In the U.S., uninsured and low-income adults face significant health and health care inequities as compared to insured and higher-income individuals. An issue brief analyzing the Commonwealth Fund 2010 Biennial Health Insurance Survey finds that when low-income adults have access to health insurance coverage and a medical home, they are less likely to report cost-related access problems, more likely to be up-to-date with preventive screenings, and report greater satisfaction with the quality of their care. Moreover, the gaps in health care between them and higher-income populations are significantly reduced. The Affordable Care Act (ACA) includes numerous provisions that will significantly expand health insurance coverage, especially to low-income patients, as well as provisions to promote medical homes. Along with supporting the full implementation of coverage expansions, it will be important for public and private stakeholders to create opportunities that enhance access to medical homes for vulnerable populations.

The Commonwealth Fund debuted the "National Scorecard on U.S. Health System Performance, 2011" in a press briefing at the Kaiser Family Foundation on October 18, 2011. Cathy Schoen, the Senior Vice President for Research and Evaluation at Commonwealth, summarized the report, which updates a series of comprehensive assessments of U.S. population health and health care quality, access, efficiency, and equity. The report notes substantial improvement on several care quality indicators. However, the U.S. fell short on key measures as well. Across 42 performance indicators, the U.S. achieved a total score of 64 out of a possible 100, when comparing national rates with domestic and international benchmarks. Costs rose sharply, access to care declined, health system efficiency remained low, health disparities persisted, and heath outcomes also fell below target. The Affordable Care Act (ACA) targets many of the important gaps identified by the Commonwealth Scorecard.

Chronically high unemployment rates have left many Americans without job-based health insurance. Affordable insurance programs such as Medicaid and the Children's Health Insurance Program (CHIP) are, at present, only available to pregnant women, children, and parents with very low incomes. Under the Consolidated Omnibus Budget Reconciliation Act (COBRA), which was in place from 2008-2010, individuals who were employed by a firm with 20 or more workers and had health insurance sponsored by that firm could retain their coverage for up to 18 months in the event that they lost their job. The Affordable Care Act (ACA), upon full implementation in 2014, will dramatically increase coverage options for people who lose their jobs. In the report, "Realizing Health Reform's Potential: When Unemployed Means Uninsured: The Toll of Job Loss on Health Coverage, and How the Affordable Care Act Will Help," the Commonwealth Fund encourages policymakers to bridge the gap for Americans until 2014. The Commonwealth Fund recommends that first, policymakers should consider an additional extension of unemployment benefits, as the current extension is set to expire in December 2011. Second, the paper suggests that government consider reestablishing the COBRA premium subsidies to help the millions of Americans who have lost their job-based health insurance until the ACA coverage takes effect in 2014.

By forging connections between federally qualified health centers (FQHCs) and other primary care providers, states may be able to connect Medicaid beneficiaries with services needed to help them manage their health and prevent costly hospital visits. FQHCs provide a comprehensive scope of primary and preventive health care and support services and have access to federal funds. This duality gives them the expertise and resources that might be leveraged to forge symbiotic relationships with states and private practices. The collaboration could benefit FQHCs by strengthening their financial position, advance quality goals, improve staffing mix, and enhance the care continuum and services available to patients. Funded by the Commonwealth Fund and authored by the National Academy for State Health Policy, the report "Developing Federally Qualified Health Centers Into Community Networks to Improve State Primary Care Delivery Systems," identifies states and FQHCs that are collaborating to build community networks to make medical home services available for vulnerable populations. Such collaborations offer important lessons for states to consider as they work to improve their primary care delivery system.