After passage of the ACA, and the decision by the Supreme Court, states have faced important implementation decisions that will profoundly affect the effectiveness of health reform in reaching the previously uninsured.   As the Affordable Care Act (ACA) is being implemented, it is becoming clear that the experience for those trying to obtain health insurance coverage is influenced by two major decisions made by the states: whether the state chose to operate their own state-based marketplace, and whether the state chose to expand Medicaid (or not).   See attached brief for full details.

Based on enrollment in October 2013, the 16 states that chose to operate their own state-based Marketplace and expand Medicaid have enrolled about 59% of the total enrolled nationwide, even though only 36% of the uninsured reside in those states.  By comparison, only 24.5% of those enrolled nationally were in states that chose not to expand Medicaid (nearly all of these using the federal Marketplace) even though 46% of the nation’s uninsured reside in these states.

The relatively strong functioning of the state-based web portals, as compared to the difficulties of the federal portal ( likely are leading to most of these trends since 56% of those who have applied for coverage in states operating a state-based Marketplace were able to enroll in a marketplace plan or Medicaid, as compared to only 17% of those in states that did not expand Medicaid and 32% of those states that expanded Medicaid but are operating a federally-facilitated Marketplace. 

The differences in the outcomes are worth monitoring over time, especially as the problems of the federal web portal are fixed.  However, if these disparities persist, then policymakers likely will need to consider the implications of these differences.