Measuring State Responsibility for Health Insurance

Camillo, Cheryl; Camillo, Cheryl

The health insurance reform debate in the United States is at a crossroads—presidential candidates, think tanks, and the populace are actively debating proposals for extending health insurance to the remaining 10 percent of the population who are uninsured despite the Affordable Care Act's (ACAs) expansion provisions. Some reform proposals would expand the Medicare program for the aged and disabled to additional groups or to all Americans; others would create a public option to supplement existing public and private health insurance plans.

A key decision point is whether the locus of health insurance should be at the federal or state level. Federal and state policymakers constantly compete for control over health policy and expenditures.

To fully inform this decision, it is necessary to assess the state role in health insurance over time. Are states ready to take on responsibility for the health insurance of their entire population or has their experience been too discrete? Although there has been much analysis of states' health policy decisions, there has been no attempt to quantify the amount of responsibility states have had.

This paper draws from publicly-available sources, including the Current Population Survey, to quantify state responsibility in succeeding years. Specifically, it measures the proportion of the population that states insured directly through Medicaid and other public programs plus the proportion whose private insurance they regulated.

The study finds that, while there is state-to-state variation, responsibility has been growing to the extent that the majority of states now act as health system stewards.

Association for Public Policy Analysis & Management

Panel Paper: Measuring State Responsibility for Health Insurance

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