There are large differences in US health insurance coverage by racial and ethnic groups, yet there have been no estimates to date on how implementation of the Affordable Care Act will affect the distribution of coverage by race and ethnicity. We used a microsimulation model to show that racial and ethnic differentials in coverage could be greatly reduced, potentially cutting the eight-percentage-point black-white differential in uninsurance rates by more than half and the nineteen-percentage-point Hispanic-white differential by just under one-quarter. However, blacks and Hispanics are still projected to remain more likely to be uninsured than whites. Achieving low uninsurance under the Affordable Care Act will depend on effective state policies to attain high enrollment in Medicaid and the Children's Health Insurance Program and the new insurance exchanges. Coverage gains among Hispanics will probably depend on adoption of strategies that address language and related barriers to enrollment and retention in California and Texas, where almost half of Hispanics live. If uninsurance is reduced to the extent projected in this analysis, sizable reductions in long-standing racial and ethnic differentials in access to health care and health status are likely to follow.

When the Affordable Care Act of 2010 is fully implemented, it will extend health insurance coverage to many adult Americans who currently lack it. It is not known, however, how the health reform legislation will affect children and parents who would otherwise be uninsured. Based on our analysis, the Affordable Care Act has the potential to cut the number of uninsured children by about 40 percent, from 7.4 million to 4.2 million, and the number of uninsured parents by almost 50 percent, from 12.7 million to 6.6 million. However, the actual impact will depend on increasing the share of children and parents who are enrolled in public coverage and on other implementation outcomes. Most strikingly, if the requirement that states continue their Medicaid and Children's Health Insurance Program (CHIP) coverage is rescinded and if Congress does not continue funding CHIP, the uninsurance rate of children could more than double, increasing from 4.2 million to 7.9-9.1 million children. In that case, the uninsurance rate among children would be higher than if the Affordable Care Act had not been adopted.

Children's participation in Medicaid and the Children's Health Insurance Program (CHIP) rose by 5 percentage points between 2013 and 2016. As a result, 1.7 million fewer Medicaid/CHIP-eligible children were uninsured in 2016. Participation was lower among adults than among children, and nearly 6 million Medicaid-eligible adults were uninsured in 2016.

ISSUE:The Tax Cuts and Jobs Act of 2017 eliminated the financial penalty of the Affordable Care Act's individual mandate. States could reinstate a similar penalty to encourage health insurance enrollment, ensuring broad sharing of health care costs across healthy and sick populations to stabilize the marketplaces. GOAL:To provide state-by-state estimates of the impact on insurance coverage, premiums, and mandate penalty revenues if the state were to adopt an individual mandate.

Millions of US children could lose access to public health care coverage if Congress does not renew federal funding for the Children's Health Insurance Program (CHIP), which is set to expire September 30, 2015—the end of the federal fiscal year. Additional cuts in public coverage for children in families with incomes above 133 percent of the federal poverty level are possible if the Affordable Care Act's "maintenance of effort" provisions regarding Medicaid and CHIP are allowed to expire as scheduled in 2019. The potential for a significant rollback of public coverage for children raises important policy questions regarding alternative pathways to affordable and high-quality coverage for low-income children. For many children at risk of losing eligibility for public coverage, the primary alternative pathway to coverage would be through their parents' employer-sponsored insurance, yet relatively little is known about the cost and quality of that coverage. Our estimates, based on data from the Insurance Component of the 2012 and 2013 Medical Expenditure Panel Surveys, show that many families would face sharply higher costs of covering their children. In many cases, the only employer-sponsored coverage available would be a high-deductible plan.