Overview
For most Americans, employment based health insurance remains the dominant form of health coverage.
According to the United States Census Bureau:
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Both the percentage and number of people with health insurance increased in 2011, to 84.3 percent and 260.2 million, up from 83.7 percent and 256.6 million in 2010.The percentage of people covered by private health insurance in 2011 was not statistically different from 2010, at 63.9 percent.
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The number of people covered by private health insurance in 2011 was not statistically different from 2010, at 197.3 million.
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The percentage and number of people covered by government health insurance increased to 32.2 percent and 99.5 million in 2011 from 31.2 percent and 95.5 million in 2010.
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The percentage and number of people covered by employment-based health insurance in 2011 was not statistically different from 2010, at 55.1 percent and 170.1 million.
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The percentage and number of people covered by Medicaid in 2011 increased to 16.5 percent and 50.8 million, up from 15.8 percent and 48.5 million. The percentage and number of people covered by Medicare increased in 2011 to 15.2 percent and 46.9 million from 14.6 percent and 44.9 million.
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In 2011, 9.4 percent of children under age 18 (7.0 million) were without health insurance, not statistically different from the 2010 estimate. The uninsured rate for children in poverty, 13.8 percent, was higher than the rate for all children, 9.4 percent.
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The rate and number of uninsured for non-Hispanic Whites decreased in 2011 to 11.1 percent and 21.7 million from 11.6 percent and 22.5 million in 2010. The uninsured rate and the number of uninsured for Blacks also decreased in 2011 to 19.5 percent and 7.7 million from 20.8 percent and 8.2 million in 2010.
Between 2009 and 2010, the number of people covered by:
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Private health insurance increased from 194.5 million to 195.9 million (64 percent of Americans)
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Government health insurance climbed from 93.2 million to 95 million (31 percent of Americans)
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Employment-based health insurance declined from 170.8 million to 169.3 million (55.3 percent of Americans)
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Medicaid coverage increased from 47.8 million to 48.6 million (15.9 percent of Americans)
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9.8 percent (7.3 million) of Children under 18 were without health insurance.
In 2010, the uninsured rates decreased as household income increased: from 26.9 percent for those in households with annual incomes less than $25,000 to 8 percent in households with incomes of $75,000 or more.
Generally, all 50 states regulate and initiate policies affecting health insurance. These statutes, the state department's of insurance and other agencies that administer them, play a significant role. With the enactment of the federal Health Reform law (the PPACA), many aspects of state involvement regarding insurance and coverage are changing substantially.
Frequently Requested Reports
State Employee Health Benefits - NCSL reports on premiums, program highlights and trends; updated periodically for 2012-13
"State Health Insurance Mandates and the Federal PPACA Essential Benefit Provisions" - updated 2013
States and Managed Care - overview and resources
States and Small and Large Business Health Insurance - overview and resources, February 2013
Individual Health Insurance - overview and resources, 2013
Federal Health Insurance Reforms: State Implementation, 2010-2013
The Affordable Care Act (ACA) includes an extensive range of provisions changing how private market health insurance works and how it is regulated. The provisions are of particular importance to state legislatures for two reasons: 1) many have taken effect during 2010-2013, or have looming effective dates in 2013 and 2014 and 2) many establish uniform federal standards in areas previously regulated only by state laws and state regulations. Key provisions affecting states:
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2011-13 Enacted Health Insurance Reform Laws - signed laws in 44 states.
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2011-12 State Health Insurance Mandate Laws.
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Health Reform 2011-2013 State Legislative Tracking Database - latest listings, with summaries and status for measures filed so far this year. Updated twice a month.
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Establish a Federal High Risk Pool Program until 2014 —Provides immediate access to insurance for residents who are uninsured because of a pre‐existing condition, through temporary federally-funded high‐risk pools, run by states or by HHS. Program launched July, 2010. [NCSL brief online, 2012]
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Establish Health Insurance Exchanges which will replace the interim high risk pools in January 2014. [NCSL brief online]
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Eliminate Co-Payments And Deductibles for Preventive Care Under New Private Plans—Requires new private plans to cover preventive services with no co‐payments and with preventive services being exempt from deductibles. Effective September 2010. (As enacted, beginning in 2018, this requirement applies to all plans.)
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Prohibit Plans from Imposing Pre-Existing Condition Exclusions on Children— Prohibits health insurers from denying coverage to children with pre‐existing conditions. Effective September 2010. (As enacted, beginning in 2014, this prohibition would apply to all persons.)
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Provide for premium rate review —A 2012 NCSL report details pre-ACA state initiatives that allow some state insurance departments to deny or renegotiate significant rate increases and provides recent updates of states efforts implementing the federal requirement for rate review when increases over 10 percent are sought by private insurers. Effective September 23, 2010. [NCSL brief online]
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Health Insurance Medical Loss Ratios and Rebates - [NCSL report online, 2012-13]
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Extend Coverage For Young People Up to 26th Year Through Parents’ Insurance – Requires health plans to allow young adults up to their 26th year to remain on their parents’ insurance policy, at the parents’ choice regardless of marital status. The result was an increase of about 3 million Policy initiated effective September 2010. [Issue Brief by HHS, 2012]
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Prohibit Plans from Imposing Lifetime Limits and Annual Limits on Coverage—Prohibits health insurance companies from placing lifetime caps on coverage, and sets $750,000 as a floor for any annual cap.
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Prohibit the Imposition of Restrictions On Coverage—Tightly restricts new plans’ use of annual limits to ensure access to needed care. These restrictions were defined by HHS, starting with $750,000 for 2010-11, with some waivers. Effective September 2010 (As enacted, beginning in 2014, the use of annual limits will be prohibited for all plans.)
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Establish a Temporary Reinsurance Program for Early Retirees—Creates a temporary re‐insurance program (until the Exchanges are available) to help offset the costs of expensive health claims for employers that provide health benefits for retirees age 55‐64. Effective June 21, 2010.
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Establish a New, Independent Appeals Process—Ensures that consumers in new plans have access to an effective internal and external appeals process to appeal decisions by their health insurance plan. Effective September 2010. [NCSL brief online, 2011]
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Ensure Value for Premium Payments (Medical Loss Ratio)—Requires plans in the individual and small group market to spend 80 percent of premium dollars on medical services, and plans in the large group market to spend 85 percent. Insurers that do not meet these thresholds must provide rebates to policyholders. Effective January 1, 2011.
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Prohibit Discrimination Based on Salary—Prohibits new group health plans from establishing any eligibility rules for health care coverage that have the effect of discriminating in favor of higher wage employees. Effective September 2010.
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Assistance to States to Provide Health Insurance Consumer Information—Provides aid to states in establishing offices of health insurance consumer assistance or ombudsman, in order to help individuals with the filing of complaints and appeals. Effective beginning in FY 2010. [NCSL brief online, 2011]
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Require Categories of Residents to Obtain Health Insurance)—Requires or "mandates" individuals, with various exceptions, to be covered by some type of health insurance. Effective January 1, 2014.
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Out-of-state Health Insurance - Allowing Purchases - The ACA provides a limited authorization for out-of-state purchases as of 2016. NCSL reports on three states with laws, out of 18 that have considered such legislation. (updated 2012)
NCSL has tracked and evaluated activities within several project areas in health care, and has collaborated with or relied on a number of outside experts in this field. This web site has more than 100 reports, articles and documents describing health insurance and related activities.
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