The Obama Administration recently lowered its expectations on the number of individuals that are likely to enroll in health insurance plans through the Marketplace by the end of 2015—suggesting that it might be more difficult than expected to find and enroll remaining uninsured residents while retaining people who signed up during the first open enrollment period (New York Times; Wall Street Journal; Washington Post’s “Wonkblog”).

One potential barrier to enrollment is low levels of Marketplace awareness among the uninsured: September 2014 estimates from the Urban Institute’s Health Reform Monitoring Survey (HRMS) indicate that only 52 percent of uninsured adults reported hearing some or a lot about the health insurance Marketplace created by the Affordable Care Act (ACA). Despite this large knowledge gap, awareness of the Marketplace has improved since last September, when only 30 percent of the uninsured reported hearing some or a lot about the Marketplace prior to the first open enrollment period.

While increasing awareness of the Marketplace will continue to be important as the second open enrollment period unfolds, there are two additional issues that may determine how many more uninsured people actually gain coverage this year. First, will the remaining uninsured be reluctant to seek coverage and enroll during the current open enrollment period, and if so, why?  Second, for people seeking information on health plans, what sources of information are they likely to turn to, and will those sources be adequate to meet the demand? 

To the extent that last year’s experience reflects what may be happening now, data from the HRMS can help answer both of these questions.

Why Remain Uninsured?

Concerns about the costs of coverage were the main reason that uninsured adults gave for not enrolling in a Marketplace health plan during the first open enrollment period. Over half of uninsured adults (55 percent) who looked for information on health plans in the Marketplace cited financial barriers as the main reason for not enrolling (Figure 1; other reasons cited for not enrolling are shown, but were less important).

Additionally, uninsured adults in states that did not expand Medicaid by March 2014 were significantly more likely to cite financial barriers as the main reason for not enrolling (59 percent) compared with uninsured adults in Medicaid expansion states (48 percent) (data not shown).

Urban-Figure-1-Dec-14

The uninsured also cited financial barriers as a significant reason for not even looking for health plans in the Marketplace. Near the end of the first open enrollment period, about one-third of uninsured adults said they had not looked and did not plan on looking for information in the Marketplace. Among this group, 31 percent cited financial reasons and 38 percent had not heard about the Marketplace (Figure 2).

Urban-Figure-2-Dec-14

The fact that financial barriers play such a large role in deterring people from getting coverage may be due to that fact that information on the availability of subsidies is not widely understood. In the September 2014 HRMS, 71 percent of uninsured adults with family incomes below 400 percent of the federal poverty level (FPL) reported hearing nothing or only a little about marketplace subsidies.

It may also be that the available subsidies are inadequate to make coverage affordable for many uninsured adults. The adequacy of the subsidies cannot be overcome during the current open enrollment period, but people running the marketplaces and the enrollment process could provide clearer information on the financial help that is available.

What Sources of Information are Used?

Although Healthcare.gov and the state-based Marketplace websites are often viewed as the cornerstone of the ACA, consumers have used, and will likely continue to use, other sources of information on health insurance plans. In fact, from November 15-28, 2014, the Federally-Facilitated Marketplace call center already received 1.6 million calls.

Despite relying heavily on websites for Marketplace plan information, half of all adults who looked for information used other sources of information during the first open enrollment period. Nearly one-third used other sources in addition to a website, and one-fifth used other sources instead of a website. These sources include formal mechanisms through call centers, navigators, insurance brokers, or Medicaid offices as well as informal channels such as family and friends, employers, tax preparers, health care providers, or the media.

But, certain subgroups were more particularly drawn to sources other than websites for information. For instance, Hispanics were more likely to use formal or informal sources other than the websites than white non-Hispanics. Similarly, adults with incomes at or below 138 percent of the federal poverty level (FPL) were considerably more likely than adults with incomes at or above 400 percent of the FPL to use non-website formal and informal sources. Adults age 50–64 and women were more likely to use direct assistance as a source of information than younger adults or men, respectively.

Although most respondents found each source to be very or somewhat helpful in obtaining information on Marketplace plans, not all sources were uniformly helpful. About three-quarters of adults who used any form of assistance involving a person, other than the call centers, found them to be very or somewhat helpful. Websites and the call center had slightly lower ratings: 65 percent of nonelderly adults who used a website and 58 percent of those who used a call center found these sources to be very or somewhat helpful. At least 60 percent of those who used a website, in all subgroups, found it to be very or somewhat helpful (data not shown).

Because sources of information other than the website are widely used by many groups, it is important that these sources not be overlooked in continuing efforts to expand health insurance coverage during the second open enrollment period. For example, navigators or similar assister programs helped an estimated 10.6 million people—including those enrolled in Marketplace plans and those determined eligible for Medicaid and CHIP—during the first open enrollment period.

But, close to four in ten assister programs reported they could not help all who sought assistance. Given the variability in the sources used across subgroups of the population, web-based outreach efforts may need to be combined with in-person targeted assistance (e.g., bilingual call centers) to maximize enrollment.