An issue brief funded by the Robert Wood Johnson Foundation as part of its Quick Strike Series examines whether there is a correlation between the progress that states have made toward establishing the health insurance exchanges called for under the Affordable Care Act (ACA), and the expected benefits for state residents.

The Urban Institute authors conclude that, under the ACA, the percentage of the population that is uninsured will decrease in all 50 states and the District of Columbia. However, the 15 states that have made the least progress toward ACA implementation, have a higher baseline uninsurance rate, on average, and would be likely to see the largest declines (i.e., most improvement) in their uninsurance rates and receive the most benefits.

The authors observe that, compared to states that have either made significant or moderate progress toward creating health insurance exchanges, these 15 states as a group:

• Are expected to have the largest percentage drop in uncompensated care spending.
• Are expected to have significantly greater increases in Medicaid/CHIP enrollment.
• Will gain more in federal subsidy dollars because both a higher share of their populations receive subsidy and their populations receive higher subsidies per capita.
• Will have a similarly modest increase in the number of individuals privately insured.

Without action by these states, their populations will still benefit from health reform through the expansion of Medicaid/CHIP, but will have to rely on the federal government to create exchanges, as called for under the ACA. This creation will be dependent on adequate federal resources and political support.

This brief divides the states into three groups based on their progress toward implementing insurance exchanges and then examines the expected benefits to the populations of those groups as a whole. There is considerable variation within each group on a state-by-state basis.