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Over the last several decades, state-level research has been one of the most fertile areas for evaluating and measuring the impact of coverage expansion initiatives. Research on states' innovation with Medicaid and the Children's Health Insurance Program (CHIP), as well as with insurance market reforms, has been critical in our understanding of the impact of policy changes to our complex public and private health care system. With the passage of the Affordable Care Act (ACA), it might appear that efforts to expand health insurance at the state level have lost their relevance for the policy community. However, this overlooks two key facts: first, lessons from state coverage expansions have formed the basis for many significant provisions of ACA. Second, and more importantly, state-level research will be a critical component of evaluating the impact of reform going forward. This special issue of Health Services Research presents eight articles from studies funded by the State Health Access Reform Evaluation (SHARE) initiative, a national program of the Robert Wood Johnson Foundation (RWJF), to support research on state-level policy efforts to expand health insurance coverage. The research described in this volume explores and studies the effect of a wide variety of coverage expansion initiatives in 29 states. SHARE is administered by the State Health Access Data Assistance Center (SHADAC) at the University of Minnesota's School of Public Health under the direction of Professor Lynn Blewett and the program's deputy director, Elizabeth Lukanen. SHADAC is funded by RWJF to refine the data and methods needed to carry out rigorous state-level research and to strengthen the capacity of states themselves to conduct research. Along with AcademyHealth's State Coverage Initiatives, Community Catalyst's Consumer Voices for Coverage, the National Academy for State Health Policy's Maximizing Enrollment for Kids, and the Center for Health Care Strategies' Medicaid Leadership Institute, SHARE is one of several national programs in RWJF's portfolio of work to support state policy efforts around insurance coverage. In this new, post-ACA health policy environment, states are a vital driver of health implementation and will continue to be critically important to the success of reform. As researchers, funders, and policy makers begin to craft a research agenda to evaluate the impact of the ACA, special attention should be paid to the importance of state-level research for two key reasons. First, the evidence from research on state experimentation with coverage and delivery system reforms paved the way for the passage of the ACA. Massachusetts' health reforms were frequently—and continue to be—cited as the blueprint for the plan that lawmakers crafted under our federal health reform law. The Massachusetts experience was helpful because it demonstrated that reforms can be successful, provided guidance on how to achieve these successes elsewhere, and helped foment and sustain political momentum throughout the legislative process. Second, the need for state-level policy research will grow as we move forward. States are going to be the center of implementation for some of the biggest and most important elements of ACA. Researchers will be in a unique position to provide feedback about how the expanded Medicaid program, health insurance exchanges, and state regulatory reforms are unfolding and impacting the care provided in our system. This work will also reveal the outcomes of state innovation and experimentation and take advantage of state-level variation to draw stronger conclusions about how these policy changes can work in different settings. With this in mind, we have recently supported a series of eight new projects under SHARE (http://www.statereformevaluation.org). Each was designed to be short term and provide insight into and information about various elements of ACA implementation by states. The projects aim to provide information for researchers and policy makers about increasing health insurance coverage through various means including public program eligibility expansions, enrollment system modifications, and premium assistance for individuals and small employers. The studies also speak to the use of new and existing data to measure the impact of reform strategies. In order to ensure that this work gets done, researchers, policy makers, and funders must consider several key questions: (1) How can we identify and prioritize the most important research questions? (2) What data do we need to answer these questions? (3) Can we get the data we need from existing sources, or do we need to think about new data sources? And (4) How can researchers do a better job getting the data into the hands of the decision makers who need them? It is true that health policy researchers at all levels face major challenges. However, these challenges are perhaps most acute in the realm of state-level research. Data limitations are a particular problem, and the disconnect between the policy community and the research community is problematic as well, because the two groups often lack the organizations and intermediaries to bridge the divide. RWJF was pleased to support the research and its dissemination in this special issue of Health Services Research. We hope you find the papers in this special issue insightful and thought provoking. We would be grateful for your feedback, as well as how we can better support projects like these in the future. |
