How Differences in State Policy and Local Insurance Markets Impact the Effectiveness of the Affordable Care Act's Expansion of Health Insurance Access

The Patient Protection and Affordable Care Act relies upon state governments for the implementation of some aspects of its provisions that are designed to expand access to health insurance. Differences in how parts of the law were implemented by state governments, along with different characteristics of the local private insurance market, allow us to measure the effectiveness of these policies and the importance of the private sector’s behavior. Previous research has confirmed that the law’s Medicaid expansion reduces the uninsured rate among the eligible population. This study expands upon this work through a regression model built on other local characteristics including state policy decisions around the ACA’s implementation and differences in the private insurance market. The model finds that the uninsured rate is lower in states which build their own Marketplace for individuals to shop for insurance, as well as in areas with less expensive insurance on the individual Marketplace. These findings have important implications for future policymaking that relies on decision making at the state level or within the private sector