March 18th, 2014
As the end of the ACA’s first open enrollment period approaches, there is a big push to get as many uninsured people signed up for coverage as possible. As of March 1, 2014, more than 4.2 million people had enrolled in a plan through a federal or state health insurance Marketplace, with 2.1 million having enrolled since January 1 alone. An additional 2.4 to 3.5 million people have enrolled in Medicaid through January 2014 as a result of the ACA.
However, recent media reports indicate that one group with historically high rates of uninsurance—Hispanics—have been slow to sign up for coverage so far, particularly in California. Low levels of Marketplace participation among this group and a delayed and poorly translated Spanish-language version of HealthCare.gov could explain, in part, why President Obama appeared at a town-hall-style event last week hosted by Univision and Telemundo, the nation’s two largest Spanish-language television networks.
Estimates from the Urban Institute’s Health Reform Monitoring Survey (HRMS) shed some light on why Hispanics might have low levels of Marketplace participation so far, and what policies may be needed to increase their enrollment in health plans or Medicaid.
The challenge. Thirty-six percent of Hispanic adults reported being uninsured in late 2013, confirming that they are much more likely to lack coverage than other racial or ethnic groups. Despite the ACA’s coverage expansions, over half of the uninsured Hispanic population (55 percent) reported that they expect to remain uninsured in 2014. (These expectations are not likely due to the immigration status of Hispanics and its effect on eligibility, because uninsured white non-Hispanic and non-white non-Hispanic adults have similar expectations about coverage.)
Attitudes among Hispanics about the need for coverage appear to be contributing to low levels of Marketplace participation. Hispanics are more likely to report that they do not need health insurance compared to other racial and ethnic groups; Only about half (48 percent) of Hispanics disagreed with the statement “I’m healthy enough that I really don’t need health insurance.” In comparison, 54 percent of non-white, non-Hispanic adults and 64 percent of white, non-Hispanic adults disagreed with the statement, indicating that they see a greater need for health insurance than Hispanics.
Low levels of health insurance literacy likely constitute another barrier to Hispanic enrollment. Among all racial and ethnic groups examined in the HRMS, health insurance literacy was found to be lowest for Hispanic adults. Only 23 percent of Hispanic adults were somewhat or very confident in their understanding of health insurance financial terms (premium, deductible, copayment, coinsurance, and maximum annual out-of-pocket spending), compared to 57 percent of white, non-Hispanic adults. Additionally, less than a third of Hispanic adults (30 percent) were somewhat or very confident in their understanding non-financial terms (provider network, covered services, annual limits on services, and excluded services), while nearly two-thirds of white, non-Hispanic adults (64 percent) reported confidence in their understanding of these terms.
Reaching Hispanics. So what outreach strategies would be most effective at targeting Hispanics? Data from the HRMS suggests that Hispanics who had looked or were planning to look for information in the Marketplace were less likely to report using a website compared with other racial and ethnic groups. (See Figure 1 at the end of this post.)
Among those who had looked or were planning to look for information, 60 percent of Hispanics used or planned to use a website, compared with 77 percent of non-white, non-Hispanic adults and 84 percent of white, non-Hispanic adults. In contrast, Hispanics were more likely to use or plan to use a call center (23 percent), navigator (15 percent), or other sources, including family and friends (28 percent), compared with white, non-Hispanic adults (16 percent, 9 percent, and 17 percent, respectively).
Taken together, these findings illustrate that enrollment and outreach efforts may need to take into account the relatively low levels of health insurance literacy among Hispanics and how they obtain information on health insurance plans. Due to the relatively low rate of website usage among Hispanics seeking information in the Marketplace, internet-based outreach efforts will likely need to be combined with bilingual call centers and in-person assistance to maximize enrollment among this group. Such outreach campaigns would also need to address population- and locality-specific barriers to health plan enrollment.
However, looking at the HRMS data alone provides an incomplete picture of the story for Hispanics, many of whom live in families with mixed immigration status. Approximately 15 to 20 percent of Hispanics in the United States are undocumented immigrants who cannot be separately identified in the HRMS. For the most part, this population is not eligible for private coverage in the Marketplace or enrollment in Medicaid. Thus, undocumented immigrants are likely to represent a growing share of the uninsured population unless other policy actions are taken.
In addition, having an undocumented family member could discourage legal immigrants from participating in the Marketplace or Medicaid, out of fear that sharing personal information could result in deportation of their family member or jeopardize their own legal status. While U.S. Immigration and Customs Enforcement announced that information obtained during the health insurance eligibility process would not place any family members at risk of deportation, such assurances may be difficult for the Hispanic community to reconcile with the increase in deportations under the current administration, a critical concern for Hispanics during this open enrollment period.
The extent to which the ACA leads to substantial reductions in uninsurance among adults will depend on how successful enrollment and outreach efforts for both the Marketplace and Medicaid are at reaching Hispanic communities with a message that resonates, a challenge intensified by Hispanics’ low levels of health insurance literacy and the prevalence of families with mixed immigration status.
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