Estimates how proposed reforms would affect health insurance coverage rates in each state and what percentage of the newly covered would benefit from provisions for Medicaid, subsidies, mandates, and children. Compares rural and urban areas

Timothy D. McBride

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     Impact of the Patient Protection and Affordable Care Act on Covered Persons   December 9, 2009 Timothy D. McBride, PhD RUPRI Center for Rural Health Policy Analysis and Washington University in St. Louis  The approach to covering the uninsured presented in the Patient Protection and Affordable Coverage Act, when fully implemented, would reduce the number of uninsured to 3.2 million persons in non‐metropolitan areas, leading to a coverage rate of 93% (Table 1). This legislation would lead to a slightly higher coverage rate for rural than for urban persons (93.4% compared to 92.7%), largely because a lower proportion of rural persons are non‐citizens who would not be covered under any of the proposed reform approaches but also because the reform proposal reaches more low‐income persons who are more represented among the rural uninsured.   The remaining tables attached present state‐by‐state estimates of the effects of the legislation on overall health insurance coverage rates (for all persons, rural and urban persons), as well as estimates of how the previously uninsured would get covered under the provisions of the legislation.  The results show significant variation in how the legislation would impact ultimate coverage rates, and how individuals would be covered under the legislation, mostly resulting from the initial characteristics of a state and their uninsured persons.      The subsidies, tax credits, and public program expansions are particularly important to rural persons (Table 1). A higher proportion of rural adults (35.1% as compared to 32%) would obtain coverage through Medicaid (largely because their income falls below 133% of the federal poverty line), while a smaller proportion (24.8% as compared to 26.4%) would be children that obtain coverage either through public programs (Medicaid or CHIP) or through private insurance obtained by their parents (through the exchange).  A slightly lower proportion of the previously uninsured in rural areas (40.1%, compared to 41.5% in urban areas) would obtain insurance through the Health Insurance Exchange.   Contact information:  Timothy D. McBride, PhD, is a professor and associate dean for Public Health in the Brown School and a faculty scholar in the Institute for Public Health at Washington University in St. Louis.  He currently serves as a Faculty Research Associate for the Rural Policy Research Center (RUPRI) Rural Health Policy Analysis Center.  He can be reached by electronic mail at tmcbride@wustl.edu , or by phone at (314)935‐4356.  This report was supported by funded provided by the Robert Wood Johnson Foundation. The views expressed are those of the authors and should not be attributed to the Robert Wood Johnson Foundation or its trustees. Health Panel Keith J. Mueller, PhD, Chairwww.rupri.org/ruralhealth(402) 559‐5260  kmueller@unmc.eduTable 1. Coverage under reform proposals in rural and urban areas   Rural  Urban  Total Number of uninsured persons (in millions):            Before reform 8.1 41.9 50.0         After reform 3.2 18.3 21.5 Insurance coverage rate:     Before reform 83.0% 83.1% 83.1%  After reform 93.4% 92.7% 92.8% Proportion of persons obtaining coverage through:     Health Insurance Exchange (adults) 40.1% 41.5% 41.3%   With subsidies or tax credits 30.0% 29.0% 29.2%   Employer or individual responsibility 10.1% 12.5% 12.1%  Medicaid expansion (adults) 35.1% 32.0% 32.6%  Children 24.8% 26.4% 26.1%  SOURCE: RUPRI Health Reform Simulation Model. (The RUPRI health simulation model, built on Current Population Survey data and a range of other data sources, is based on a series of assumptions about the policies described here, and the responses of individuals to those policy settings, such as the likelihood of taking up coverage (based on a probability model and the characteristics of individuals). Further details about the results and the RUPRI health insurance model are available from the RUPRI Center for Rural Health Policy Analysis (www.unmc.edu/ruprihealth).  STATEBefore ReformAfter Reform Subsidies Mandates ChildrenTOTAL 83% 93% 33% 29% 12% 26%AK 81% 93% 24% 33% 20% 23%AL 85% 94% 42% 30% 13% 15%AR 82% 93% 41% 33% 9% 17%AZ 79% 92% 32% 27% 10% 31%CA 80% 91% 32% 31% 12% 25%CO 82% 93% 28% 28% 15% 29%CT 89% 95% 27% 33% 18% 23%DC 87% 93% 36% 29% 13% 22%DE 87% 94% 25% 31% 13% 32%FL 78% 91% 29% 29% 11% 30%GA 80% 92% 37% 27% 12% 25%HI 91% 96% 27% 31% 20% 22%IA 90% 95% 37% 27% 14% 22%ID 83% 94% 30% 32% 11% 27%IL 85% 93% 37% 27% 10% 25%IN 86% 93% 37% 25% 14% 24%KS 88% 94% 38% 24% 11% 27%KY 84% 94% 42% 27% 9% 21%LA 80% 92% 38% 27% 12% 23%MA 91% 96% 27% 30% 21% 22%MD 86% 93% 28% 31% 15% 26%ME 89% 95% 26% 35% 18% 21%MI 87% 94% 39% 26% 16% 19%MN 90% 95% 28% 27% 14% 31%MO 86% 94% 37% 27% 10% 26%MS 81% 93% 42% 23% 9% 27%MT 83% 93% 34% 30% 10% 25%NC 82% 92% 36% 30% 8% 27%ND 88% 95% 34% 25% 12% 28%NE 88% 95% 32% 27% 12% 28%NH 89% 95% 24% 33% 25% 18%NJ 84% 93% 24% 29% 17% 30%NM 77% 91% 34% 30% 9% 27%NV 80% 92% 26% 27% 12% 34%NY 85% 93% 30% 32% 16% 22%OH 87% 94% 38% 26% 11% 24%OK 82% 93% 36% 29% 12% 23%OR 81% 92% 34% 30% 13% 23%PA 89% 95% 28% 32% 15% 25%RI 87% 94% 27% 31% 18% 23%SC 82% 93% 34% 30% 11% 25%SD 88% 95% 37% 23% 11% 29%TN 84% 93% 39% 29% 10% 22%TX 75% 90% 32% 28% 8% 32%UT 84% 94% 22% 32% 13% 33%VA 85% 94% 28% 29% 17% 25%VT 88% 95% 19% 38% 23% 20%WA 86% 94% 27% 36% 15% 22%WI 89% 95% 37% 20% 17% 26%WV 84% 94% 37% 36% 13% 13%WY 85% 94% 26% 37% 15% 22%SOURCE: Rural Policy Research Institute (RUPRI) Health Reform Simulation Model.The RUPRI health simulation model, built on Current Population Survey data and a range of other data sources, is based on a series of assumptions about the policies described here, and the responses of individuals to those policy settings, such as the likelihood of taking up coverage (based on a probability model and the characteristics of individuals). Further details about the results and the RUPRI health insurance model are available from the RUPRI Center for Rural Health Policy Analysis (www.unmc.edu/ruprihealth).Table 2.  Effects of Health Reform on Uninsurance rate, and options used to cover uninsured, All PersonsInsurance rateHealth Insurance Exchange (adults)Percent newly covered by:Adults: MedicaidSTATEBefore ReformAfter Reform Subsidies Mandates ChildrenTOTAL 83% 93% 35% 30% 10% 25%AK 79% 92% 27% 35% 17% 21%AL 83% 93% 43% 28% 10% 19%AR 79% 93% 44% 30% 9% 17%AZ 80% 92% 37% 31% 5% 27%CA 81% 92% 28% 37% 12% 23%CO 78% 92% 25% 28% 17% 30%CT n.a. n.a. n.a. n.a. n.a. n.a.DE 82% 92% 24% 36% 15% 24%FL 79% 92% 31% 38% 7% 24%GA 78% 92% 39% 26% 9% 25%HI 88% 95% 34% 29% 15% 23%IA 91% 96% 40% 24% 14% 22%ID 82% 94% 30% 31% 12% 27%IL 86% 93% 36% 31% 12% 21%IN 84% 93% 36% 28% 9% 26%KS 88% 95% 37% 23% 14% 26%KY 82% 93% 42% 28% 9% 21%LA 79% 92% 43% 37% 6% 13%MA n.a. n.a. n.a. n.a. n.a. n.a.MD 85% 94% 43% 22% 21% 13%ME 88% 95% 27% 35% 17% 21%MI 89% 95% 44% 32% 5% 18%MN 89% 95% 24% 29% 11% 36%MO 83% 93% 37% 30% 8% 25%MS 79% 93% 43% 24% 5% 28%MT 82% 94% 31% 30% 10% 29%NC 80% 92% 35% 32% 8% 25%ND 86% 94% 37% 25% 7% 31%NE 87% 95% 30% 27% 10% 33%NH 88% 95% 23% 36% 21% 20%NM 74% 91% 30% 32% 9% 28%NV 79% 92% 26% 26% 13% 34%NY 85% 94% 28% 30% 12% 30%OH 88% 95% 36% 31% 10% 22%OK 78% 92% 38% 26% 11% 26%OR 78% 92% 34% 31% 13% 22%PA 87% 95% 26% 33% 13% 29%SC 81% 93% 40% 26% 9% 25%SD 87% 95% 36% 22% 12% 31%TN 81% 92% 46% 32% 6% 17%TX 78% 92% 32% 31% 7% 31%UT 83% 94% 20% 36% 13% 31%VA 83% 94% 32% 28% 13% 27%VT 88% 95% 20% 37% 21% 22%WA n.a. n.a. n.a. n.a. n.a. n.a.WI 89% 95% 33% 23% 18% 25%WV 83% 93% 42% 36% 10% 12%WY 85% 94% 24% 39% 16% 21%SOURCE: Rural Policy Research Institute (RUPRI) Health Reform Simulation Model.NOTE:  n.a.=estimates not available due to sample size in state.Table 3. Effects of Health Reform on Uninsurance rate, and options used to cover uninsured, Rural Personsp y gsources, is based on a series of assumptions about the policies described here, and the responses of individuals to those policy settings, such as the likelihood of taking up coverage (based on a probability model and the characteristics of individuals). Further details about the results and the RUPRI health insurance model are available from the RUPRI Center for Rural Health Policy Analysis (www.unmc.edu/ruprihealth).Percent of newly covered by:Insurance rateAdults: MedicaidHealth Insurance Exchange (adults)STATEBefore ReformAfter Reform Subsidies Mandates ChildrenTOTAL 83% 93% 32% 29% 13% 26%AK 82% 93% 23% 32% 21% 24%AL 86% 94% 42% 30% 14% 13%AR 83% 93% 38% 36% 9% 18%AZ 79% 92% 31% 27% 11% 32%CA 80% 91% 32% 31% 12% 25%CO 83% 93% 29% 28% 15% 28%CT 89% 95% 26% 33% 18% 23%DC 87% 93% 36% 29% 13% 22%DE 88% 95% 26% 29% 12% 34%FL 78% 91% 29% 29% 12% 30%GA 81% 91% 36% 27% 12% 25%HI 92% 97% 24% 32% 23% 22%IA 89% 95% 35% 29% 15% 21%ID 84% 94% 30% 33% 11% 26%IL 85% 93% 37% 27% 10% 26%IN 86% 93% 37% 24% 17% 23%KS 87% 94% 39% 24% 9% 28%KY 86% 94% 43% 27% 9% 20%LA 80% 92% 37% 25% 13% 25%MA 91% 96% 27% 30% 21% 22%MD 86% 93% 28% 32% 14% 26%ME 90% 95% 23% 36% 19% 22%MI 87% 93% 38% 25% 17% 20%MN 90% 95% 31% 26% 16% 28%MO 87% 94% 37% 26% 10% 26%MS 82% 94% 39% 23% 14% 24%MT 84% 93% 41% 31% 12% 16%NC 82% 92% 36% 29% 7% 28%ND 91% 95% 29% 26% 22% 23%NE 88% 95% 34% 28% 13% 25%NH 89% 95% 25% 30% 28% 18%NJ 84% 93% 24% 29% 17% 30%NM 79% 92% 36% 28% 9% 27%NV 80% 92% 27% 27% 12% 34%NY 85% 93% 31% 32% 16% 21%OH 87% 94% 39% 25% 11% 25%OK 85% 94% 35% 31% 14% 21%OR 82% 92% 34% 29% 13% 24%PA 89% 95% 29% 31% 16% 24%RI 87% 94% 27% 31% 18% 23%SC 82% 93% 31% 32% 12% 25%SD 88% 95% 39% 25% 10% 27%TN 85% 93% 37% 28% 12% 24%TX 75% 90% 32% 28% 8% 32%UT 85% 94% 23% 30% 13% 34%VA 86% 94% 27% 30% 18% 24%VT 89% 95% 14% 42% 28% 16%WA 86% 94% 28% 37% 14% 22%WI 89% 95% 38% 19% 16% 26%WV 85% 94% 34% 36% 16% 14%WY 87% 95% 32% 31% 13% 25%SOURCE: Rural Policy Research Institute (RUPRI) Health Reform Simulation Model.The RUPRI health simulation model, built on Current Population Survey data and a range of other data sources, is based on a series of assumptions about the policies described here, and the responses of individuals to those policy settings, such as the likelihood of taking up coverage (based on a probability model and the characteristics of individuals). Further details about the results and the RUPRI health insurance model are available from the RUPRI Center for Rural Health Policy Analysis (www.unmc.edu/ruprihealth).Table 4. Effects of Health Reform on Uninsurance rate, and options used to cover uninsured, Urban PersonsPercent newly covered by:Insurance rateAdults: MedicaidHealth Insurance Exchange (adults)STATE TOTAL Rural Urban TOTAL Rural UrbanTOTAL 829,526      174,029    655,497    119,472     25,198 94,274  AK 11,307        3,518        7,789        1,902          662        1,240      AL 8,636          2,366        6,270        1,090          328        762         AR 8,917          3,352        5,565        1,535          658        877         AZ 11,566        1,516        10,050      2,310          268        2,042      CA 78,763        1,284        77,479      14,735        208        14,527    CO 17,325        2,251        15,074      2,865          466        2,399      CT 17,837        865           16,972      1,661          74          1,587      DC 10,235        -- 10,235      1,114          -- 1,114      DE 12,542        2,492        10,050      1,485          427        1,058      FL 33,615        1,397        32,218      6,960          273        6,687      GA 18,096        2,789        15,307      3,240          564        2,676      HI 14,547        4,082        10,465      1,099          402        697         IA 14,921        6,270        8,651        1,345          527        818         ID 10,005        3,819        6,186        1,484          646        838         IL 25,676        2,782        22,894      3,399          319        3,080      IN 12,634        3,501        9,133        1,482          469        1,013      KS 11,744        4,028        7,716        1,400          455        945         KY 11,399        5,675        5,724        1,547          829        718         LA 7,502          1,235        6,267        1,398          246        1,152      MA 12,334        303           12,031      828             4            824         MD 19,260        777           18,483      2,444          108        2,336      ME 14,152        7,241        6,911        1,282          716        566         MI 19,963        3,070        16,893      2,031          300        1,731      MN 18,603        5,026        13,577      1,621          493        1,128      MO 13,356        2,962        10,394      1,614          459        1,155      MS 7,766          4,468        3,298        1,409          868        541         MT 7,538          4,985        2,553        1,226          869        357         NC 16,226        5,590        10,636      2,648          990        1,658      ND 9,705          5,211        4,494        1,107          745        362         NE 11,795        4,647        7,148        1,416          620        796         NH 16,505        6,306        10,199      1,599          660        939         NJ 18,095        -- 18,095      2,694          -- 2,694      NM 8,791          3,288        5,503        1,949          857        1,092      NV 13,080        1,597        11,483      2,416          336        2,080      NY 35,934        3,078        32,856      4,655          410        4,245      OH 21,971        5,087        16,884      2,315          514        1,801      OK 10,257        3,246        7,011        1,753          703        1,050      OR 11,226        2,675        8,551        1,793          522        1,271      PA 23,992        4,603        19,389      2,267          519        1,748      RI 13,140        -- 13,140      1,325          -- 1,325      SC 10,933        3,735        7,198        1,762          645        1,117      SD 11,989        6,480        5,509        1,384          801        583         TN 10,937        2,779        8,158        1,475          431        1,044      TX 46,857        5,492        41,365      11,805        1,229     10,576    UT 11,241        2,518        8,723        1,668          394        1,274      VA 17,464        2,508        14,956      2,318          405        1,913      VT 10,806        7,658        3,148        1,069          791        278         WA 14,078        1,155        12,923      1,659          130        1,529      WI 15,271        3,636        11,635      1,293          317        976         WV 8,885          3,729        5,156        1,259          578        681         WY 10,109        6,957        3,152        1,337         963      374       Appendix.  Number of persons in sample, RUPRI Health Reform Simulation ModelSOURCE: Rural Policy Research Institute (RUPRI) Health Reform Simulation Model.  The RUPRI health simulation model is built on samples drawn from the March 2006-2009 Current Population Surveys. Further details about the results and the RUPRI health insurance model are available from the RUPRI Center for Rural Health Policy Analysis (www.unmc.edu/ruprihealth). Uninsured persons  All persons 

Impact of the Patient Protection and Affordable Care Act on Covered Persons

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Impact of the Patient Protection and Affordable Care Act on Covered Persons

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