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How Would State-Based Individual Mandates Affect Health Insurance Coverage and Premium Costs?

July 20, 2018

Issue: The Tax Cuts and Jobs Act of 2017 eliminated the financial penalty of the Affordable Care Act's individual mandate. States could reinstate a similar penalty to encourage health insurance enrollment, ensuring broad sharing of health care costs across healthy and sick populations to stabilize the marketplaces.Goal: To provide state-by-state estimates of the impact on insurance coverage, premiums, and mandate penalty revenues if the state were to adopt an individual mandate.Methods: Urban Institute's Health Insurance Policy Simulation Model (HIPSM) is used to estimate the coverage and cost impacts of state-specific individual mandates. We assume each state adopts an individual mandate similar to the ACA's.Findings and Conclusion: If all states implemented individual mandates, the number of uninsured would be lower by 3.9 million in 2019 and 7.5 million in 2022. On average, marketplace premiums would be 11.8 percent lower in 2019. State mandate penalty revenues would amount to $7.4 billion and demand for uncompensated care would be $11.4 billion lower. The impact on coverage and on premiums varies in significant ways across states. For example, in 2019, the number of people uninsured would be 19 percent lower in Colorado and 10 percent lower in California if they implemented their own mandates. With mandates in place, average premiums would be 4 percent lower in Alaska and 15 percent lower in Washington.

Who’s Gained Affordable Care Act Coverage with Financial Help? Estimated Characteristics of Adults Ages 50 to 64 Gaining Health Insurance Coverage with the ACA Premium Tax Credit

January 26, 2017

The ACA Premium Tax Credit provides federal financial assistance to help make health insurance coverage affordable for people up to 400 percent of the federal poverty level (FPL). As of the end of 2015, the Premium Tax Credit provided assistance to an estimated 1.4 million adults ages 50 to 64 who were previously uninsured and not yet eligible for Medicare. This fact sheet takes a closer look at the characteristics of this population who were able to gain health insurance coverage with the assistance of the Premium Tax Credit. The majority of these older adults reported being employed and in good health. The impact on these individuals should be taken into account as any future policy changes are considered.

Transitioning From Medicaid Expansion Programs to Medicare: Making Sure Low-Income Medicare Beneficiaries Get Financial Help

January 16, 2015

The Affordable Care Act allows states to offer Medicaid coverage to low-income adults who would not have qualified under previous law. This population will face higher cost-sharing requirements when they transition to Medicare, although some may be eligible for traditional Medicaid benefits and/or Medicare Savings Programs (MSPs) that will reduce their costs. This report discusses how Medicare beneficiaries can qualify for traditional Medicaid and MSPs. It also provides new state data on the number and characteristics of eligible individuals and discusses the potential impact of expanding traditional Medicaid income and asset rules in the Medicaid expansion states. Finally, the report outlines policy options that would make it easier for Medicare beneficiaries to qualify for traditional Medicaid benefits and MSPs.

State and Local Coverage Changes under Full Implementation of the Affordable Care Act

July 24, 2013

The Affordable Care Act (ACA) of 2010 includes a number of new policies intended to substantially reduce the number of people without health insurance. Key provisions to be implemented in 2014 include new health insurance exchanges, subsidies for coverage in those exchanges, health insurance market reforms, and an individual mandate. The ACA also includes an expansion of Medicaid coverage to individuals with incomes up to 138 percent of the Federal Poverty Level ($15,856 for an individual or $26,951 for family of three in 2013). The Medicaid expansion under the ACA became a state option following the Supreme Court ruling in June of 2012. At this point, it is not clear how many states will elect to expand Medicaid coverage. If all states were to do so, enrollment in Medicaid is projected to increase nationwide by about 18.1 million and the uninsured would decline by 23.1 million. This brief provides highlights from new state and sub-state estimates of how the number and composition of individuals enrolled in Medicaid/CHIP would change with full implementation of the ACA, including the Medicaid expansion (see These estimates provide more detail on the projected coverage changes under the ACA at the state level than in prior research. They also provide new information on the expected coverage changes resulting from the ACA at the local level in all states. This analysis demonstrates that there is substantial variation across and within states in the magnitude and composition of the population that is projected to gain Medicaid coverage under the ACA. These estimates also provide guidance on the areas that are likely to experience the largest declines in the uninsured and where the residual uninsured are likely to be concentrated.

The Individual Mandate in Perspective

March 27, 2012

Estimates the number and percentage of Americans who are exempt from the healthcare reform law's requirement to have insurance coverage; those who are subject to it but already have coverage; and those who are required to purchase coverage or pay a fine.

State Progress Toward Health Reform Implementation

January 22, 2012

Provides updated state-level estimates of the effects of the 2010 healthcare reform act on coverage and costs, including correlations between a state's progress in establishing insurance exchanges and expected benefits in coverage and federal subsidies.

Eliminating the Individual Mandate: Effects on Premiums, Coverage, and Uncompensated Care

January 11, 2012

Outlines how removing the requirement to buy health insurance could affect coverage; government, employer, individual, and uncompensated spending; premiums; subsidies in the exchange; and Medicaid and Children's Health Insurance Program enrollment.

Consider Savings as Well as Costs

July 11, 2011

Estimates 2014-19 state and federal spending and savings on Medicaid and Children's Health Insurance Programs as a result of the 2010 healthcare reform, including reductions in spending on uncompensated care. Considers factors in differences by state.

The Effects of Health Reform on Small Businesses and Their Workers

June 21, 2011

Synthesizes research findings about how the 2010 healthcare reform will affect small business owners and employees, including savings in healthcare costs and premium contributions, coverage for workers and dependents, offer rates, and number of uninsured.

House Republican Budget Plan: State-by-State Impact of Changes in Medicaid Financing

May 10, 2011

Estimates how the April 2011 Budget Plan passed by the House of Representatives would affect federal Medicaid funding for states between 2012 and 2021 and how in turn this would affect Medicaid spending and enrollment and hospitals under three scenarios.

Who Will Be Uninsured After Health Insurance Reform?

March 10, 2011

Projects state-by-state compositions of the uninsured after reforms take effect including those eligible for Medicaid or exchanges but not enrolled, those exempt from the individual mandate due to a lack of affordable options, and undocumented immigrants.

Health Reform Across the States: Increased Insurance Coverage and Federal Spending on the Exchanges and Medicaid

March 1, 2011

Estimates state-by-state effects of healthcare reform, including variations by state in the impact on uninsurance rates, exchange subsidies, Medicaid enrollees, and federal spending. Analyzes state characteristics contributing to the variations.