Obamacare's impact: Differences emerge between states

Two weeks after the close of open enrollment on the new Obamacare marketplaces, various surveys and studies released have given different estimates of the Affordable Care Act's impact on the uninsured. One clear finding, however, is the disparity between states that have more openly embraced the controversial health law and those that haven't.

By design, the health care law gave significant flexibility to states: Sixteen states (plus the District of Columbia) chose to build and run their own Obamacare marketplaces, 27 chose to rely on the federally-run HealthCare.gov, and seven partnered with the federal government to run their respective marketplaces. In 2012, two years after the law was passed, the Supreme Court gave states even more flexibility by letting them opt out of the Obamacare policy expanding Medicaid (a joint federal-state program) to everyone below 138 percent of the federal poverty line. So far, 26 states and the District of Columbia have decided to expand the program.

States run by Republicans tended to rely on HealthCare.gov and have been more likely to reject the Medicaid expansion. More data is needed to assess just how the new law is impacting health coverage across the nation. However, two studies released this week illustrate how it may affect the coverage rates in red states versus the coverage rates in blue states.

One survey, funded by the Robert Wood Johnson Foundation, the Ford Foundation, and the Urban Institute, found that the number of uninsured nonelderly adults fell by around 5.4 million from September 2013 (one month before open enrollment on the Obamacare marketplaces began) through early March 2014. The uninsured rate fell particularly among low- and middle-income adults -- people who would either qualify for the expanded version of Medicaid or subsidies on an Obamacare marketplace.

The survey also saw a difference in the uninsured rate between states that expanded Medicaid and those that haven't. In the states that did expand the program, the uninsured rate fell 4 percent since September, compared to just 1.5 percent in the other states. In the states that have not expanded the program, the uninsured rate in March stood at 18.1 percent while the states that did expand Medicaid had an average uninsured rate of 12.4 percent.

The authors of the report noted that other factors besides the expansion of Medicaid could potentially account for the discrepancies. In particular, they note, the figures could have been impacted by whether a state chose to run its own Obamacare marketplace or left that up to the federal government.

In a separate paper released last month, Urban Institute researchers noted the discrepancy between outreach efforts in states running their own marketplaces compared with those that aren't. Since the passage of the Affordable Care Act in 2010, the federal government has awarded $86 million to public relations firms for an outreach campaign -- coming to $5.90 spent per uninsured person eligible for coverage. The Urban Institute compared that with the spending in five states running their own marketplaces and found they spent significantly more on outreach -- about $21 per targeted consumer. On top of that, federal outreach efforts were delayed because of the technical problems that plagued HealthCare.gov when it launched in October.

A second study released this week by Gallup shows similar disparities between states that have embraced Obamacare and those that haven't. The uninsured rate declined an average of 2.5 percentage points in the 21 states (plus the District of Columbia) that have both expanded Medicaid and established their own marketplaces. By comparison, states that did only one or neither saw just a 0.8 percent decline in the uninsured rate.

The survey showed that Texas, which rejected the Medicaid expansion and has relied on HealthCare.gov, had the highest uninsured rate as of March at 27 percent. Massachusetts (at 4.9 percent) and Hawaii (at 7.1 percent) had the lowest.

The debate over embracing Obamacare is not over. In fact, the question of whether to expand Medicaid could be on the November ballot in some states like Montana or Louisiana. Enticing Republican-led states to get on board with the Affordable Care Act is just one of the significant challenges ahead for Sylvia Mathews Burwell, President Obama's nominee to serve as the next Health and Human Services secretary.

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