The Need for State Health Services and Policy Research

Many provisions of the Affordable Care Act of 2010 (ACA) are being implemented at the state level, and state decisions will play a significant role in the successful implementation of the law. Effective evaluation of the ACA will depend on rigorous health services research conducted at the state level.

The Supreme Court decision of 2012 rejected the requirement that states must expand their Medicaid programs to include individuals with incomes up to 133 percent of the federal poverty level (FPL). This decision made the Medicaid expansion optional for states and guaranteed variability in ACA implementation. To date, 28 states including the District of Columbia are moving ahead with the Medicaid expansions, 21 states are not moving forward, and 2 states are considering the expansion option (The Henry J. Kaiser Family Foundation, Status 2014).

The ACA also included provisions for the development and implementation of Health Insurance Marketplaces across the states. The Marketplace is an online resource for comparing, selecting, and enrolling in competing private health plans. The Marketplace also provides the opportunity, if income eligible, to apply for and receive tax credits to help applicants with purchasing coverage. States have the option of implementing a State-Based Marketplace, partnering with the federal government to implement a Marketplace, or defaulting to a Federally Facilitated Marketplace. As of this writing, 17 states had initiated State-Based Marketplaces, 7 had established State-Federal Partnership Marketplaces, and 27 states had defaulted to the Federally Facilitated Marketplace (The Henry J. Kaiser Family Foundation, State 2014).

To further muddy the waters, in July 2014, the U.S. Court of Appeals for the District of Columbia Circuit ruled that the ACA, as written, “unambiguously” restricts the tax credits provided to help subsidize the purchase of health plans sold through the Marketplace to State-Based Marketplaces (Jacqueline Halbig v. Sylvia Burwell 2014). The Obama administration has appealed this decision, but the implementation of the ACA has certainly not gone as smoothly or as uniformly as initially envisioned.

The rollout of the ACA has been complex and varied across states. Researchers and policy makers are eagerly awaiting data and research to answer many questions about the impact of health reform. What impact did the ACA have on reducing the uninsured? What were the relative roles played by Medicaid expansion and the Marketplaces in expanding coverage? Do federal and state Marketplaces appear to differ in terms of important market characteristics such as premium prices? What are the characteristics of the remaining uninsured?

Data and Methods for State Research

Fortunately, state health services and policy research have improved over time as has the breadth and timeliness of data resources needed to answer these important policy questions. The Census Bureau's American Community Survey (ACS), with its annual sample size of over 3.1 million, has provided new opportunities for monitoring health insurance coverage at the state and substate level. The sample size of the ACS is considerably larger than that of the Current Population Survey (CPS), at 203,000, and the National Health Interview Survey (NHIS), at 108,000 (Planalp, Sonier, and Turner 2014). The large sample of the ACS allows for monitoring the impact of reform for various subpopulations (children, race/ethnicity) and at small levels of geography (regions, county). The Census Bureau even released health insurance coverage estimates at the zip code level using 5 years of pooled ACS data (U.S. Census Bureau 2013).

Several new data resources have also been recently developed to fill the gaps left by lagging federal survey data. These resources provide a first look at the impact of the ACA, focusing mostly at the national level. Some of these new data resources include the Urban Institute's Health Reform Monitoring Survey (HRMS), the Gallup-Healthways Well-Being Index, and the RAND Health Reform Opinion Study (HROS) (Cobb, Avery, and Turner 2014). Each of these surveys provides evidence of the early impact of the ACA, reporting significant declines in uninsured rates across the country, with a greater decline in states that expanded their Medicaid programs. While timely and immediately relevant, these surveys are limited by their sample size, lack of state representativeness and response rates.

We also are encouraged by the early-release programs of several federal surveys led by the National Health Interview Survey (NHIS). In September 2014, NHIS released preliminary data for the first quarter of 2014 (January–March 2014) and in March 2015, preliminary data for the first three quarters (January–September 2014) will be released (Claxton et al. 2014). Also, in September 2014, the Current Population Survey (CPS) released current coverage data (February-April 2014) for the first time. In addition to collecting current coverage, the CPS added new questions to its survey requesting health insurance by month over the course of the year to identify transitions between sources of coverage over time (Turner and Boudreaux 2014).

The methods used to study variation in policy across states have also advanced. Policy change is influenced by many economic and political factors that vary across states. Researchers have gone beyond the traditional cross-sectional analytic framework and are commonly applying methods for addressing potential endogeneity in their analyses of policy outcomes. Researchers now commonly apply state and year fixed effects, use control groups and difference-in-differences modeling, and continue to use instrumental variables, but perhaps in a more targeted way (Besley and Case 2000).

The papers in this Health Services Research theme issue—and papers in previous HSR issues devoted to state-level health services research—highlight some of the best methods and data resources currently available. For example, Sharon Long and her colleagues at the Urban Institute in their paper, “Expanding Coverage to Low-income Childless Adults in Massachusetts: Implications for National Health Reform,” leverage the state-based Massachusetts Health Reform Survey (MHRS) by linking it to data from the federal National Health Interview Survey (NHIS). They then apply a difference-in-difference model to estimate the impacts of the Massachusetts reform on low-income adults by comparing Massachusetts to neighboring states that had not implemented reform. The researchers find improved access to coverage for low-income adults in Massachusetts and foreshadow the significant increase in public program enrollment for states expanding their Medicaid programs.

Brett Fried and his colleagues at the University of Minnesota, State Health Access Data Assistance Center (SHADAC) in their paper, “Implementing Federal Health Reform in the States: Who Is Included and Excluded and What Are Their Characteristics?” also leverage the unique data in two federal surveys, the American Community Survey (ACS) and the Survey of Income Program Participation (SIPP). They use a multiple imputation process to predict the immigration status of respondents in the ACA from information provided in the SIPP. They estimate that 3.5 million nonelderly adults from the ACA Medicaid Expansion and 2 million from the health insurance marketplace will be excluded nationally because of their immigration status and present similar estimates by state.

While the methods and data sources for state research are advancing, researchers continue to struggle with the lengthy lag time in the release of public use files for the large federal surveys. These lags hinder the production of timely research that can have a meaningful policy impact in the form of evidence-based decision making. For example, the full sample of federal survey data, including the ACS and the CPS, will not be available until the fall of 2015. Meanwhile, the ACA is entering its second year of implementation, and policy makers are waiting for information on its impact and for the evidence needed to make informed policy decisions.

Funding and Dissemination

The Robert Wood Johnson Foundation (RWJF) has continued to support state policy research and is now in its fourth round of grant funding through the State Health Access Reform Evaluation (SHARE) program. SHARE supports the evaluation of health policy reform at the state level and works to develop evidence-based resources to inform future health reform efforts at both the state and national levels. SHARE also produces and disseminates informative, accessible findings for state and federal policy makers and agencies, as well as for researchers (State Health Access Reform Evaluation 2013). In the last several years, the SHARE program has contributed numerous resources on the impacts of health reform implementation at both the state and national levels—two that are presented in this issue.

SHARE grantee Lindsey Leininger in her paper, “Using Self-Reported Health Measures to Predict High-Need Cases among Medicaid-Eligible Adults,” uses federal survey data from the National Health Interview Survey (NHIS) linked to the Medical Expenditure Panel Survey (MEPS) to demonstrate the ability of self-reported health measures to prospectively identify individuals with high future health care needs among adults eligible for Medicaid. Lara Shore-Sheppard, in her paper, “Income Dynamics and the Affordable Care Act,” uses several rounds of the SIPP to examine churn and find that income volatility arising from employment and family structure changes is likely to trigger changes in marketplace subsidy eligibility within a year but that how these changes occur depends largely on an individual's income. SHARE continues to fund research and this past fall funded 10 new projects with findings expected next summer (State Health Access Reform Evaluation 2014).

Finally, the Journal of Health Services Research (HSR) has been a critically important partner for the SHARE program with this release of its fourth issue devoted entirely to state health policy research. In this role, the Journal has facilitated the promotion of rigorous quantitative research and evaluation, helping to advance state health policy research as a field of study. We have been pleased to have state-level research take center stage in HSR to this end.