Overview

During the past decade, states have made major strides in health coverage expansion through both public programs and publicly subsidized private insurance. These expansions were aided by a strong economy with low unemployment, budget surpluses due to increasing tax revenues, and an influx of tobacco settlement funds. Although the current budget shortfalls have placed most states in a "holding" or "cut-back" mode, history has proven that economic downturns are not permanent and that state revenues and opportunities eventually rise again. The path taken in response to short-term fiscal problems can even lay the groundwork for future health care reform to expand coverage.
This paper summarizes lessons from case studies of coverage expansions in 10 states. The states were selected to represent a cross-section of those with innovative strategies and/or a history of successful coverage expansion. We also studied the final reports of the 20 states that received initial State Planning Grants from the Health Resources and Services Administration (HRSA) in 2000 and 2001 to determine what additional innovations lie ahead. The following themes and lessons emerged from this analysis:
• State-specific data are essential for identifying gaps in coverage and access, understanding the factors behind those gaps, developing strategies, and securing support for reform.
• There are opportunities to obtain external funding from public and private sources to support research and policy development.
• Designing a program for expansion (e.g., building on existing programs versus starting new programs) involves trade-offs concerning fragmentation, administrative complexity, financial stability, and state autonomy. The right balance for each state depends on ideological, historical, financial, and political factors.
• A common enrollment process and communication among various coverage programs eases transitions and minimizes having people "fall through the cracks."
• Successful coverage reform requires political leadership and a clearly defined mission.

Citation