Editor’s note: In addition to Sharon Long, this post is coauthored by Genevieve Kenney, Stephen Zuckerman, and Katherine Hempstead.
Since early last year, the Urban Institute’s Health Reform Monitoring Survey (HRMS) has been collecting relevant, timely data that is providing insights on the implementation of the ACA and changes in health insurance coverage and related outcomes. (An article describing the survey was published in Health Affairs last December.)
Beginning in late 2013, the HRMS set the stage by exploring adults’ understanding of key ACA provisions, their level of health insurance literacy, and expectations about coverage changes in 2014 based on information collected just before the beginning of the first open enrollment period. More recently, the HRMS has shed light on the characteristics of the newly insured, identified who’s not shopping for insurance, and explained how some states’ decisions to expand Medicaid has reduced uninsurance rates.
The HRMS and other surveys have confirmed that the number of uninsured adults has declined significantly since the first open enrollment under the ACA started. On Tuesday July 29, Health Affairs Editor-in-Chief Alan Weil moderated a panel discussion on what the HRMS shows about the ACA’s performance thus far and what it implies for next year’s open enrollment period. (A recording will be available for those who couldn’t join live.) At the event, we released three new policy briefs that, respectively, provide the latest detailed coverage estimates, describe the remaining uninsured, and explore how consumers are navigating the ACA’s Marketplaces.
Here’s a sample of what we’ve learned from this latest release of HRMS data and what was covered at today’s event:
- Uninsurance is on the decline. Between September 2013 and June 2014, the number of uninsured adults fell by an estimated 8 million. Most of the gain was among low- and middle-income adults targeted by the ACA’s Medicaid and Marketplace provisions and in states that implemented the Medicaid expansion. The largest coverage gains occurred in groups that historically have high uninsurance rates: young, male, and minority adults.
- Direct assistance helps drive coverage. Uninsured adults who gained coverage, but not necessarily through the Marketplace, were less likely to use a website as an information source and more likely to use call centers; navigators, application assisters, certified application counselors, or community health workers; Medicaid or other program agencies; or insurance agents/brokers than uninsured adults who sought information but remain uninsured.
- Uninsured adults are now more concentrated in Medicaid nonexpansion states, and are more likely to be Hispanic, Spanish speakers, unmarried, and to have less than a high school education. Plus, two-thirds have family incomes at or below 138 percent of the federal poverty level. Two-fifths are both low-income and live in Medicaid nonexpansion states.
- Cost is a concern but many have not heard of the subsidies. Most uninsured want health coverage, but remain uninsured for financial reasons. Only 20 percent are uninsured because they don’t want coverage or would rather pay the fine. In addition, many uninsured are unaware of available subsidies. Three out of five uninsured adults have heard some or a lot about the Marketplaces and the individual mandate, but fewer than two out of five have heard some or a lot about subsidies.
The HRMS is establishing itself as a valuable source of data on a wide range of issues related to ACA implementation and effects. For example, HRMS findings related to changes in coverage between Medicaid expansion and nonexpansion states were used in media analysis of the recent court decision questioning the legality of providing subsidies through the federally facilitated Marketplace.
The survey is also being used by federal and state policymakers as they plan for the next open enrollment period and by researchers trying to develop new approaches to measuring sources of health insurance in this much more complicated ACA landscape. The flexibility of the HRMS to quickly adapt to policy questions and data needs by changing many of the questions that are asked on a quarterly basis will likely make it a valuable resource for the foreseeable future.