Navigating the Marketplace: How Uninsured Adults Have Been Looking for Coverage
Stephen Zuckerman, Michael Karpman, Fredric Blavin, and Adele Shartzer
July 29, 2014
A growing body of evidence shows that the number of uninsured adults declined significantly since the Affordable Care Act’s (ACA’s) open enrollment period started in October 2013 (Long et al. 2014; Blumenthal and Collins 2014; Carman and Eibner 2014).1 This decline was achieved despite many widely publicized early problems with health insurance Marketplace websites. Although the vast majority of people turned to websites for information on the federal or state Marketplaces (Blavin et al. 2014a), many consumers used, and will likely continue to use, other sources for health insurance plan information (Blavin et al. 2014b). With the second open enrollment period on the horizon, new research is beginning to examine the paths people followed to (1) get information on Medicaid eligibility or Marketplace health plans and subsidies and (2) ultimately gain insurance coverage (PerryUndem 2014). These new findings provide guidance for refining outreach and education strategies.
In this brief, we focus on adults who were uninsured for some or all of the 12 months before June 2014. We consider the share who looked for information on health plans in the Marketplaces, comparing the approaches used by those who obtained coverage with those who remained uninsured as of June 2014. Our objective is to identify which approaches to obtaining Marketplace information are more likely to be associated with gaining insurance coverage. We also report on why the remaining uninsured who had looked for Marketplace information said they remained uninsured.
What We Did
This brief draws on data collected from the Health Reform Monitoring Survey (HRMS) in June 2014, well after the completion of the ACA’s first open enrollment period. We define our sample of uninsured adults as nonelderly adults (ages 18–64) who were uninsured for some or all of the 12 months prior to the June 2014 survey. At the time of the survey, 57 percent of these adults remained uninsured and 43 percent had insurance coverage. The insured adults include (1) adults who used the Marketplaces to obtain coverage through Medicaid or a qualified health plan and (2) adults who had been uninsured during the year but obtained coverage outside the Marketplaces (for example, from their employer, Medicaid, or directly from an insurer). Thus, not all the insured necessarily sought information on health plans through the Marketplaces, and many may not be enrolled in a Marketplace plan.
We examine how the insured and uninsured adults in the sample differed in their awareness of the Marketplaces and in their efforts to seek information on health plans. We also identify differences between insured and uninsured adults in the sources used to obtain information on, or assistance enrolling in, health insurance plans through the Marketplaces. For this analysis, we group nine sources of Marketplace information used into the following three categories:
Because some people used multiple sources of information, we also create a measure that captures the source of information used into four mutually exclusive categories: (1) website only; (2) website and other sources; (3) other sources only; and (4) none of the above or not reported.
What We Found
As of June 2014, 56.7 percent of insured adults who had been uninsured for some or all of the previous 12 months had looked for information on Marketplace health plans, compared with only 31.7 percent of those who remained uninsured (figure 1). Just over half (52.1 percent) of those remaining uninsured had not looked for information, and the remainder (16.2 percent) still had not heard about the Marketplaces. In contrast, only 36.0 percent of insured adults who had been uninsured for some or all of the previous 12 months but had gained coverage as of June 2014 had not looked for information, and only 7.3 percent had not heard about the Marketplaces.
Neither those adults who remained uninsured nor those who gained coverage were just window-shopping when they looked for information in the Marketplaces. For both groups, over 85 percent of those who looked for information indicated that they were seeking to purchase health insurance or find out if they were eligible for subsidies or Medicaid (data not shown).
Adults who had been uninsured for some or all of the previous 12 months and had gained coverage as of June 2014 were less likely to use a website as a source of information and more likely to use direct assistance than adults who remained uninsured (table 1). About half of the insured subgroup (51.1 percent) used a website (including an online chat option) compared with 60.3 percent of the uninsured. However, the insured were more likely to use direct assistance than the uninsured (45.9 percent versus 32.1 percent). These differences in the use of direct assistance were the result of greater use of navigators and application assisters by the insured than the uninsured subgroup (11.2 percent versus 6.4 percent) as well as greater use of insurance agents and brokers (12.4 percent versus 5.1 percent).
Using a mutually exclusive classification of information sources, we find that adults who had been uninsured for some or all of the previous 12 months and had gained coverage as of June 2014 were less likely to use websites exclusively and more likely to use only other sources than those who remained uninsured (figure 2). Over one-third (35.5 percent) of adults who gained coverage looked for information without using a website compared with only 22.2 percent of those who remained uninsured. Those who remained uninsured were also significantly more likely to use a website exclusively (40.1 percent) than adults who had gained coverage (29.3 percent). About the same proportions of the two groups were unable to identify their source of information from the choices provided in the survey.
Even after looking for information, 71.8 percent of the adults who remained uninsured cited financial barriers as a reason for not signing up for coverage (figure 3). Other barriers to enrollment were cited much less frequently. Although the websites had well-documented problems, only 1 in 5 cited time and technical barriers as a reason for remaining uninsured. Some (14.6 percent) of the adults who remained uninsured as of June 2014 indicated that they had enrolled and their application was still being processed. Federal policymakers clearly recognize such processing delays as a real problem, because the Centers for Medicare and Medicaid Services has issued a letter to six states, including California, requiring them to come up with a plan to ease their Medicaid enrollment backlogs.2
What It Means
Even among adults who had been uninsured for some or all of the previous 12 months—a group with strong incentives to understand and act on the ACA’s coverage expansion provisions—only about 40 percent had looked for coverage through the Marketplaces as of June 2014. The remainder had either not heard about the Marketplaces, had decided not to seek information, or had simply let the opportunity pass. Compared with adults who were still uninsured at the time of the survey, previously uninsured adults who had gained coverage as of June 2014 were more likely to have sought information from the Marketplaces, even though the coverage they gained may not have been from a Marketplace qualified health plan.
Among those who remain uninsured, some may have had the information they needed on health plan options available through the Marketplaces but do not yet have coverage because they (1) live in a Medicaid nonexpansion state and therefore are ineligible for Medicaid, (2) are not eligible for subsidies because of their immigration status or other reasons, or (3) consider the costs of coverage too high. For many who remain uninsured, however, our findings suggest that more effective motivation to seek information from the Marketplaces may be a necessary first step toward increasing enrollment in a Marketplace plan or Medicaid. Given all the publicity around the ACA, it is somewhat surprising that 1 in 6 adults who were uninsured for some or all or the 12 months before the survey and remain uninsured had not heard about the Marketplaces even at this late date.
Even motivating more uninsured adults to visit the Marketplace is unlikely to be enough, however. Some who remained uninsured and sought information on Marketplace health plans may have been much harder to reach with information they understood during the initial open enrollment period. For both the uninsured who did not visit the Marketplace and for those who visited but may not have understood the information available, a different and more aggressive outreach and education plan is clearly necessary.
The findings reported here suggest that a nonwebsite approach may work better for many people. Adults who got beyond websites and received help from navigators, application assisters, and insurance agents, for example, were more prevalent among those who gained coverage than among those who remained uninsured. A particularly dramatic finding is that adults who said they never used a website—working solely through other sources of information—represented the largest share of adults who had been uninsured for some or all of the 12 months before the survey but had gained insurance as of June 2014. This strongly suggests that next year’s open enrollment period should recognize the important role played by direct assistance and include enough resources of this type in the application process, as opposed to simply making sure the websites are functioning.
It is also noteworthy that a large share of those who remain uninsured still perceives the costs of coverage as a major barrier. For many, this perception may be correct. For example, they may live in a state that has not chosen to expand Medicaid and therefore does not offer a no-cost option to poor uninsured adults. Alternatively, they may be in a family in which there is an employer offer that is affordable for the covered worker but precludes other family members from seeking subsidies, even if they have low incomes.
But two other reasons must also be considered: (1) information about Medicaid eligibility or Marketplace subsidies may be hard to communicate and is still not getting through to some; and (2) even the subsidies available in the Marketplaces may not make health insurance affordable for everyone.
Blavin, Fredric, Stephen Zuckerman, and Michael Karpman. 2014a.“Who Has Been Looking for Information in the ACA Marketplaces? Why? And How? Washington, DC: Urban Institute.
Blavin, Fredric, Stephen Zuckerman, and Michael Karpman. 2014b. Obtaining Information on Marketplace Health Plans: Websites Dominate but Key Groups Also Use Other Sources. Washington, DC: Urban Institute.
Blumenthal, David, and Sara R. Collins. 2014. “Health Care Coverage under the Affordable Care Act–A Progress Report.” New England Journal of Medicine 371 (13): 275–81.
Carman, Katherine Grace, and Christine Eibner. 2014. Changes in Health Insurance Enrollment Since 2013. Santa Monica, CA: RAND Corporation.
Long, Sharon K., Genevieve M. Kenney, Stephen Zuckerman, Douglas Wissoker, Adele Shartzer, Michael Karpman, and Nathaniel Anderson. 2014. QuickTake: Number of Uninsured Adults Continues to Fall Under the ACA: Down by 8.0 Million in June 2014. Washington, DC: Urban Institute.
PerryUndem. 2014. Voices from the Newly Enrolled and Still Uninsured. 2014. Washington, DC: Enroll America.
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
Stephen Zuckerman is senior fellow and co-director, Fredric Blavin is senior research associate, and Michael Karpman and Adele Shartzer are research associates in the Urban Institute’s Health Policy Center.
The authors gratefully acknowledge the suggestions and assistance of Katherine Hempstead and Sharon K. Long.
1Jenna Levy, “U.S. Uninsured Rate Holds Steady at 13.4%,” Gallup, June 5, 2014.
2Associated Press, “States Told to Find Way to Clear Medicaid Backlog,” Washington Post, July 14, 2014.