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In 2015, Indiana expanded eligibility for Medicaid under the Affordable Care Act (ACA) through a unique waiver, Healthy Indiana Plan 2.0, which requires enrollees to make monthly contributions to an account that is similar to a health savings account to receive full benefits. Enrollees who fail to make these contributions receive less generous benefits if their income is below the federal poverty level, and if it is 100-138 percent of poverty, they are locked out of coverage for six months. We estimated the impact of this expansion on coverage rates and compared the effects to results from other states that expanded Medicaid after 2014. We found that Indiana's coverage gains (relative to pre-ACA uninsurance rates) were smaller than gains in neighboring expansion states, but larger than those in other states. These results imply that while one potential reason for Indiana's lower gains relative to neighboring states was its cost-sharing requirements, expansion led to unquestionable coverage gains in the state.

Millions of uninsured Americans rely on hospital emergency departments (EDs) for medical care. Throughout the United States, uninsured patients treated in or admitted to the hospital through the ED receive hospital bills based on what hospitals call "billed charges." These charges are much higher than those paid by insured patients. In 2006 California approved "fair pricing" legislation to protect uninsured patients from having to pay full billed charges. We found that by 2011 most California hospitals had responded to the law by adopting financial assistance policies to make care more affordable for the state's 6.8 million uninsured people. Ninety-seven percent of California hospitals reported that they offered free care to uninsured patients with incomes at or below 100 percent of the federal poverty level. California's approach offers a promising policy option to other states seeking to protect the uninsured from receiving bills based on full billed charges.

The Affordable Care Act will expand Medicaid eligibility in 2014 to adults with incomes of up to 133 percent of the federal poverty level. To maximize this opportunity, policy makers need to ensure that participation, or "take-up," among eligible adults exceeds current rates. Using the Current Population Survey 2005-10, we estimated that the nationwide Medicaid participation rate was 62.6 percent among eligible adults ages 19-64 without private insurance. Take-up varied widely by state, from 43.0 percent in Arkansas and Louisiana to 82.8 percent in Massachusetts, after adjusting for population demographics. Participation was highest among disabled adults, 75.8 percent, and lowest among childless adults, 38.3 percent. Factors linked to higher take-up rates included low cost sharing for beneficiaries; more generous benefits; and greater use of managed care programs for Medicaid populations. Factors associated with lower take-up rates included the existence of asset tests in some states. Massachusetts's health reform was associated with a major increase in Medicaid participation. Our results suggest that when Medicaid is expanded in 2014, take-up may be less than anticipated because new enrollees will be offered a more restrictive set of benefits--known as "benchmark coverage"--compared to those in traditional Medicaid, and the majority of newly eligible adults will be in groups with traditionally low take-up (primarily nondisabled adults). To encourage high participation in the expanded Medicaid program, states will need to offer comprehensive coverage of needed benefits; provide community-based outreach; and consider more dramatic changes to their enrollment processes, such as automatically enrolling people in Medicaid based on their participation in other public programs.

To provide a baseline and assess the potential of changes brought about under the Affordable Care Act, this study estimates the number of US adults who were underinsured or uninsured in 2010. Using indicators of medical cost exposure relative to income, we find that 44 percent (81 million) of adults ages 19-64 were either uninsured or underinsured in 2010-up from 75 million in 2007 and 61 million in 2003. Adults with incomes below 250 percent of the federal poverty level account for sizable majorities of those at risk of becoming uninsured or underinsured. If reforms succeed in increasing the affordability of care for people in this income range, we could expect a 70 percent drop in the number of underinsured people and a steep drop in the number of uninsured people.

So-called neglected tropical diseases are the most common infections of the world's poor. Almost all of the "bottom billion"--the 1.4 billion people who live below the poverty level defined by the World Bank--suffer from one or more neglected diseases including hookworm infection, sleeping sickness, or Chagas disease. These diseases are actually a cause of poverty because of their adverse effects on child growth and development and worker productivity. Vaccines to combat such diseases have come to be known as "antipoverty vaccines." Unfortunately, the recent surge in the development and delivery of vaccines to combat the major childhood killers--such as pneumococcal pneumonia and measles--has bypassed neglected diseases. Nevertheless, some vaccines for these neglected diseases are now entering the clinical pipeline. In this article I describe how some antipoverty vaccine development is proceeding and offer recommendations for stimulating further development such as through pooled funding for innovation, developing-country manufacturers, and public-private partnerships for product development.

David Himmelstein and colleagues recently contended that medical problems contribute to 54.5 percent of personal bankruptcies and threaten the solvency of solidly middle-class Americans. They propose comprehensive national health insurance as a solution. A reexamination of their data suggests that medical bills are a contributing factor in just 17 percent of personal bankruptcies and that those affected tend to have incomes closer to poverty level than to middle class. Moreover, for national health insurance to have an impact, it would have to define “medical” expenses in a much broader way than is now typical of either private or government-funded plans.

We estimated state-specific changes in health insurance coverage rates for children between 1996-1998 and 2001-2002. We found considerable variation in the changing distribution of health insurance coverage for children across states, with significant increases in public program coverage in twenty-nine states and significant decreases in uninsured children in twenty-seven. Children in families with incomes below 200 percent of the federal poverty level were the most likely to enroll in public programs. We provide an overview of state outreach and administrative simplification efforts and raise concerns about the persistent variation in children's health insurance coverage across states.

During the mid-1990s Minnesota, Washington State, Oregon, and Tennessee implemented programs to provide subsidized health insurance for low-income persons who were not previously eligible for Medicaid. We estimate the effects of these programs on the health insurance status of low-income adults in these states. We find that among persons with family incomes below 100 percent of the federal poverty level, subsidized public coverage reduced the number of uninsured persons with very little effect on private coverage rates. Among persons with income between 100 percent and 200 percent of FPL, public coverage reduced the number of uninsured persons and crowded out some private insurance. The partial successes achieved by these programs should be kept in perspective: Even after program implementation, approximately 30 percent of low-income adults in the four states were uninsured.

This study disputes the common notion that many hospitalized patients whose expenses are written off to bad debt are able to pay their bills. By matching 1996 state tax returns to more than 350,000 bad-debt and free-care claims at seven Massachusetts hospitals, we found that most patients involved had incomes below the federal poverty level and thus were presumably eligible for either public programs or hospital-based free care. This suggests that hospitals and public officials need to investigate further why low-income, uninsured patients are not receiving benefits for which they are eligible. Our results also suggest that measurements of indigent care levels in hospitals for purposes of research or regulation should include some portion of bad debt.

Prologue: In recent years, those in Congress who seek to increase health care coverage, particularly for poor women and children, have relied on mandates to expand Medicaid. The latest iteration of such action is the 1990 Omnibus Budget Reconciliation Act (OBRA), which mandates that states phase in Medicaid coverage by 2002 for children age eighteen and under in families earning up to 100 percent of the federal poverty level Such expansion will greatly affect states' budgets, perhaps by as much as $17 billion over the next five years. At a National Governors' Association meeting in February 1991, governors called on Congress to delay implementation of the Medicaid mandates in OBRA 1990 by two years. Deeply concerned about the budgetary effects, the governors seek the delay “to assess the depth of the recession and the opportunity to develop long-term solutions for the restructuring of the Medicaid program,” according to the resolution. In this article, John Holahan and Sheila Zedlewski simulate the effect...