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Understanding the Impact of Health Reform on the States: Expansion of Coverage through Medicaid and Exchanges




  • Lilliard E. Richardson ( is a Professor at the School of Public and Environmental Affairs, Indiana University-Purdue University Indianapolis and Tansel Yilmazer ( is an Assistant Professor at the Department of Human Sciences, The Ohio State University.


The Affordable Care Act (ACA) expands Medicaid coverage and creates subsidized state health insurance exchanges. The implementation of the ACA will impact the states and consequently the state residents differently. We discuss the factors contributing to the variation in uninsured rates and the Medicaid population, and we predict that these underlying economic, demographic factors and state policies will continue to affect health insurance coverage. Using data from the March 2010 Current Population Survey (CPS), we examine health care coverage at the state level prior to the ACA and forecast the percentage of state residents eligible for expanded Medicaid and the exchanges. Our results suggest the percentage of state population eligible for expanded Medicaid and subsidized exchanges will vary considerably, especially for adults. Further, we show that current state Medicaid eligibility rules, the percentage of employers offering health insurance and poverty rates will continue to shape the variation in projected health insurance coverage across the states. Finally, we discuss the potential impact of the Supreme Court decision that allowed states to opt-out of Medicaid expansion.