AT A GLANCE
  • Most nonelderly adults have heard little about the ACA’s coverage provisions, with knowledge levels particularly low among those with the most to gain—low-income and uninsured adults.
  • Consistent with their limited knowledge of the coverage provisions, very few nonelderly adults know whether their state planned to expand Medicaid eligibility under the ACA.
  • Knowledge of the financial penalty for failing to comply with the ACA’s individual mandate is also low.

Most Adults Are Not Aware of Health Reform's Coverage Provisions

 

Sharon K. Long and Dana Goin

February 6, 2014

 

The Affordable Care Act (ACA) includes many changes to the health care system—some implemented as early as 2010 (e.g., allowing children to stay on a parent’s health insurance plan until age 26), others to be implemented much later (e.g., the tax on high-cost insurance plans that will take effect in 2018).1 Of particular relevance to the coverage provisions of the law (see table 1) are the rollout of the Marketplaces, which began in October 2013 with coverage starting in January 2014; the Medicaid expansion taking effect in January 2014 in those states that choose to expand eligibility;2 and the mandate on individuals to buy insurance beginning in 2014, with penalties for 2014 noncompliance to be assessed in 2015.

 

This brief focuses on knowledge of the ACA coverage provisions among nonelderly adults overall and among those most likely to be affected by the different provisions of the law. This includes lower- and higher-income adults, uninsured adults, and adults in states pursuing different ACA policies related to the Medicaid expansion and the Marketplaces.

 

What We Did

 

This brief draws on data collected in September 2013 from a sample of nonelderly adults (age 18–64) through the Health Reform Monitoring Survey (HRMS), just before the October rollout of the ACA Marketplaces. This survey asked respondents how much, if anything, they had heard about the key coverage provisions of the ACA listed in table 1.3 Respondents were also asked about their knowledge of their state’s decision on whether or not to implement the Medicaid expansion to low-income adults and about the financial penalty for noncompliance with the individual mandate.

 

Table 1. Implementation Timeline for Key Coverage Provisions of the Affordable Care Act

Provision

Implementation date

Availability of health insurance Marketplaces

2014

Medicaid expansion to low-income adults2

2014

Individual mandate

2014 (noncompliance penalties assessed in 2015) 

Elimination of pre-existing condition exclusions

2010 for children

2014 for adults

Elimination of higher insurance premiums for women

2014

Requirement that insurance companies spend at least 80% of their insurance premiums on health care services or refund customers

2011 (with rebate in 2012)

Availability of Marketplace subsidies for some lower-income adults

2014

Availability of dependent coverage for children to age 26

2010

Elimination of dollar limits on coverage of essential health benefits

2010 for lifetime limits

2014 for annual limits

Availability of preventive care without
co-payments or coinsurance

2010

Source:  Kaiser Family Foundation, “Health Reform Implementation Timeline,” accessed December 29, 2013, http://kff.org/interactive/implementation-timeline/.

 

What We Found

 

Most adults had heard little about the coverage provisions of the law, with knowledge levels particularly low among those with the most to gain—uninsured and low-income adults. While the American public is broadly aware of the ACA, with 82 percent of nonelderly adults reporting an opinion of it (34 percent favorable and 48 percent unfavorable) in December 2013,4 most know little about its specific coverage provisions. Only about a quarter to a third of nonelderly adults in the HRMS said they had heard “some” or “a lot” about most of its coverage provisions (figure 1). Even for the best-known provisions—the individual mandate, elimination of pre-existing condition exclusions, and the availability of dependent coverage—only about half reported having heard “some” or “a lot” about them. Further, many reported having heard “nothing at all” about many of the provisions, including the Medicaid expansion (44.6 percent), elimination of dollar limits on coverage for essential benefits (45.1 percent), availability of preventive care without copayments or co-insurance (45.7 percent),


 

 

Awareness of the ACA coverage provisions is particularly low among the low-income and uninsured groups (table 2). Less than one-third of low-income and uninsured nonelderly adults reported having heard “some” or “a lot” about the Marketplaces, Medicaid expansion, and Marketplace subsidies for some adults. Considerably higher proportions (from over one-third to over half) reported having heard “nothing at all” about the Marketplaces, Medicaid expansion, or Marketplace subsidies.

 

Table 2. Awareness of ACA  Coverage Provisions  among Adults Age 18–64, by Family Income (percent)

 

Family Income Relative to the Federal Poverty Level

Current Health Insurance Coverage

Above 138%^

At or below 138%

Insured^

Uninsured

Have heard "some" or "a lot" about different provisions of the ACA:

 

 

 

 

 

 

Availability of health insurance Marketplaces

37.3

30.4

***

36.6

29.5

***

Medicaid expansion to low-income adults

26.9

23.4

**

27.0

21.0

***

Individual mandate

54.7

38.3

***

52.3

39.8

***

Elimination of pre-existing condition exclusions

61.4

39.4

***

58.5

39.7

***

Elimination of higher insurance premiums for women

32.6

26.6

***

32.5

23.5

***

Requirement that insurance companies spend at least 80% of premiums on services or refund customers

27.7

19.9

***

27.3

17.1

***

Availability of subsidies for some lower-income adults

38.9

25.4

***

37.8

22.9

***

Availability of dependent coverage for children up age 26

62.2

36.4

***

59.5

33.7

***

Elimination of dollar limits on coverage for essential health benefits

34.9

21.2

***

33.5

19.5

***

Availability of preventive care without co-payments/coinsurance

32.7

21.9

***

31.9

18.9

***

 

Have heard "nothing at all" about different provisions of the ACA:

 

Availability of health insurance Marketplaces

27.8

36.8

***

29.1

36.3

***

Medicaid expansion to low-income adults

43.0

48.6

***

43.3

50.5

***

Individual mandate

16.5

32.4

***

19.3

28.6

***

Elimination of pre-existing condition exclusions

19.2

38.2

***

21.4

39.1

***

Elimination of higher insurance premiums for women

47.6

56.3

***

48.3

58.5

***

Requirement that insurance companies spend at least 80% of premiums on services or refund customers

50.4

60.5

***

51.3

62.5

***

Availability of subsidies for some lower-income adults

33.4

50.5

***

35.6

50.2

***

Availability of dependent coverage for children up age 26

20.3

42.4

***

22.7

44.1

***

Elimination of dollar limits on coverage for essential health benefits

40.9

56.2

***

42.3

58.5

***

Availability of preventive care without
co-payments/coinsurance

42.2

54.9

***

43.5

56.3

***

 

 

Sample size

6,220

1,691

 

6,780

1,131

 

Source: Health Reform Monitoring Survey, quarter 3 2013.
**/*** Estimate differs significantly from the reference group, marked by ^, at the 0.05/0.01 levels, using two tailed tests. No estimates differ significantly at the 0.10 (*) level.

 

Nonelderly adults in states with federal-based Marketplaces were more likely to report familiarity with the availability of the Marketplaces and Medicaid expansion than nonelderly adults in states that managed their own Marketplaces (figure 2). This is unexpected given the increased spending that states with state-based Marketplaces have committed to education and outreach efforts for coverage expansion; however, because the bulk of those efforts occurred in late summer and early fall of 2013, it may be that any gains in awareness associated with that spending would not have been observed by September, when these HRMS data were collected. Awareness of other ACA provisions was not statistically different in states with their own Marketplaces compared with states with federal-based Marketplaces.

 

 

Consistent with their limited knowledge of the ACA coverage provisions, very few nonelderly adults reported knowing about the Medicaid expansion in their state. Only 11.8 percent (data not shown) could accurately report on the decision their state had made regarding Medicaid expansion, with little difference between adults in states implementing (11.3 percent) versus not implementing (12.9 percent) the expansion (figure 3). Awareness of their state’s Medicaid decision was particularly low (about 7 percent) for nonelderly adults with family incomes at or below 138 percent of the federal poverty level (the target population for the Medicaid expansion under the ACA), current Medicaid enrollees, and uninsured nonelderly adults (data not shown). In all cases, more than three-quarters of nonelderly adults reported being unsure of the decision their state had made (data not shown).

 

Knowledge of the financial penalty for failing to comply with the individual mandated was also low. With less than half of nonelderly adults reporting they had heard “some” or “a lot” about the individual mandate, it is not surprising that the share aware of the penalty amount for failing to comply with the individual mandate was low, at 50.1 percent (figure 4). This uncertainty was highest among the uninsured and those with public coverage (almost 58 percent), as compared with adults with private coverage (46.3 percent).

 

 

 

What It Means

 

Despite high levels of media coverage, many Americans had heard little about key coverage provisions of the ACA by September 2013. Of most concern, many of the uninsured reported having heard little about either the health insurance Marketplaces or the Medicaid expansion, and most were unsure whether or not their state was opting for the expansion. The low level of awareness of many of the provisions specifically designed to improve access to health insurance and its new benefits doubtless contributes to the stronger negative rather than positive perceptions of the law among the American public at the end of 2013.5

 

But the challenge of communicating details of the ACA provisions in a crowded media market with so many competing messages is enormous. Outreach efforts need to be tailored to two audiences. The first audience consists of low-income and uninsured populations, who need to learn specifics about the Medicaid expansion, the Marketplace insurance plans and potential subsidies, and the individual mandate. The second audience consists of American consumers more generally, emphasizing the full range of ACA provisions that provide broad benefits to all. Such education efforts could help to expand overall awareness for the positive changes introduced under the ACA—particularly expanded coverage for young adults and persons with pre-existing conditions, improved access to preventive care, and increased financial protection from health care costs.

 

Reference

 

Hill, Ian, Margaret Wilkinson, and Brigette Courtot. Forthcoming. “The Launch of the Affordable Care Act in Eight States: Outreach, Education, and Enrollment Assistance.” Urban Institute; Washington DC.

 

About the Series

 

This brief is part of a series drawing on the Health Reform Monitoring Survey (HRMS), a quarterly survey of the nonelderly population that is exploring the value of cutting-edge Internet-based survey methods to monitor the Affordable Care Act (ACA) before data from federal government surveys are available. The briefs provide information on health insurance coverage, access to and use of health care, health care affordability, and self-reported health status, as well as timely data on important implementation issues under the ACA. Funding for the core HRMS is provided by the Robert Wood Johnson Foundation, the Ford Foundation, and the Urban Institute.

 

For more information on the HRMS and for other briefs in this series, visit www.urban.org/hrms.

 

About the Authors

 

Sharon K. Long is a senior fellow and Dana Goin is a research associate in the Urban Institute’s Health Policy Center

 

Note


1 Kaiser Family Foundation, “Health Reform Implementation Timeline,” Accessed December 29 2013.

 

2 The 2012 Supreme Court ruling determined that states have the option to expand Medicaid under the ACA. Some states chose to expand coverage earlier than 2014.

 

3 The survey asked respondents to choose whether they had heard “a lot”, “some”, “only a little” or “nothing at all” about each of the ACA provisions.

 

4 Kaiser Family Foundation, “Kaiser Health Tracking Poll: December 2013,” accessed January 27, 2014.

 

5 Ibid.

Ford Foundation Urban Institute Robert Wood Johnson Foundation