whereas others placed greater emphasis on expanded eligibility for public insurance.

Data Sources/Study Setting

Data were drawn from the Current Population Survey from 2000 to 2007. The target populations for the HIFA waiver demonstrations consisted of individuals who were eligible for the HIFA waiver demonstrations in demonstration states.

Study Design

The estimation approach was a probit model using a difference-in-differences approach.

Principal Findings

In states that fully implemented their HIFA waiver, HIFA increased the rate of insurance coverage by 6.4 percentage points on average in the targeted adult population, suggesting that approximately 118,848 adults gained health insurance due to HIFA. Total HIFA adult enrollment in the six states studied was 280,739. The effect size varied by state, with Maine having the largest effect and Illinois the smallest. The results were robust to different specifications of the control group.


Our findings suggest that public insurance initiatives that provide states with flexibility regarding eligibility and plan design are a viable policy approach to reducing uninsurance rates.