Since October, the focus within the media and the health policy community has been on the troubled roll-out of and some of the state websites set up to enroll people in coverage under the Affordable Care Act (ACA).  But most Americans have paid little attention to how the changes taking place can affect their health insurance coverage.

Despite the media frenzy, findings from the Health Reform Monitoring Survey show that only about a third of adults have heard some or a lot about the Marketplaces, and only a quarter have heard about the Medicaid expansion to low-income adults.  Even for the more well-known ACA provisions, such as the expansion of dependent coverage to 26 year olds, the elimination of pre-existing condition exclusions, and the individual mandate, only about 50 percent report having heard much about those changes.

This gap in awareness of the ACA’s coverage provisions may be as much to blame as the widely publicized IT problems in driving the low levels of Marketplace enrollment. As shown in the figure below, only 24.3 percent of young adults (age 18 to 30) in the target population for the Marketplaces—defined as adults with incomes above 138 percent of the federal poverty level who are either uninsured or who have private non-group coverage—were aware of the availability of subsidies for coverage purchased through the Marketplace, compared to 43.6 percent of adults age 50 to 64.

Further, only 25.4 percent of young adults in the target population were aware of the availability of the Marketplaces themselves. Only 40.9 percent were aware of the individual mandate.


Expanding enrollment in the Marketplaces and Medicaid will require more than improving the websites. Policymakers will need to put targeted outreach and education efforts in place to increase awareness of the ACA coverage options, particularly among young adults. The first step is making sure they are aware of their options, and the administration is already making strides toward that goal.

However, the job isn’t over when these young adults know about their coverage options. Many of them simply know very little about health insurance, and will need help choosing a health plan that best meets their needs.

When asked about their understanding of key health insurance terms, fewer than a third (29.0 percent) of young adults in the HRMS were very or somewhat confident in their understanding of nine key health insurance concepts, well below the 50.1% for older adults. The results suggest that they don’t understand the factors that are essential for choosing health insurance coverage that will meet their needs.

They were also much less likely to say they that would look for information from Consumer Reports or from a health insurance plan, insurance agent, or broker, and more likely to say that they would look to family members, friends and coworkers, or to their employer or a family member’s employer when choosing a health insurance plan. To address these knowledge gaps, outreach efforts geared toward making young adults aware of the ACA will need to be combined with education efforts that help them enroll in appropriate plans.

The acrimony about who’s to blame for IT problems should not obscure the need for more and better outreach and education. Well-functioning websites won’t solve the enrollment problem if the target population isn’t aware of the Marketplace and lacks the confidence to enroll, make choices, and pay their premiums.