The U.S. government has a long history of supporting efforts to improve the health of women and families around the world. While many U.S. programs address women and family health generally, several are focused on them directly, including: maternal and child health (MCH), which includes immunization activities; family planning and reproductive health (FP/RH); and nutrition.¹  The accompanying papers examine U.S funding for each of these sectors. They look at funding trends over time, the top country recipients of aid, the share of funding provided to the sector within the larger U.S. global health funding portfolio, and the role of the U.S. as a donor in the context of overall donor support. Among the key findings are the following:

• Combined U.S. funding for these sectors has risen somewhat in recent years, increasing from $1.9 billion in FY10 to $2.0 billion in FY16 ($180 million or 10%). This increase has been driven almost entirely by funding for maternal and child health programs (which rose by $271 million or 29%). Funding for the other two sectors has fluctuated and even decreased in some years, with funding for FP/RH declining over the period (a decrease of $108 million or 15%). The President’s budget request for FY17 includes a 5% increase for these sectors combined, most of which would go to MCH programs (See Figure 1).

• U.S. funding for these sectors represents a relatively small share of the U.S. global health budget, which has been dominated by funding for disease-specific efforts – primarily PEPFAR and the Global Fund – over the last decade. In FY16, the three sectors accounted for 20% of the global health budget (see Figure 2). Funding for MCH was 12%, the third largest program after PEFPAR and the Global Fund. A significant share of funding for MCH is directed at immunization activities (at least 42% in FY16). Funding for FP/RH in FY16 was 6% of U.S. global health funding, and nutrition was 2%.

• Most of the U.S. effort in these sectors is bilateral, with funding provided directly to countries or regions. Still, over time, an increasing share has been provided multilaterally, rising from 14% in FY10 to 20% in FY16. Most of this has been driven by the MCH portfolio, which channeled 30% of funds multilaterally in FY16 to GAVI and UNICEF. FP/RH funding included 5% for multilateral efforts through UNFPA. All nutrition funding was provided through bilateral channels. (see Figure 3).

• Within each sector, the U.S. government has increasingly focused its funding on a subset of “priority countries” which represent those with the most severe health needs. For example, both the maternal and child health and family planning and reproductive health programs focus on 24 priority countries, which account for 76% and 70% of funding, respectively.
• The U.S. is the largest donor to these sectors in the world,²  though no single donor provides the majority of funding in any of the three sectors.

Taken together, these papers show that funding for these three sectors has, overall, remained relatively flat over the past several years, though funding for MCH programs has grown as a priority. Combined, the sectors account for just a fifth of the U.S. global health budget. Still, it is important to note that funding for these three sectors alone does not fully capture U.S. support for activities that address women and family health; other programs, including PEPFAR and the President’s Malaria Initiative, indirectly support such activities, though their focus is not on women and family health per se. Ultimately, as the largest donor to each area in the world, future funding by the United States stands to have a significant impact in the field.

1. While the separation of these sectors into distinct areas is somewhat artificial, they are funded separately by Congress which, in some cases, also includes specific guidelines and criteria for how such funding can be used. ↩︎
2. The U.S. was the largest donor to family planning in 2014, the most recent year with available data; when family planning and reproductive health are combined, the U.S. was the second largest, after the UK. ↩︎

Summary

The U.S. government has supported international family planning and reproductive health (FP/RH) efforts for 50 years and is one of the largest donors to FP/RH in the world.^1 ,2  Since 1965, the U.S has obligated approximately $14 billion to international FP/RH activities, though funding has fluctuated over time, including significant decreases in some periods, largely due to political debates surrounding family planning and abortion in the U.S.³  For FY16, the U.S. Congress provided $608 million for FP/RH activities (both bilateral and multilateral funding combined), and the President’s budget request for FY17 includes $620 million for FP/RH.⁴  This brief provides an overview of U.S. funding for FP/RH, including trends in bilateral and multilateral funding and top country recipients of U.S. funding, and places the U.S. within the larger context of overall donor support for the sector.⁵ 

Introduction

The U.S. government has provided financial and other support for international FP/RH efforts for 50 years and is one of the largest donors to FP/RH in the world; since 1965, the U.S has obligated approximately $14 billion to international FP/RH activities.^6 ,7 ,8  The U.S. Agency for International Development (USAID) serves as the lead agency for FP/RH, carrying out programs in nearly 40 countries, with a focused effort in 24 priority countries.⁹  USAID works to increase access to voluntary family planning information, commodities, and services, and is a core partner of FP2020 (see below).¹⁰  While most of its effort is focused specifically on family planning, USAID also supports some broader RH activities, including efforts to address child marriage, female genital mutilation, and gender based violence and the provision of post abortion care.¹¹  Other U.S. agencies involved in international FP/RH efforts include the Centers for Disease Control and Prevention (CDC) (research, surveillance, technical assistance, and a designated WHO Collaborating Center for Reproductive Health), the Department of State (diplomatic and humanitarian efforts), the National Institutes of Health (NIH) (research), and the Peace Corps (volunteer activities). Additionally, USAID’s FP/RH efforts are closely linked to its maternal and child health (MCH) programs, although Congress directs funding to and USAID operates these programs separately. Recent years have also seen greater emphasis on coordinating FP investments with HIV efforts through the President’s Emergency Plan for AIDS Relief (PEPFAR).

Overview of Funding Trends

U.S. support for international FP/RH is provided through both bilateral programs and contributions to the United Nations Population Fund (UNFPA). Most U.S. funding for FP/RH activities is provided through bilateral efforts (95% in FY16), while 5% is channeled through multilateral efforts. Funding has fluctuated over time, including declines in some periods largely due to changing party control in the Administration and Congress and political debates surrounding family planning and abortion in the U.S.¹²  As a result, there are several legal, policy, and programmatic requirements that govern the use of U.S. funding for international FP/RH efforts.¹³  U.S. policy, under the Helms amendment, for example, currently prohibits funding for abortion as a method of family planning in international programs.¹⁴ 

Funding for the program rose steadily over its first two decades but saw significant cuts during the 1980s under the Reagan Administration. Funding was subsequently increased reaching a peak in 1994 under President Clinton, coinciding with the International Conference on Population and Development, but then decreased again under the Republican controlled Congress. After increasing slightly, funding remained essentially flat under President George W. Bush. Funding increased significantly after President Obama took office in 2009 and reached $715 million in FY10 (the highest level to date), including the restoration of funding for UNFPA (see below).¹⁵  Funding declined to $633 million in FY11, but has since remained relatively flat (see Figure 1).

Despite increases in FP/RH funding in recent years, funding for the sector represents a relatively small share of the overall U.S. global health budget, and its share has declined over time with the rise of other U.S. global health programs and focus areas, most notably PEPFAR. FP/RH has accounted for approximately 5-8% for much of the past decade (see Figure 2).

Bilateral Funding

Bilateral funding provided by USAID increased from $425 million in FY06 to $575 million in FY16.^16 ,17  It reached its highest point, $664 million, in FY10; since then, funding has been between $585-$608 million per year (see Table 1).¹⁸  The President’s FY17 budget request includes $585 million for bilateral FP/RH activities, which would represent a $10 million increase.

Of the $585 million in bilateral funding in FY15 (the most recent year for which country-specific data are available), $407 million (70%) was provided to the 24 FP/RH priority countries. An additional 9 countries received bilateral funding directly (totaling $48 million) and others were reached through regional funding provided by the agency. The top recipient of funding in FY15 was Nigeria ($34.5 million), followed by Ethiopia ($31.6 million), Uganda ($27.5 million), Bangladesh ($27.0 million), Tanzania ($26.4 million), Kenya ($26.0 million), Afghanistan ($21.4 million), Jordan ($20.3 million), the Philippines ($18.0 million), and Democratic Republic of the Congo ($16.7 million) (see Table 2). These top 10 recipients accounted for 43% of overall bilateral assistance in FY15.

Multilateral Funding

The U.S. also supports FP/RH through multilateral contributions to UNFPA, the lead UN agency supporting sexual and reproductive health activities in many low- and middle-income countries. Although the U.S. helped create UNFPA in 1969 and was a leading contributor for many years, there have been several years in which funding has been withheld due to executive branch determinations that UNFPA’s activities in China violated the Kemp-Kasten Amendment, which prohibits funding any organization or program, as determined by the President, that supports or participates in the management of a program of coercive abortion or involuntary sterilization, despite that fact that UNFPA does not support such activities in China. Funding was first withheld by President Reagan in 1985 and later restored by President Clinton (who provided funding in each year except for 1999). George W. Bush also suspended funding to the agency which was restored in FY09 by President Obama. In FY16, the U.S. provided $33 million for UNFPA. Due to policy conditions put in place by Congress, actual annual contributions to UNFPA are frequently lower than the enacted levels with the difference being transferred to bilateral programs (see Figure 3).

The United States in Context: International Donor Assistance for Family Planning

The U.S. is the single largest donor to international family planning efforts in the world.¹⁹  In July 2012, the U.K. Government and the Bill & Melinda Gates Foundation, in partnership with UNFPA, civil society organizations, developing countries, donor governments, the private sector, and multilateral organizations met at the London Summit on Family Planning (FP2020) and made commitments aimed at improving access to voluntary family planning services. While the U.S. did not make a formal commitment at the Summit, USAID is a core partner in helping reach the goals of the Summit. In 2014, the most recent year for which data are available, donor governments provided $1.4 billion to support bilateral family planning programs in low- and middle-income countries, an increase of more than $100 million (9%) above 2013 levels and 32% above 2012 levels (see Figure 4).²⁰  The U.S. was the single largest bilateral donor in 2014, disbursing US$636.6 million and accounting for almost half (44%) of total bilateral funding (see Figure 5). The U.K. (US$327.6 million, 23%) was the second largest bilateral donor, accounting for nearly a quarter of all funding, followed by the Netherlands (US$163.6 million, 11%), Sweden (US$70.2 million, 5%), and France (US$69.8 million, 5%).

Figures & Tables

1. KFF. Donor Government Assistance for Family Planning in 2014; November 2015. ↩︎
2. KFF analysis of official development assistance funding as reported to the Organisation for Economic Co-operation and Development (OECD) Credit Reporting System (CRS) database, April 2016. ↩︎
3. Congressional Research Service (CRS). International Family Planning Programs: Issues for Congress. June 2012. ↩︎
4. The FY16 Omnibus bill (P.L. 114-113) states that, of the funding appropriated for bilateral assistance, “not less than $575,000,000 should be made available for family planning/reproductive health,” and provides an additional $32.5 million for the U.S. contribution to the United Nations Population Fund (UNFPA). In recent years, final funding amounts for FP/RH have been higher than the enacted level. For instance, enacted FP/RH funding in FY15 totaled $610 million ($575 million for bilateral programs and $35 million for UNFPA), but the final funding level for FP/RH (bilateral and UNFPA) in FY15 totaled $616 million. ↩︎
5. With the exception of FY16 and FY17, all funding totals in this analysis represent the final planned funding level for that fiscal year. This includes both base and supplemental appropriations for bilateral FP/RH activities as well as U.S. contributions for UNFPA. FY16 represents the enacted level and FY17 represents the President’s budget request. ↩︎
6. KFF. Donor Government Assistance for Family Planning in 2014; November 2015. ↩︎
7. KFF analysis of official development assistance funding as reported to the Organisation for Economic Co-operation and Development (OECD) Credit Reporting System (CRS) database, April 2016. ↩︎
8. Congressional Research Service (CRS). International Family Planning Programs: Issues for Congress. June 2012. ↩︎
9. USAID. Family Planning Program Overview; October 2015. ↩︎
10. USAID. Family Planning Program Overview; October 2015. ↩︎
11. USAID. Reproductive Health; February 2016. ↩︎
12. PAI. 50 Years of US International Family Planning Assistance; December 2015. ↩︎
13. Congressional Research Service (CRS). U.S. International Family Planning Programs: Issues for Congress; January 2016. ↩︎
14. Congressional Research Service (CRS). U.S. International Family Planning Programs: Issues for Congress; January 2016. ↩︎
15. Funding totals include both base and supplemental appropriations. For instance, the FY10 total includes $64.5 million that was provided through a supplemental appropriation. ↩︎
16. Includes both base and supplemental funding. In recent years, bilateral funding for FP/RH activities is provided through the Global Health Programs (GHP) and Economic Support Fund (ESF) accounts at USAID, and historically, funding has also been provide through the Assistance for Europe, Eurasia and Central Asia (AEECA) and Development Assistance (DA) accounts at USAID. ↩︎
17. FY16 is based on funding provided in the “Consolidated Appropriations Act, 2016” (P.L. 114-113) and is a preliminary estimate. Final family planning numbers may differ from the initially enacted level as the FY16 omnibus bill specified the minimum level of bilateral FP funding ($575.0m through the GHP and ESF accounts), not the actual level. For example, final FY15 FP funding totaled $616.0m for bilateral programs and the U.S. contribution to UNFPA. Final FP funding for FY16 is expected to follow suit. ↩︎
18. Funding totals include both base and supplemental appropriations. For instance, the FY10 total includes $64.5 million that was provided through a supplemental appropriation. ↩︎
19. KFF. Donor Government Assistance for Family Planning in 2014; November 2015. ↩︎
20. KFF. Donor Government Assistance for Family Planning in 2014; November 2015. ↩︎

Summary

The U.S. government has a long history of supporting international maternal and child health (MCH) efforts, including global immunization activities, and is the largest donor government to MCH activities in the world.^1 ,2  Between FY10 and FY16, the U.S. Congress provided $7.5 billion for MCH-specific activities (both bilateral and multilateral funding combined), of which $2.6 billion (35%) supported global immunization efforts.^3 ,4  In FY16, Congress provided $1.21 billion for MCH and the President’s FY17 budget request includes $1.28 billion, a $69 million increase. Most funding for MCH is provided bilaterally, though the share given through multilateral channels has increased in recent years. This brief provides an overview of U.S. funding for MCH, including trends in bilateral and multilateral funding and top country recipients of U.S. funding, and places the U.S. within the larger context of overall donor support for the sector.⁵ 

Introduction

The U.S. government has provided financial and other support for international MCH efforts, including global immunization activities, since the 1960s and is the largest donor government to MCH activities in the world.^6 ,7  The U.S. Agency for International Development (USAID) serves as the lead agency for MCH and focuses its support on 24 priority countries.⁸  USAID works to improve the accessibility and quality of antenatal care, delivery care, and postnatal care; newborn health; immunizations (including polio); child health through the treatment of diarrhea, pneumonia, and malaria; as well as water, sanitation, and hygiene. Other U.S. agencies involved in international MCH efforts include the Centers for Disease Control and Prevention (CDC) (research and technical assistance), the Department of State (diplomatic and humanitarian efforts), the National Institutes of Health (NIH) (research), and the Peace Corps (volunteer activities). Additionally, USAID supports the integration of family planning with maternal care services, although Congress directs funding to and USAID operates these programs separately.⁹ 

Overview of Funding Trends

U.S. support for international MCH activities is provided through both bilateral programs and contributions to multilateral organizations, including the United Nations Children’s Fund (UNICEF) as well as Gavi, the Vaccine Alliance (Gavi).¹⁰  Most U.S. funding for MCH activities is provided through bilateral efforts (70% in FY16), though an increasing share has been channeled through multilateral efforts in recent years (rising from 22% in FY10 to 30% in FY16). Funding for MCH activities has increased over time, rising from $936 million in FY10 to $1.2 billion in FY16, largely due to increased funding for immunizations; between FY10 and FY16 U.S. support for global immunization programs rose from $266 million to $513 million.^11 ,12  The president’s FY17 request includes $1.28 billion for MCH activities, $69 million above the FY16 level (see Figure 1). Funding for MCH activities has also increased as a share of the global health budget rising from 9% in FY10 to 12% in FY16 (see Figure 2). Despite accounting for a relatively small share of the budget, funding for MCH activities account for the third largest amount of funding after HIV and the Global Fund.

Bilateral Funding

Bilateral funding for MCH is provided through USAID and CDC’s Global Immunization program. Total bilateral funding for MCH increased from $726 million in FY10 to $839 million in FY16.^13 ,14  The President’s FY17 budget request includes $869 million for bilateral MCH activities, which would represent a $30 million increase (4%). Most of the bilateral funding is provided through USAID (74%) with the remainder at CDC (26%). While total funding for both agencies increased between FY10 and FY16, USAID’s funding fluctuated over the period (see Table 1).

Of USAID’s $632 million in bilateral funding in FY15 (the most recent year for which country level data are available; CDC funding is not available by recipient country), $477 million (76%) was provided to the 24 MCH priority countries. An additional 12 countries received bilateral funding directly (totaling $56 million) and others were reached through regional funding provided by the agency. The top recipient of funding in FY15 was Afghanistan ($67.1 million), followed by Nigeria ($48.0 million), Ethiopia ($39.3 million), Democratic Republic of the Congo ($34.8 million), Bangladesh ($30.0 million), Jordan ($24.8 million), Pakistan ($24.7 million), Indonesia ($20.0 million), South Sudan ($18.0 million), and Uganda ($16.0 million) (see Table 2). These top 10 recipients accounted for 59% of USAID’s country and regional specific assistance in FY15.

Multilateral Funding

The U.S. also supports MCH efforts through multilateral contributions to UNICEF as well as to Gavi, the vaccine alliance. U.S. contributions to UNICEF, the lead UN agency supporting child health activities in many low- and middle-income countries, have remained relatively stable over the past decade, increasing slightly from $125.7 million in FY06 to $132.5 million in FY16.

Gavi, an independent public-private partnership and multilateral funding mechanism that aims to “save children’s lives and protect people’s health by increasing access to immunization in poor countries”, was created in 1999 and formally launched in 2000.¹⁵  The U.S. made its first contribution of $48 million in FY01 and U.S. contributions have greatly increased in recent years with multi-year funding commitments made by the Obama administration.¹⁶  In FY16 the U.S. provided $235 million to Gavi and the President’s FY17 request includes $275 million for Gavi, an increase of $40 million (17%). The U.S. is the second largest donor government, followed by the U.K., contributing $1.4 billion since Gavi was established.

Immunization Funding

U.S. support for global immunization activities is provided through USAID’s MCH program, CDC’s Global Immunization program, and through the U.S. contribution to Gavi. Between FY10 and FY16, total U.S. global immunization funding rose from $266 million to $513 million, an increase of $247 million over the period (see Figure 3 and Table 3).^17 ,18  This increase accounted for almost the entire increase (91%) in total MCH funding between FY10 and FY16. The President’s FY17 request includes $551 million for global immunization activities, an increase of $38 million (7%) above FY16.

The majority of U.S. funding for global immunization activities is provided through bilateral programs, which increased from $188 million in FY10 to $278 million in FY16. However, U.S. multilateral support provided through its contribution to Gavi has increased more rapidly, rising from $78 million in FY10 to $235 million in FY16, and has increased as a share of total immunization funding over the period rising. The President’s FY17 budget request includes $276 million in bilateral funding, a decrease of $2.4 million (-1%) below FY16, and $275 million for Gavi, an increase of $40 million (17%) above FY16.

The majority of U.S. bilateral funding for global immunization activities supports polio vaccination efforts at both USAID and CDC. Total U.S. polio funding increased from $136 million ($34 million at USAID and $102 million at CDC) in FY10 to $228 million ($59 million at USAID and $169 million at CDC) in FY16. The President’s FY17 budget request includes $226 ($52 million at USAID and $174 million at CDC) million for polio activities, a decrease of $2 million (1%) compared to FY16.

The United States in Context: International Donor Assistance for Maternal & Child Health

The U.S. is the largest donor government to MCH activities in the world. A recent Lancet study analyzed donor assistance for MCH activities from 2003 to 2012 and found that the U.S. was the single largest donor government to international MCH efforts in the world in each year during the period. According to the study, in 2012, the U.S. accounted for 16% of total donor assistance for MCH, followed by GAVI (11%), the Global Fund (10%), EU Institutions (9%), and the Bill & Melinda Gates Foundation (8%).¹⁹  The Institute for Health Metrics and Evaluation (IHME) also conducted a similar analysis examining development assistance for health. This analysis also found that the U.S. was the largest donor government to MCH activities in each year between 1990 and 2014.²⁰ 

Figures & Tables

1. IHME. Financing Global Health 2014: Shifts in Funding as the MDG Era Closes; 2015. ↩︎
2. Arregoces, L. et al., Countdown to 2015: changes in official development assistance to reproductive, maternal, newborn, and child health, and assessment of progress between 2003 and 2012, The Lancet Global Health, Volume 3, Issue 7, 410 – 421. ↩︎
3. U.S. immunization totals include funding provided through the CDC’s Global Immunization program, USAID funding for polio, and the U.S. contribution to Gavi. U.S. funding for UNICEF that may, in turn, be used to support immunization efforts, is not included. As such, the immunization funding totals presented in this analysis should be considered a conservative estimate. ↩︎
4. USAID estimates that, in addition to funding for polio and Gavi, approximately $20 million in bilateral MCH funding is provided for immunization activities annually. However, since these activities are funded at the country level as components of integrated health systems strengthening or health service delivery activities within the larger MCH portfolio, specific per year funding totals are not available. ↩︎
5. With the exception of FY16 and FY17, all funding totals in this analysis represent the final funding level for that fiscal year. This includes both base and supplemental appropriations for bilateral MCH activities as well as U.S. contributions for UNICEF and Gavi. FY16 represents the enacted level and FY17 represents the President’s budget request. ↩︎
6. IHME. Financing Global Health 2014: Shifts in Funding as the MDG Era Closes; 2015. ↩︎
7. Arregoces, L. et al., Countdown to 2015: changes in official development assistance to reproductive, maternal, newborn, and child health, and assessment of progress between 2003 and 2012, The Lancet Global Health, Volume 3, Issue 7, 410 – 421. ↩︎
8. USAID. Maternal and Child Health; March 2016. ↩︎
9. USAID. Ending Preventable Maternal Mortality: USAID Maternal Health Vision for Action; June 2014. ↩︎
10. Prior to FY10, funding for MCH programs included support for nutrition activities. For comparison purposes, MCH funding prior to FY10 is not included. ↩︎
11. U.S. immunization totals include funding provided through the CDC’s Global Immunization program, USAID funding for polio, and the U.S. contribution to Gavi. U.S. funding for UNICEF that may, in turn, be used to support immunization efforts, is not included. As such, the immunization funding totals presented in this analysis should be considered a conservative estimate. ↩︎
12. USAID estimates that, in addition to funding for polio and Gavi, approximately $20 million in bilateral MCH funding is provided for immunization activities annually. However, since these activities are funded at the country level as components of integrated health systems strengthening or health service delivery activities within the larger MCH portfolio, specific per year funding totals are not available. ↩︎
13. Includes both base and supplemental funding. In recent years, bilateral funding for MCH activities is provided through the Global Health Programs (GHP) and Economic Support Fund (ESF) accounts at USAID, and historically, funding has also been provide through the Assistance for Europe, Eurasia and Central Asia (AEECA) and Development Assistance (DA) accounts at USAID. Does not include funding provided through Food for Peace (FFP) due to the unique nature of the program, in FY15 the U.S. provided $3 million for MCH activities through FFP. ↩︎
14. FY16 is based on funding provided in the “Consolidated Appropriations Act, 2016” (P.L. 114-113) and is a preliminary estimate. ↩︎
15. Gavi, Gavi’s mission, available at: http://www.gavi.org/about/mission/. ↩︎
16. KFF. The U.S. & Gavi, the Vaccine Alliance; March 2015. ↩︎
17. U.S. immunization totals include funding provided through the CDC’s Global Immunization program, USAID funding for polio, and the U.S. contribution to Gavi. U.S. funding for UNICEF that may, in turn, be used to support immunization efforts, is not included. As such, the immunization funding totals presented in this analysis should be considered a conservative estimate. ↩︎
18. USAID estimates that, in addition to funding for polio and Gavi, approximately $20 million in bilateral MCH funding is provided for immunization activities annually. However, since these activities are funded at the country level as components of integrated health systems strengthening or health service delivery activities within the larger MCH portfolio, specific per year funding totals are not available. ↩︎
19. Arregoces, L. et al., Countdown to 2015: changes in official development assistance to reproductive, maternal, newborn, and child health, and assessment of progress between 2003 and 2012, The Lancet Global Health, Volume 3, Issue 7, 410 – 421. ↩︎
20. IHME. Financing Global Health 2014: Shifts in Funding as the MDG Era Closes; 2015. ↩︎

Millions of people have gained access to health insurance coverage under the Affordable Care Act (ACA) through Medicaid and the Marketplaces. While research shows that coverage improves access to care and promotes financial stability, issues around access and affordability remain, and are more acute for the low-income population. To learn more about how low-income individuals have fared with their new coverage, we conducted nine focus groups (three groups with Medicaid enrollees and six groups with low-income Marketplace enrollees) in six states (California, Florida, Maryland, Missouri, Ohio, and Virginia).  Many participants were struggling financially and reported substantial debt (including medical debt). Many had ongoing physical and mental health needs and were accessing health services to treat those conditions. Following are key themes from the groups:

1. New coverage did not change underlying financial struggles and hardship due to medical debt incurred prior to gaining coverage. Many participants were stretched financially, had limited capacity to absorb unexpected costs, and struggled with finding secure employment in their area.
2. Medicaid stands up well for the lowest income participants in terms of ease of enrollment, out-of-pocket costs and affordability, and ability to find providers and access care. A small number of participants reported trouble affording care that wasn’t covered (particularly for vision or dental) and difficulty finding some providers, including mental health providers.
3. Largely due to premium tax credits in the Marketplace, premiums were generally affordable, but out-of-pocket costs weighed heavily on Marketplace participants, especially those with high deductible plans. Many reported being overwhelmed by plan choices. Some were able to make trade-offs to purchase higher cost plans with lower deductibles to meet anticipated care needs, but not everyone was able to afford higher premiums.
4. The fear of unknown costs was a constant worry for many Marketplace participants. Many got bills for services they thought were covered, such as screenings, colonoscopies and mammograms when issues were discovered and treated. These bills caused many to avoid getting needed care. Marketplace participants also reported trouble affording care that wasn’t covered by their plan, notably vision and some dental services.
5. Most participants had accessed care and were positive overall about new ACA coverage through Medicaid and the Marketplace. They were grateful that coverage was available to them, particularly those who had been previously ineligible for Medicaid or barred from private coverage due to pre-existing conditions. However, many Marketplace participants wanted coverage to be more affordable.

Introduction

Since the implementation of the Affordable Care Act in 2010, millions of people have gained health coverage through health insurance Marketplaces and expanded Medicaid in states that have opted to adopt the Medicaid expansion. This new coverage has improved access to care and provided financial protection against medical expenses for many.¹  However, affording this coverage is a problem for some. Particularly for low-income individuals with private insurance through the Marketplaces, premiums and out-of-pocket costs can be difficult to afford, creating barriers to accessing needed care. Although Medicaid offers protection from premiums and deductibles, some beneficiaries may still face challenges getting the care they need. Additionally, problems paying medical bills continue to plague many, even those with insurance.²  These problems can be especially acute for low and moderate-income individuals and families, many of whom are burdened by debt and struggle to pay monthly bills.

The ACA expanded Medicaid to nearly all nonelderly adults with incomes at or below 138% of the federal poverty level (FPL).  With the June 2012 Supreme Court ruling, the Medicaid expansion effectively became optional for states, and as of January 2016, 31 states and DC had expanded Medicaid eligibility under the ACA. In states that did not adopt the expansion, individuals with incomes between 100-138% FPL are eligible for tax credits in the Marketplace, but Marketplace coverage has more out-of-pocket costs than Medicaid.

This report is based on focus group discussions with low and moderate income adults who gained Medicaid or Marketplace coverage following the implementation of the ACA. It explores several areas about their coverage, including their experiences signing up for coverage; their knowledge of what their plan covers and what factors they weighed in choosing their plan; what they pay for their coverage and their perceptions of whether these costs are affordable; their experiences accessing care; and the impact of out-of-pocket costs on their ability to get needed care. Building on other research in this area, this report provides valuable insights into the ongoing financial struggles facing low-income individuals and the problems they confront affording health coverage.

Methods

The findings are based on nine focus group discussions conducted by the Kaiser Family Foundation and Belden Russonello Strategists in six cities during January and February 2016. Sites included Baltimore, MD; Richmond, VA; Columbus, OH; St. Louis, MO; Oakland, CA; and Tampa, FL.  Three of these cities are in states that have expanded Medicaid—California, Maryland, and Ohio—and in these sites, we conducted separate focus groups with individuals (income 50-138% FPL) who were enrolled in Medicaid and with those enrolled in coverage through the Marketplace (income 139-250% FPL). In the three non-expansion states—Florida, Missouri, and Virginia—we conducted focus groups only with individuals (income 100-250% FPL) who were enrolled in coverage through the Marketplace. Annual income at 138% FPL is equal to $16,242 for an individual and $27,724 for a family of three in 2015.  Annual income at 250% FPL is equal to $29,700 for an individual and $50,400 for a family of three.

Each focus group consisted of 9-11 participants, with a total of 91 participants including 30 covered by Medicaid and 61 covered through the Marketplace.  Participants were selected to provide a mix of demographic characteristics, including age, race/ethnicity, marriage status, and work status.  All individuals had used services since obtaining their current coverage and most reported having at least one chronic condition. Additionally, all reported that they had trouble affording some aspect of their current coverage, including premiums, deductibles, and/or copayments. (For more details on participants see Appendix A).

Prior to enrolling in their current coverage, three-quarters of those with Medicaid were previously uninsured while about half of those with Marketplace coverage were uninsured. Across both groups, the length of time that participants were uninsured ranged from a few months to many years, with several participants reporting they had been uninsured their entire adult lives. Most participants were aware of the coverage options available through the ACA and signed up when the coverage became available in 2014 or when they lost their previous coverage.  Most participants said they learned about new coverage options through the news and media, were eager to have coverage, and signed up when the coverage became available. Some, however, were motivated to sign up to avoid paying the penalty.  Often the reason for signing up influenced how they chose their plans.

Key Findings

1.  Underlying financial struggles and hardship due to medical debt incurred prior to gaining Medicaid or Marketplace coverage remain

Participants reported struggling financially, with many saying they had difficulty paying for basic expenses each month. Most participants in the Medicaid and Marketplace groups were working. Despite improvements in the economy since the recession, most said it was still difficult to find work or full-time jobs, and as a result, many were working part-time. In part, because of the inability in the current job market to find stable, full-time jobs, over half of participants described their financial situation as poor or just getting by. Many participants across both groups said they were having trouble affording basic needs like housing (rent or mortgage), food, utilities and transportation, and were often unable to pay monthly bills. To get by, participants said they relied on family members and churches, in some cases. Participants in the Medicaid groups were more likely to report relying on other social services, but Marketplace participants also said they went to food pantries for support.

Nearly all participants sought ways to cut expenses, including dropping internet or cable television, consolidating cell phone plans, as well as limiting the number of times they eat out. Some juggled bills by skipping some bills one month and others the next month or paying just enough to avoid having services shut off.  Most tried to live within their means, but often faced unexpected bills such as car repairs, a leaky roof, or medical expenses that added to their financial struggles.

I think there’s jobs, I just think it’s hard to get a full time job… most people I know work a couple jobs to equal one full-time job. (Nancy, Richmond Marketplace)
–
Things are coming up all the time. Whether it’s a medical expense, whether it’s something that involves your vehicle. All kinds of things can come up at any point in time. If you’re just making it, that’s going to throw a cramp in your spending, or in your finances. (Donnie, Baltimore Marketplace) –

Contributing to financial problems, participants reported a range of chronic and acute health issues, some of which affected their ability to work. Overall the groups reported that they were in “good” health.  However, across both the Medicaid and Marketplace groups, participants reported many health conditions. The most common chronic health issues across the groups were high cholesterol and blood pressure; depression, anxiety, or other mental or emotional conditions; arthritis; asthma/emphysema; and diabetes.  Some participants described more serious health problems like cancer, stroke, and autoimmune diseases. A number suffered injuries on the job and others said they suffered from chronic pain. For some, these injuries and illnesses limited their job options and their ability to work, particularly when health conditions, including pain, were not well managed.

I work part-time because of my anxiety. It’s a lot easier than working full-time. (Sophie, Baltimore Marketplace)
–
I was injured on the job, that’s why I ended up losing the job. It was a rotator cuff…. I’ve never seen a company abandon me as fast as, “We love you Paul, but when you get hurt, you’re gone.” (Paul, St. Louis Marketplace)

The large majority of participants had some or a lot of debt, including debt from medical bills, that contributed to their financial challenges. Nearly three-quarters of participants (64 out of 91) reported having at least some debt, and many reported having a lot of debt. Student loans and medical expenses were the biggest sources of debt, but car loans and credit cards were also contributors. Among participants who reported medical debt, most of the medical expenses were incurred while they were uninsured, though some reported incurring medical debt while previously insured. Participants in both the Medicaid and Marketplace groups reported experiencing significant health problems while they were uninsured, including cancer, stroke, and kidney stones, as well as chronic conditions, such as diabetes and asthma. Getting treatment for these more severe conditions often resulted in large medical bills, but even minor issues, such as a trip to the emergency room for a broken foot, could result in unaffordable medical bills. Many were not able to make payments on this debt and were often sent to collections, ultimately damaging their finances and credit.

I have [student loans], I have been paying it for 16 years. I came out of school owing $70,000. That’s just for the Master’s degree. (Womson, Baltimore Marketplace)
–
There was two years we weren’t insured before the whole Obamacare. My wife had cysts she had to have removed and whatnot. We didn’t have insurance. She wasn’t working. I was the only worker. Couldn’t really afford that and pay all your bills at the same time, so that’s still piled up…it’s affecting the credit. I try to pay when I can, but there’s months you can’t pay. (Dave, St. Louis Marketplace)
–
I had a separate physician’s bill for one time at the ER…I thought everything was covered but no. It’s in my closet. I’ll pay it eventually. (Shaeeda, Baltimore Medicaid)

2.  Medicaid coverage stands up well for the lowest income participants in terms of enrollment, access and out of pocket costs

Most participants with Medicaid said the enrollment process was simple and appreciated the ability to enroll online. Medicaid participants reported applying for their coverage through multiple avenues. Many applied through new websites, either through their state’s integrated Marketplace and Medicaid website or directly through the Medicaid agency website. Some received help enrolling at a provider’s office when they sought care or with the help of an enrollment assister. While most reported that the process was easy, a small number experienced delays in obtaining coverage and others had problems with the website. Some participants had to pick a Medicaid managed care plan once they enrolled.  If they did not pick a plan they may have been assigned to a plan.  Participants said they chose the plan based on brand or reputation and if they could keep their doctor.

With the new Medicaid expansion they have a hotline you can call now where if you sent in your paperwork or if you do it online, they answer the phone right away and answer questions and its great customer service. I couldn’t believe how good it was compared to dealing with the local Job and Family Services office. (Rachel, Columbus Medicaid)
–
I applied online. It took me like 10 or 15 minutes. You put in social security numbers. How much you make. I didn’t hear from them for a while. I think it took like two months or maybe three months before I got a letter. Eventually I got a letter saying I was approved. They send you packets with different providers. You pick a provider. They send you an insurance card. Then we had insurance. (Johntai, Baltimore Medicaid)

Several participants reported confusion and difficulty signing up for Marketplace coverage in the first year; for those signing up for the first time or renewing their coverage in 2015 the process was smoother. A number of participants said they first signed up in the fall of 2013 so they would have coverage beginning in January 2014. Those applying early indicated they faced problems with the website and other difficulties enrolling in coverage. Some faced delays in the process and reported receiving conflicting or incorrect information from enrollment assisters or the call center when they sought assistance with their application. In contrast, participants signing up for the first time in 2015 indicated the website was more functional and the process was easier. Similarly, those who renewed their Marketplace coverage in 2015 reported the process to be free of the problems from the first year and relatively easy to navigate. Despite improvements, many individuals had trouble figuring out their income, and therefore, eligibility for subsidies.  Many low-income individuals may have multiple jobs, or jobs without steady income streams, so projecting their income for the year for purposes of determining eligibility for subsidies is difficult.

I felt that the website was also built for people in really traditional jobs. I’m an independent contractor, so I don’t get pay stubs every two weeks. Verifying my income and all that stuff was not easy for someone in my position. (Shannon, Baltimore Marketplace)
–
At first they had problems with the website but once that got going, I went to the family services and on the computer it took me like maybe five minutes. It was really easy. (Billy, Columbus Marketplace)

Participants with Medicaid described their coverage as comprehensive and affordable. Despite being screened for having affordability issues as a condition for participation in the focus group, Medicaid participants expressed satisfaction with their coverage, describing it as very affordable and providing coverage, in most cases, for the services they need. Several participants noted their affordability challenges stemmed from medical debt they were trying to pay off, unrelated to their current Medicaid coverage. They thought that coverage through Medicaid could help address prior medical bills and were disappointed when they learned that would not be the case. Once they gained coverage, participants with Medicaid obtained care to address ongoing health needs. Especially for those who were uninsured prior to enrolling in Medicaid, having coverage meant they were able to get treatment and medications for chronic conditions, including diabetes, asthma, and mental health issues.  Participants appreciated not having to pay premiums and while they noted modest copayment requirements for certain services, they said these were affordable.  Participants who previously had private insurance contrasted the low out-of-pocket costs in Medicaid to the larger copayments for doctor’s visits they paid previously.

It was a relief to not have to always worry about what the co-pay was going to be this time. When I had private insurance I was always worried about whether or not I was going to be able to afford the visit. (Johntai, Baltimore Medicaid)

–I’ve gone once [to the doctor] and it was completely covered. They didn’t want a copay or anything. (Cynthia, Columbus Medicaid)

–I think the good thing with this is I know the visit’s going to be covered. I don’t have to worry about how much am I going to have to shell out at the end of the visit and the guess work around how much it will be. (Shaeeda, Baltimore Medicaid)

A small number of Medicaid participants said they had problems affording services not covered by insurance, particularly dental and vision, and finding some doctors.  Medicaid does not always cover vision or dental for adults or alternative treatments such as acupuncture or chiropractic care. Some participants faced out-of-pocket costs for these services; others avoided accessing these services knowing they could not afford the costs.  In addition, some Medicaid enrollees reported difficulty finding certain types of providers, such as mental health providers.

I don’t want to have dental work because I don’t have dental coverage and dentists are so expensive. (Daniel, Oakland Medicaid)

–I think with specialists like chiropractors, mental health, optometry things like that, [Medicaid] could be a little better. (Jason, Columbus Medicaid)

Most Medicaid enrollees thought that paying a monthly premium would be difficult.  Medicaid participants in the three locations do not face a monthly fee or premium.  A limited number of states have approval or are seeking approval to impose these fees on their Medicaid expansion population, particularly for enrollees at or above 100% of poverty.  Most Medicaid enrollees in these groups valued their coverage and said they would be able to pay a small amount for coverage. However, most participants felt that a fee of up to 2% of income ($20-$25 for an individual or $50-$55 for a family of four with incomes up to 138% of poverty) was high and would be a burden to pay.

It would be a struggle. (Deborah, Baltimore Medicaid)

–It feels reasonable right now because I have an income and I don’t have a lot of debt…But there have been times in my life where I was so poor and so much in debt, there is no way I could have afforded even twenty dollars a month. (Rachel, Columbus Medicaid)

–I wouldn’t have it probably. I’d probably just go without. (Jana, California Medicaid)

3.  While premiums were generally affordable, out-of-pocket costs weighed heavily on Marketplace participants

Understanding of health insurance concepts, particularly deductibles and out-of-pocket maximums, varied widely among participants. Many Marketplace participants reported being overwhelmed by the plan choices and had difficulty weighing different plan options. They admitted being confused by terms like deductibles and out-of-pocket maximums when first signing up. As a result, they reported focusing more on the monthly cost of the coverage in the first year.  That price sensitivity, in combination with their lack of understanding how insurance works, led some to select a plan with a lower premium but higher deductible. Knowledge improved as participants gained experience using their coverage.  Most participants switched plans after their first year of coverage; some sought to avoid large premium increases while others sought a better balance between premiums and deductibles. After using their coverage for a year, some participants reported placing greater emphasis on choosing plans with lower out-of-pocket costs or those in which their providers participated when they renewed their coverage.

No one ever explained to you what deductibles were or what the difference between a premium and a deductible was, or why they were different. (Joanne, Richmond Marketplace)

–It’s just more simplification of the whole thing would be nice. There’s too many options, and in essence you don’t know the results of what you choose, until you actually have an operation, and then you get that $6,600 [bill from the deductible]. (Paul, St. Louis Marketplace)

–I think everybody was more prepared because they were going in this year with better information than the first year. At first it was money and now they’re through it for a year so now, they know that they need a lower deductible and they’re willing to pay a higher premium. (Billy, Columbus Marketplace)

–I did want to stay with my doctor, but the reason I chose the specific plan from the specific organization was balancing out what I pay per month, how it’s subsidized and the deductible… (Roger, Oakland Marketplace)

Availability of premium tax credits helped to make premiums affordable for many Marketplace enrollees.  The premium tax credits available to low and moderate income individuals and families were important to making coverage affordable for participants. Many acknowledged that without the subsidies they received, their premiums would have been too high for them to afford each month. Some participants who had previous coverage through an employer or coverage they purchased on their own, found premiums to be lower in the Marketplace than what they had paid before. While most participants said their monthly premium was affordable, several reported having missed a premium payment because of unexpected expenses in a particular month. These individuals and families were constantly having to balance competing expenses, sometimes having to choose between paying their premium or buying food or keeping their electricity on. In addition, some mentioned it was difficult to determine eligibility for the subsidies due to fluctuations in income.

I had private insurance and I was paying through the nose, $700 and $600…when I signed up for Covered California that first year my rates dropped to like $250 for roughly the same type of coverage. (Po, Oakland Marketplace)

–What I have now, the premium is really low, and my doctors are in it.  (Michelle, St. Louis Marketplace)

–We just haven’t paid [the premium] this month…I’ll pay the bills first. Whatever is left, I’ll deal with the incidentals. (Shannon, Baltimore Marketplace)

–I’m getting a premium, but I know I have to pay it back as soon as I file my taxes. I work as a waiter, and the year that they took my taxes, not much was reported. This year, I know every tax credit I got, I have to pay back as soon as I file. Not looking forward to that. (Zak, Baltimore Marketplace)

Participants expressed concern about their ability to afford the out-of-pocket costs related to their plan deductibles, especially those participants with higher deductible plans. Nearly all participants reported their plan included an annual deductible that required them to pay out of pocket for services before their insurance would take effect. These deductibles ranged from less than $500 to over $6,000 for those with individual coverage and double these amounts for those with family coverage. When asked whether they could afford their full deductible, if needed, responses varied. While some said no, others had included the deductible in the calculation of their costs for the coverage and felt they could afford it. For participants enrolled in high deductible bronze plans, the costs associated with the deductibles prevented them from getting care they felt they needed. These participants described feeling as if they were uninsured for anything other than a catastrophic event. Some described their coverage as a backstop against financial ruin should a severe health care issue arise, rather insurance that covered needed medical services. As a consequence, some participants said they did not go the doctor or get treatment for chronic conditions because they knew they could not afford the costs.

My insurance last year, like I said, the deductible was really high. They didn’t really cover much. I was left with a lot of bills. I would just suffer through anything to not have to pay it. (Kimberly, Richmond Marketplace)

–There’s just too much out-of-pocket. Way too much. (Paul, St. Louis Marketplace)

–I’d really like to see some specialists but I know I wouldn’t be able to afford the copay. I have $2,000-$3,000 out of pocket every year that I, I can’t afford that. That’s why I have health insurance. If I could afford $3,000, why would I need health insurance? (Matthew, Richmond Marketplace)

–It’s a Bronze plan and the deductible is like $6,000, so basically it’s a catastrophic plan and I’ve never used it. (Po, Oakland Marketplace)

–Sometimes, it’s hard making those choices. I don’t want to decide whether to get medical treatment that I crucially need, as opposed to buying dinner. (Womson, Baltimore Marketplace)

Some participants reported making financial trade-offs to purchase plans with lower deductibles so they could get care they anticipated needing during the year. Choosing plans with lower deductibles or those that offered broad provider networks was particularly important for participants with ongoing health needs. Participants with greater understanding of how health insurance works and what to look for in a plan were able to weigh competing priorities of price versus out-of-pocket costs to select plans that would enable them to access the care they expected to need during the year. These participants reported spending a great deal of time examining different options and investigating provider networks so that they could make an informed choice. However, only those with greater financial resources were able to make these choices. Some participants who needed ongoing care said they could not afford the higher premiums associated with the lower deductible plans.

You see, with me being diabetic, high blood pressure…I needed a good medication … you know, a good drug program …so I had to go with the higher premiums. (Alan, Tampa Marketplace)

–At the marketplace, I got the most expensive plan that I could get because I knew I had to have surgery and I got the deductible…I think $1,150… and I knew that my surgery would be covered …but I still got to pay premiums and whatnot and I had to pay the deductible. The same with this year, I had surgery again so I just kept the same insurance. If I didn’t have the issue that I have I probably would have just gotten the basic with the $6,000 cap or whatever. (Brandy, Columbus Marketplace)

4.  The fear of unknown costs was a constant worry for many participants, which caused many to avoid needed care

Despite some challenges, many Marketplace participants, particularly those with lower deductible plans, reported accessing needed care. Participants offered many examples of being able to go to the doctor or get needed care once they enrolled in their Marketplace coverage. They reported getting treatment for chronic conditions, such as diabetes or high blood pressure, and for mental health conditions, including anxiety and depression. Several participants said they were able to get long-standing issues addressed, and in some cases, finally had surgeries they had been putting off for years. Many also said they were able to get check-ups and routine screenings. Coverage of prescriptions drugs was particularly important for many. However, some participants expressed frustration that their drugs weren’t covered or were included in a higher tier, which meant they were forced to pay large monthly copayments.

Before I had health coverage, this was probably 3 years ago, it turns out, I had pneumonia for a month and the cough went on for another year. I just never went to the doctor. I didn’t have insurance. Finally, when I did end up getting coverage, I was told, “You have damage in your lungs from this cough that’s been going on for a year.” I was able to get medication for that. (Chris, Richmond Marketplace)

–The few visits I’ve gone in for would have buried me in debt if I didn’t have insurance. I’ll pay the $65 dollars… if it saves me from getting a $10,000 bill for what I thought was a routine test. (Shannon, Baltimore Marketplace)

–[Since gaining insurance] I filled some cavities and just took care of some stuff before I’d actually lose my front tooth and not be able to fix it. That’s a real scare because that affects your everyday life…people look at you different. (Billy, Columbus Marketplace)

However, when they used their coverage, nearly all Marketplace participants reported receiving an unexpected bill for services they thought were covered. Several participants, even those with lower deductible plans, said they were afraid to use their coverage because they worried about hidden costs, including lab tests or procedures that were not covered.  In some cases, the bills participants received were the result of not yet having met the deductible for the year. However, in other cases, participants reported receiving bills because they failed to get prior authorization for the service, or because the claim was denied, or because the service was provided by a participating provider but at a non-participating facility. Several participants reported bills related to receiving a colonoscopy. In this case, participants scheduled the colonoscopy believing it would be covered as a preventive screening.  However, when a polyp was discovered and removed, they received a bill for the procedure. Participants said it was impossible to anticipate these types of bills in advance, leading some to forego care to avoid unexpected costs. Some participants contacted the insurance companies and were able to resolve the problems. For others, these bills presented a financial burden, and many reported they were still paying them off.

Even though I have coverage, just for me. I still try not to go to the doctor. I try. I don’t want a bill. Every time I go to the doctor, they send me a bill in the mail. Here we go. Fax me this. Fax me that. Send me this. Prove this. Prove that. It’s ridiculous. (Regina, Baltimore Marketplace)

–You get a procedure done that you’re supposed to get done, a colonoscopy. You read the information in your health plan that says, “We cover screenings, screenings are free,” but if you find something it’s not covered. I went in and got it done thinking, I’m perfectly healthy, there’s nothing wrong with me. “Oh no, we had to take something out.” Well I’m glad they found it… Now it’s like I get this series of bills.  Now the premium is higher than it was and you have medical bills. What I’ve done is I’ve not gone in to get blood screens anymore because I don’t know what they’re going to pay for. (Margie, Columbus Marketplace)

–I broke my arm and my hip and everything. I was covered by the insurance but the ambulance wasn’t. It was $900 just to take me to the hospital… Nobody tells you; I didn’t know that it wasn’t covered. I thought it was a free service. (Laura, Tampa Marketplace)

–We never hardly go to the eye doctor anymore, even though we both have glaucoma because it’s like $300, one visit to the ophthalmologist. (Dave, St. Louis Marketplace)

A number Marketplace participants said they had problems affording services not covered by insurance, particularly dental and vision, and finding some doctors.  In particular, participants consistently reported that vision care, glasses, some prescription drugs, and alternative treatments (such as acupuncture or chiropractic care) were not covered.  Some said they had trouble getting dental care or certain medical supplies.  For participants who needed these services and supplies, they either paid out of pocket for the care or did not get the care because they could not afford it. Some also reported difficulty finding certain doctors, particularly mental health providers. In some cases, participants were forced to pay out of pocket to see specialists who were out-of-network.

It covers children but not adult [vision]. I pay for my glasses out of pocket. It’s cheaper than getting vision insurance. (JoAnna, Richmond Marketplace)

–This year, I saw on my card that I had dental… I’d gone to the dentist and I said, “Oh good, I have dental.” It turns out my dental, if somebody knocks my teeth off, I’m covered, but just to get x-rays, or cleaning, or fillings, or anything else I’m not covered. (David, St. Louis Marketplace)

5.  Overall, most were positive about ACA coverage and grateful that coverage was available to them

Most participants were positive about their Medicaid and Marketplace coverage and were grateful that coverage was available to them, particularly those with pre-existing conditions. Many noted that they were able to get care and diagnose long-standing medical issues.  Many with chronic needs like diabetes or asthma, highly valued their coverage and the ability to see doctors and get necessary medications. A number of individuals who had previously had private or employer coverage found Medicaid and Marketplace coverage comparable in benefits and much more affordable. Some participants who had been unable to get coverage in the individual market before the ACA due to pre-existing health conditions were especially grateful for the coverage.

For me I’m glad I have the healthcare because there’s been a couple of situations this year if I didn’t I would have been out of work for a lot longer making less money. In the long run I was able to work because of it. (Zak, Baltimore Marketplace)

–I thank God for the marketplace because if I had to pay that [for surgery] out of pocket, I just would have had to live through the pain and I wouldn’t be able to have kids anymore…if I’d had insurance before, we would’ve caught it much, much sooner. It wouldn’t have been the issue that it is today. (Brandy, Columbus Marketplace)

–I feel grateful too especially about my health care for my kids. My son has had to have surgery. He has had multiple broken bones. Things that would have been so expensive if I was uninsured and paying for it. (Rachel, Columbus Medicaid)

–Insurers turned me down [because my wife had cancer]. That’s why I was glad that they have this. Nobody can deny you because of previous or prior medical problem. That saved my wife because she has so many medical problems. We could never get insurance for her. (David, St. Louis Marketplace)

–I feel blessed because having asthma and being uninsured, to get proper medication and not being able to work because of the asthma… I feel healthier and I am able to work when I can when I need to now. Those four or five years that I didn’t have it [health insurance] was a very rough time. It was a struggle.  (William, Columbus Medicaid)

While they were appreciative of the coverage, many Marketplace participants wanted better coverage that was more affordable.  While people were grateful for coverage, unexpected bills, dealing with insurance companies, and facing known deductibles were sources of stress which made those with Marketplace coverage fearful to use the coverage they had. They were particularly frustrated by the out-of-pocket costs, which were unaffordable to many and wanted insurance that didn’t come with so many hidden costs. They also wanted a more streamlined system that was easier to navigate and better information to know whether services would be covered and what their out-of-pocket costs would be.

Before my surgery, I would say, probably 10 hours a week on the phone, back and forth, getting things approved. Just, I was like, this is causing me more stress than anything I’ve ever dealt with in my whole life… How in God’s name are we giving you so much money? There’s no other industry where I would give you this much money to treat me this way. (Rebecca, Richmond, Marketplace)

–I feel like I do somewhat well. I’m able to meet my bills. I own a home and everything. I have a modest savings, but at the same time, my deductible is extremely high. It’s what I can afford. I know that all it takes is one accident or something to happen and all of my savings is wiped out. (Chris, Richmond Marketplace)

–Yeah I have a mixed feeling…in my prior life when I was working full time and had health insurance. I never had to worry about if I got sick, would I be able to pay this bill or whatever. Now with this insurance and because I only work part time, it’s kind of like, I have insurance but is it going to be covered? Is something not going to work out to my advantage? I’m going to owe money.”   (Joy, Columbus Marketplace)

–Yeah, it’s good to have coverage. Just in general I wish insurance was better in some way, but is this a better option? I’m not so sure it is, not the $6,600 [deductible]. I would rather if we had a choice and I would rather have a better choice. This is not the best thing. (Paul, St. Louis Marketplace)

Without coverage, many felt like they would be stressed, anxious and face negative health and financial consequences.  Across Medicaid and Marketplace groups, participants said they would worry about their health and finances if they lacked coverage. For those with on-going issues, loss of coverage would mean that they could lose access to needed services or prescription drugs. For those without on-going health issues, they feared they would not be able to access primary and preventive care and that an emergency or accident would have devastating financial consequences.

I would probably suffer an anxiety attack from shock! I would limit my doctor’s visits to extreme emergencies and take my medication every other day instead of daily.  (Kym, Baltimore Medicaid)

–I would not go to the doctor for well visits – or even if I were sick. I would only go to the emergency room in a crisis or to the free medical clinic at my church. I would definitely be worried and “what if I get sick” is always hanging over my head.  (Corey Ann, Columbus Marketplace)

–I feel very secure having the 87 silver plan from Covered CA.  If I didn’t have coverage I might move to Canada or to another country where I could buy health insurance. (Roger, Oakland Marketplace)

–PANIC!! I would feel scared and vulnerable! I would cut back on utilization and wait longer to seek care. (Julia, Tampa Marketplace)

Conclusion

Millions of people have gained access to health insurance coverage under the ACA through Medicaid and the Marketplaces. Focus groups with low-income individuals who have Medicaid or Marketplace coverage in California, Florida, Maryland, Missouri, Ohio, and Virginia reveal that many are struggling financially—they have difficulty paying their bills each month and many are burdened by debt (including medical debt). Their new coverage did not change these underlying financial struggles. However, gaining coverage enabled many to access care they needed to treat ongoing conditions giving them peace of mind.

Participants with Medicaid were generally able to access care with few out-of-pocket costs. This protection from out-of-pocket costs provided by Medicaid was important as participants with Medicaid had incomes below 138% FPL, and thus, had limited capacity to shoulder any extra costs. For Marketplace participants, premiums were generally affordable largely due to the tax credits, but some struggled with their monthly payments. In addition, out-of-pocket costs and, the fear of unexpected bills were a constant worry for Marketplace participants and caused many to avoid needed care. In states that did not expand Medicaid, individuals with incomes between 100-138% FPL can receive coverage through the Marketplace, but coverage through Medicaid would be more affordable with fewer out-of-pocket costs if their state expanded.

Most participants were positive about gaining coverage and grateful that coverage was available to them, particularly those who had been barred from coverage due to pre-existing conditions. While many Marketplace participants wanted more affordable coverage and protection from unexpected costs, they agreed that without coverage, they would not be able to access needed care and would face more stress, anxiety and worry about getting sick and how to pay for care.

 

1. Garfield, R and K Young. How Does Gaining Coverage Affect People’s Lives? Access, Utilization, and Financial Security among New Insured Adults. (Washington, DC: Kaiser Family Foundation), June 19, 2015. Available at: https://modern.kff.org/health-reform/issue-brief/how-does-gaining-coverage-affect-peoples-lives-access-utilization-and-financial-security-among-newly-insured-adults/ ↩︎
2. Hamel, L, et. al. The Burden of Medical Debt: Results from the Kaiser Family Foundation/New York Times Medical Bills Survey. (Washington, DC: Kaiser Family Foundation), January 5, 2016. Available at: https://modern.kff.org/health-costs/report/the-burden-of-medical-debt-results-from-the-kaiser-family-foundationnew-york-times-medical-bills-survey/ ↩︎

The 2016 Survey of Americans on the U.S. Role in Global Health is the latest in a series of surveys designed, conducted, and analyzed by the Kaiser Family Foundation in order to shed light on the American public’s perceptions, knowledge, and attitudes about the role of the United States in efforts to improve health for people in developing countries. This most recent survey updates trends on Americans’ perceptions of the most urgent problems facing developing countries, views on U.S. spending on health, and U.S. priorities for women’s health in developing countries. It also explores new questions on Americans’ awareness of the Zika virus outbreak and recent U.S. efforts to combat the outbreak both at home and in developing countries.

Executive Summary

The latest survey finds that a majority of the public wants the U.S. to take either the leading role or a major role in trying to solve international problems generally, as well as in improving health for people in developing countries specifically. However, improving health for people in developing countries is not one of the public’s top priorities for the ways in which the U.S. might engage in world affairs, falling behind fighting global terrorism and protecting human rights. Seven in ten Americans believe that the current level of U.S. spending on health in developing countries is too little or about right, yet the public is somewhat skeptical about the ability of more spending to lead to progress, with more than half saying that spending more money will not lead to meaningful progress. Republicans and independents are more skeptical than Democrats, and these partisan differences have increased over time. Another notable trend is the decreasing visibility of U.S. efforts to improve health in developing countries; just over a third of the public says they have heard “a lot” or “some” about these efforts in the past 12 months, a decrease of 21 percentage points since 2010.

The most recent survey took an in-depth look at the public’s views on the U.S. role in improving women’s health, with a particular focus on the recent outbreak of the Zika virus in Central and South America. Most Americans view promoting opportunities for women and girls as an important priority for U.S. engagement in foreign affairs, and about half (52 percent) say U.S. government is currently not doing enough to improve the lives of women and girls in developing countries. The public also largely recognizes that most women in developing countries are disadvantaged compared with their male counterparts, and that most women in developing countries (including those affected by Zika) do not have adequate access to birth control.  Despite this, there are mixed reactions to U.S. involvement in this area. While most want the U.S. to help women in Zika-affected countries access birth control, the public is split into equal thirds who say the U.S. is doing enough or not doing enough to help women in these countries make family planning and preventive health decisions (with another third unsure).

Most See a Major Role for U.S. in World Affairs Generally and in Global Health Specifically

Broadly, the public is largely supportive of the U.S. playing a significant role in trying to solve international problems. About six in ten Americans (57 percent) say the U.S. should play at least a major role in world affairs, including 16 percent who say the U.S. should take the leading role and 41 percent who say the U.S. should play a major role but not the leading one. This is a decline from December 2015, when 65 percent said the U.S. should play at least a major role in world affairs, but similar to results from 2012.

Similarly, six in ten Americans (61 percent) say the U.S. should play at least a major role in improving health for people in developing countries, including 15 percent who say we should take the “leading role” and 46 percent who say a “major role.” While majorities of Democrats, Republicans, and independents say the U.S. should take at least a major role in trying to solve international problems and improving health for people in developing countries, Democrats are somewhat more likely to support such a role.

The majority of Americans think President Obama and his administration have made improving health for people in developing countries about the same level of a priority (54 percent) or a higher priority (27), compared to previous presidential administrations, with only about one in ten (11 percent) saying President Obama has made it a lower priority. Consistent with the overall sense that the U.S. should take a major role in this area, over four in ten (43 percent) say they would like the next president to make improving health for people in developing countries an even higher priority, while a similar share (39 percent) say the current priority level is about right and just 14 percent would like it to be a lower priority. Democrats are more likely to say that President Obama has made improving health a higher priority (38 percent) and are more likely to say they would like to see the next president make it a higher priority (53 percent) compared with independents (23 percent and 42 percent) or Republicans (21 percent and 31 percent).

Improving Health in Developing Countries Viewed as One of Many Important Priorities

When it comes to different ways in which the U.S. might engage in world affairs, fighting global terrorism (64 percent) and protecting human rights (60 percent) top the public’s priority list. These are closely followed by protecting the environment and fighting climate change (51 percent) and helping out in areas affected by natural disaster (50 percent).

While improving health for people in developing countries does not top the list of priorities, more than one-third (35 percent) of Americans say it is one of the top priorities, and another 51 percent deem it an important priority. This is similar to the share that say promoting opportunities for women and girls around the world (36 percent) and improving education in developing countries (34 percent) are a top priority, and slightly more than the share who say helping to reduce poverty in developing countries (30 percent) is a top priority. Fewer prioritize helping refugees from countries like Syria (20 percent), promoting democracy in other countries (19 percent), and providing military assistance to developing countries (13 percent).

Despite the fact that improving health for people in developing countries does not top the public’s list of priorities for world affairs, two issues related to health – hunger and clean water – are named by the largest shares of Americans as the most urgent problems facing developing countries. In an open-ended question, one in four Americans name hunger or lack of food as the most urgent problem facing developing countries, followed closely by 23 percent who mention clean water. When the question is framed in terms of the most urgent health problem facing developing countries, the top two responses are similar: 28 percent name hunger or malnutrition and 22 percent say clean water.

The share of Americans who name clean water as an urgent problem in both these questions has increased significantly in the past four years. In 2012, only 7 percent of Americans said that clean water was one of the most urgent problems facing developing countries, and just 12 percent named it as the one of the most urgent health problems. The increased concern regarding access to clean water in developing countries may be due to recent media attention about water quality issues in the U.S., particularly surrounding the water crisis in Flint, Michigan.

The focus on clean water and reducing hunger is also evident in opinions about priorities for U.S. efforts to improve health in developing countries. Topping the list, 69 percent of Americans say that improving access to clean water should be one of the top priorities. This is slightly more than the percent who say by combating global outbreaks of diseases like Ebola and Zika (62 percent), improving children’s health (61 percent), and reducing hunger and malnutrition (61 percent) are top health priorities. While others – including combatting specific diseases like HIV/AIDS, malaria, tuberculosis, and polio as well as improving access to family planning – fall farther down the list, majorities of the public view each one of these areas as important, with fewer than a quarter saying each is “not that important.”

Mixed Attitudes on Whether U.S. Efforts Have Led To Progress

When asked about the success of U.S. global health efforts to date, the majority of the public, 67 percent, believes that over the past ten years, at least some progress has been made as a result of U.S. efforts to improve the health for people in developing countries, though relatively few (12 percent) feel that “a lot” of progress has been made. These views are shared across the political spectrum, with large shares of Democrats, independents, and Republicans all saying that at least some progress has been made.

At the same time that most Americans believe progress has been made as a result of U.S. global health efforts, overall visibility of these efforts appears to have decreased. Just over a third (36 percent) of the public in the most recent survey say that in the past year they have heard “a lot” or “some” about U.S. government efforts to improve health for people in developing countries, down from nearly half in 2013 and 2012, and 57 percent in 2010.

More Support For Global Health Spending Than For Foreign Aid

Previous Kaiser surveys have found that the public vastly overestimates the amount of the federal budget that is actually spent on foreign aid. In December 2015, just 3 percent of Americans correctly stated that 1 percent or less of the federal budget is spent on foreign aid, and on average, Americans say spending on foreign aid makes up 31 percent of the federal budget.¹  The 2016 survey finds that half of Americans say the U.S. is spending “too much” on foreign aid while only one in five say the U.S. is spending “too little” (19 percent) or the right amount (21 percent). Yet, after hearing the fact that foreign aid spending is about one percent of the federal budget, the percent of individuals who say spending is “too much” drops from 49 percent to 30 percent.

The public is more supportive of U.S. spending on global health than foreign aid more generally. When asked specifically about global health spending, seven in ten say the U.S. is now spending too little (32 percent) or about the right amount (38 percent) on efforts to improve health for people in developing countries, and fewer than one-fifth say the U.S. is spending too much (18 percent).  Over time, opinions on U.S. spending on improving health in developing countries have remained fairly stable, but the most recent survey does record the lowest share (18 percent) of Americans saying that the U.S. is spending too much on health in developing countries. This share is down from 30 percent in December 2015, a decrease that was seen across partisan subgroups.

Partisan Differences In Views On U.S. Global Health Spending

Similar to partisan differences on the role of government and federal spending on domestic priorities found in other surveys, there are differences in views of U. S. spending on global health by political party identification. Democrats are more likely to say the country is spending “too little” than “too much” (49 percent vs. 9 percent), whereas Republicans are more likely to say the opposite, that the country is spending “too much” rather than “too little” (31 percent vs. 14 percent). Independents fall in the middle, with 32 percent saying the U.S. spends “too little” and 18 percent saying the U.S. spends “too much” on health in developing countries.

At the same time that the public generally supports maintaining or increasing government spending on health in developing countries, there is also doubt about the potential effectiveness of increased spending from the U.S. and other developed nations. More than half of Americans (57 percent) believe that spending more money will not make much of a difference in improving health for people in developing countries, while about four in ten (39 percent) say that more spending will lead to meaningful progress.

Republicans and independents are particularly skeptical, with majorities saying increased spending will not make much of a difference, 71 percent and 60 percent, respectively. This is compared to nearly six in ten Democrats (56 percent) who say increased spending will lead to meaningful progress and 42 percent who say increased spending will not make much of a difference.

These partisan differences have increased over time, from a margin of 13 percentage points separating the shares of Republicans and Democrats who believed spending more would lead to progress in 2009, compared to a difference of 32 percentage points today.

Americans see a variety of benefits, both at home and abroad, to U.S. spending to improve health in developing countries. About three-fourths (74 percent) say such spending helps protect the health of Americans by preventing the spread of diseases like Ebola and Zika, and nearly six in ten (59 percent) say it helps to improve the image of the U.S. throughout the world. Two-thirds (68 percent) also believe such spending helps make people and communities in developing countries more self-sufficient. Americans are more skeptical about the impact of such spending on U.S. national security and the U.S. economy, with about four in ten saying spending helps in these areas (41 percent each) and over half saying it doesn’t have much impact (56 percent each). Partisan differences exist here, too, with Democrats more likely than Republicans to say that spending on global health helps in each of these areas. Still, majorities of Republicans say spending helps protect Americans from disease (68 percent), helps make people and communities in developing countries more self-sufficient (59 percent), and helps to improve the U.S. image around the world (52 percent).

Determining How Global Health Spending Should Be Directed

In terms of which criteria should be used to determine allocation of U.S. spending on health in developing countries, the public, regardless of party identification, ranks two factors at the top of the list: whether a problem mainly affects children, and whether the U.S. could be threatened by a similar health problem (nearly seven in ten say each of these should be “very important” in determining how U.S. dollars are spent). Roughly half also say “how many people die each year from a given health problem” (55 percent) and “the number of lives saved relative to the amount spent” (49 percent) should be very important criteria. U.S. foreign policy concerns rank lower on the list, with 41 percent placing great importance on whether a country is friendly to the U.S., and just over one-third (36 percent) saying the same about whether spending is in the interest of U.S. foreign policy.

When asked how funds should be directed, a majority of the public thinks the U.S. should give money to international organizations like the Global Fund to Fight Aids, Tuberculosis and Malaria (77 percent), the United Nations and the World Health Organization (71 percent), or directly to U.S. based non-profits operating programs in developing countries (65 percent). Half of Americans also say the U.S. should give money directly to local non-profits based in developing countries. On the other side, majorities say the U.S. should not give money directly to religious or faith-based organizations (55 percent) or directly to governments in developing countries (65 percent).

More broadly, seven in ten Americans (69 percent) want the U.S. to participate in international efforts when giving aid to improve health in developing countries, compared to 28 percent who want the U.S. to operate on its own so it has more control over how the money is spent and gets more credit and influence in the country receiving aid.  The share who want the U.S. to participate in international efforts has increased steadily over the past seven years, from 55 percent in 2009 to 69 percent in 2016.

 

Many health issues in developing countries have a disproportionate impact on women and girls, and the most recent survey took an in-depth look at the public’s views on the U.S. role in improving women’s health, with a particular focus on the recent outbreak of the Zika virus in Central and South America. As noted above, nearly all Americans (90 percent) view promoting opportunities for women and girls as an important priority for U.S. engagement in foreign affairs, with over a third (36 percent) deeming it one of the top priorities.

The public also largely recognizes that most women in developing countries are disadvantaged compared with their male counterparts. Large majorities say that women in developing countries are worse off than men in their legal rights (81 percent), ability to get a good education (78 percent), likelihood of living in poverty (71 percent), and their ability to get the health care services they need (63 percent).

Interestingly, men and women provide similar responses, with majorities of both sexes saying that women are worse off. The only item in which women are more likely than men to say that women are worse off is the likelihood of living in poverty with 75 percent of women saying the women are worse off compared to 67 percent of men.

More than half (52 percent) of Americans think the U.S. government is not doing enough to improve the lives of women and girls in developing countries, while about one-third of Americans (32 percent) think the U.S. government is currently doing enough and 4 percent say the U.S. is either doing too much or shouldn’t be involved. A large majority of Democrats (68 percent) and a slim majority of independents (52 percent) say the U.S. government is not doing enough, while Republicans are more evenly split with 42 percent saying the U.S. government is doing enough and 36 percent saying it is not doing enough.

The Zika Virus

One recent global health development that has a disproportionate impact on women in developing countries is the Zika virus outbreak. The mosquito-borne Zika virus, which has mostly affected South and Central American countries and has been associated with birth defects in babies born to infected mothers, was declared a global health emergency by the United Nations on February 1^st.²  Eight in ten Americans say they have heard or read about the Zika virus, with 23 percent saying they have heard or read “a lot” and 32 percent saying they have heard “some.”

The majority of the American public is aware of the potential ways to spread the virus and potential effects of the virus. About three-quarters (73 percent) are aware that a person can become infected through a bite from an infected mosquito, more than half (53 percent) are aware that a person can become infected by having sex with someone who is infected, and 64 percent are aware that it does not appear to be spread through shaking hands with an infected person.

Six in ten Americans know about the connection between the Zika virus and birth defects in children born to infected mothers. This connection was confirmed by the CDC on April 13^th, 2016.³ 

Given this link, concerns have been raised about women’s access to contraception in Zika-affected areas⁴ . Three-fourths (76 percent) of Americans say that most women in developing countries do not have adequate access to birth control while just 12 percent believe these women have adequate access and another 12 percent are unsure. When asked specifically about developing countries affected by the Zika virus, results are somewhat similar. Most (65 percent) of those who have heard or read about the Zika virus say women in developing countries affected by the virus do not have adequate access to birth control, while 16 percent believe they do have adequate access and 18 percent are unsure.

Women are somewhat more likely than men to know about the connection between the Zika virus and birth defects in babies born to infected mothers. Sixty-four percent of women report knowing about this connection compared to 57 percent of men. In addition, women are more likely than men to worry that they or someone in their family will be affected by the Zika virus and to worry that the U.S. will see a large number of cases of the Zika virus in the next 12 months. Nearly half of women (46 percent) are “very” or “somewhat” worried that the U.S. will see a large number of Zika cases, compared to 35 percent of men. Three in ten women (31 percent) are worried that they or someone in their family will be affected by the Zika virus, compared to 23 percent of men.

Despite this, fewer than one in ten Americans (9 percent) report they have changed their travel plans to avoid countries affected by Zika, including 12 percent of women of reproductive age (those between the ages of 18 and 49).

Attitudes Towards U.S. Efforts to Fight the Zika Virus

Among those who have heard or read anything about the Zika virus, a majority give mostly positive ratings to government efforts to combat Zika in the United States, though many are unsure about U.S. efforts in Central and South America. Six in ten (58 percent) say the U.S. is doing enough to protect Americans from the virus, while one in four (26 percent) say the U.S. is not doing enough and another 15 percent say they don’t know enough to say. Comparatively, four in ten (38 percent) say the U.S. is doing enough to fight the Zika virus in Central and South America, while 26 percent say the U.S. is not doing enough and almost a third (32 percent) say they don’t know enough to say. Two percent volunteer that the U.S. is doing too much in this area or should not be involved.

Attitudes are also split on whether the U.S. is doing enough to help women in developing countries who may be at risk for the Zika virus make family planning and preventive health decisions. One-third (34 percent) of Americans who have heard or read anything about Zika, say the U.S. government is not doing enough, which is roughly equal to the share who say it is doing enough (33 percent). Democrats are more likely to say the U.S. government is not doing enough (45 percent), compared to 33 percent of independents and 19 percent of Republicans.

When asked whether the U.S. should or should not take several actions in response to the Zika virus, nine in ten of those who have heard or read anything about Zika say the U.S. should invest resources to prevent the spread of Zika in the U.S. More than eight in ten (83 percent) also say the U.S. should invest more money in research on Zika, while three-fourths want the U.S. to help women in Zika-affected countries access birth control (77 percent), and provide financial aid to Zika-affected countries (72 percent).

The Kaiser Family Foundation 2016 Survey of Americans on the U.S. Role in Global Health was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The survey was conducted March 1-26 2016, among a nationally representative random digit dial telephone sample of 1,508 adults ages 18 and older, living in the United States, including Alaska and Hawaii (note: persons without a telephone could not be included in the random selection process). Computer-assisted telephone interviews conducted by landline (606) and cell phone (902, including 549 who had no landline telephone) were carried out in English and Spanish by Princeton Data Source under the direction of Princeton Survey Research Associates International (PSRAI). Both the random digit dial landline and cell phone samples were provided by Survey Sampling International, LLC. For the landline sample, respondents were selected by asking for the youngest adult male or female currently at home based on a random rotation. If no one of that gender was available, interviewers asked to speak with the youngest adult of the opposite gender. For the cell phone sample, interviews were conducted with the person who answered the phone. The survey fieldwork was funded through a grant from the Bill & Melinda Gates Foundation.

The combined landline and cell phone sample was weighted to balance the sample demographics to match estimates for the national population using data from the Census Bureau’s 2014 American Community Survey (ACS) on sex, age, education, race, Hispanic origin, nativity (for Hispanics only), and region along with data from the 2010 Census on population density. The sample was also weighted to match current patterns of telephone use using data from the January-June 2015 National Health Interview Survey. The weight takes into account the fact that respondents with both a landline and cell phone have a higher probability of selection in the combined sample and also adjusts for the household size for the landline sample. All statistical tests of significance account for the effect of weighting.

The margin of sampling error including the design effect for the full sample is plus or minus 3 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below.  For results based on subgroups, the margin of sampling error may be higher. Sample sizes and margin of sampling errors for other subgroups are available by request. Note that sampling error is only one of many potential sources of error in this or any other public opinion poll. Kaiser Family Foundation public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

 

1. B DiJulio, M Norton, and M Brodie, Americans’ Views on the U.S. Role in Global Health, Kaiser Family Foundation, January 20, 2016. https://modern.kff.org/global-health-policy/poll-finding/americans-views-on-the-u-s-role-in-global-health/ ↩︎
2. World Health Organization, February 1, 2016. http://www.who.int/mediacentre/news/statements/2016/emergency-committee-zika-microcephaly/en/ ↩︎
3. Centers for Disease Control and Prevention, April 13, 2016. http://www.cdc.gov/media/releases/2016/s0413-zika-microcephaly.html ↩︎
4. J Kates, J Michaud, and A Valentine, Zika Virus: The Challenge for Women, Kaiser Family Foundation, February 1, 2016. https://modern.kff.org/global-health-policy/perspective/zika-virus-the-challenge-for-women/ ↩︎

This brief reviews Kentucky’s experiences expanding coverage under the Affordable Care Act (ACA) to highlight lessons learned about what has contributed to the state’s implementation success. It also highlights changes being made to the Marketplace and Medicaid coverage in Kentucky and the potential impact of these changes moving forward. Through case studies and other research, the Kaiser Family Foundation has tracked ACA implementation experiences in Kentucky and several other states through the end of the second open enrollment period in January 2015 (Appendix). Going forward, state experiences through the third open enrollment period and into early 2016 will be examined. Key findings based on the work conducted to date include the following:

• Kentucky has had one of the most successful ACA implementation experiences among states. Beginning in 2014, the state expanded Medicaid to low-income adults and built its own State-Based Marketplace, kynect. Since implementing the ACA, Kentucky’s uninsured rate fell from 16% in 2013 to 8% in 2014, one of the largest reductions in the country.¹  A number of components contributed to Kentucky’s enrollment success. One of the most pivotal components was the single, integrated eligibility system it built for kynect and Medicaid. Other elements included strong leadership and collaboration, broad outreach and marketing efforts, and a robust and diverse network of enrollment assistance.
• Following the expansion, Medicaid enrollees generally have been able to access needed services, with some challenges for specific services and in certain areas. Access for enrollees in Marketplace coverage varies by choice of plan. Per enrollee costs of care for Medicaid expansion adults have been lower than anticipated, and the state has reported cost savings as a result of the expansion.
• Kentucky’s newly elected Governor has begun transitioning the fully state-run Marketplace, kynect, to a federally-supported State-Based Marketplace. With this transition, the state will rely on Healthcare.gov for some functions, including Marketplace eligibility determinations and enrollment.²  In addition, the Governor plans to seek a waiver to make changes to the Medicaid expansion.³  Looking ahead it will be important to assess how these changes may reshape coverage in Kentucky, including how the Marketplace transition affects Medicaid and Marketplace outreach and enrollment, insurer participation and plan offerings, and, if implemented, the impact of the Medicaid waiver.

What has been Kentucky’s ACA implementation experience to date?

Kentucky has had one of the most successful ACA implementation experiences among states. Beginning in 2014, the state expanded Medicaid to low-income adults and built its own State-Based Marketplace, kynect. Since implementing the ACA, Kentucky’s uninsured rate fell from 16% in 2013 to 8% in 2014, one of the largest reductions in the country.⁴  Much of this reduction is attributed to the Medicaid expansion. Total enrollment in Medicaid grew by over 570,000 or 94% from the pre-ACA baseline period of July – September 2013 to December 2015.⁵  As of December 2015, the program covered roughly a quarter of the state’s population. Nearly 94,000 people are enrolled in coverage through kynect, which represents about 38% of the potential Marketplace population.⁶ 

Several components have contributed to Kentucky’s success implementing the ACA, including strong leadership and collaboration; a high-functioning integrated eligibility system for Medicaid and Marketplace coverage; broad outreach and marketing efforts; a robust and diverse network of enrollment assistance; and initiatives to strengthen access to care for Medicaid enrollees as more individuals enroll as discussed below.

Leadership and Collaboration

Stakeholders reported that kynect and Medicaid officials were highly engaged and personally committed to achieving success and were often present at outreach and enrollment events. The previous Governor made successful implementation of the coverage expansions in 2014 a priority, and this leadership carried down through state officials. Many of the state agencies involved in health reform implementation, including Medicaid, kynect, and the Department for Community Based Services, are peer agencies housed within the Kentucky Cabinet for Health and Family Services. Stakeholders indicated that this structure helped promote strong working relationships among the agencies and that they worked hand-in-hand throughout planning and implementation of the coverage expansions. There was also close coordination between kynect and the Department of Insurance. Further, the state engaged with other stakeholders early and often, including the community, advocates, assisters, agents, and providers.

“We have weekly stakeholder meetings over at kynect. It gets us all in a room and it’s a lot harder to fuss when you’re looking at somebody because we’re all peer agencies. We’re all under the same umbrella but it’s easy to get frustrated. If you all get in a room once a week it’s hard to stay frustrated because you just ask the questions and work through things. I think they’ve been very effective.”—Medicaid official

Eligibility System

One of the most pivotal components of Kentucky’s enrollment success is the single, integrated eligibility system it built for kynect and Medicaid. When the ACA coverage expansions took effect in January 2014, Kentucky launched a new integrated eligibility system that made eligibility determinations for both kynect Marketplace coverage and for non-disabled Medicaid groups, including children, pregnant women, parents and adults newly eligible through the ACA Medicaid expansion. While the Federally-Facilitated Marketplace (FFM), Healthcare.gov, and most State-Based Marketplaces experienced large system problems during the initial year of implementation in 2014, Kentucky was one of the few states that had a largely successful system launch. This successful system launch facilitated streamlined enrollment of eligible individuals in both kynect and Medicaid coverage.

Stakeholders point to a number of factors that contributed to the state’s system success. One key component is that it is a fully integrated system, which eliminates the need to transfer data between kynect and Medicaid. Moreover, consumers only receive a single notice of their determination rather than separate notices from each program, minimizing confusion. At its outset, the system also was able to make real-time determinations for most cases and could handle complex situations in which members of a family may be eligible for different types of coverage. The system also included features that consumers valued, such as a pre-screen feature that allowed consumers to anonymously shop for coverage after answering a few quick questions, as well as the ability to electronically upload documentation when it is required.

“It’s a one stop shop. You know, it takes maybe 30 to 45 minutes. You enter your information. If you’re Medicaid eligible, you pick a Medicaid managed care organization. If you’re QHP eligible, you pick a qualified health plan. So, certainly that one stop shop streamlined application process I think really contributed to our success.” –kynect official

The system’s success was underpinned by the state’s close work with contractors, ongoing implementation of workarounds and incremental fixes as needed, and use of data and feedback loops to identify problems. Stakeholders stressed that close collaboration among policy staff, IT systems staff, and contractors was vital during both the initial build of the system and on an ongoing basis to manage the system and quickly resolve problems. Contractors were co-located on site with state policy and IT staff to facilitate close and constant communication. Stakeholders also noted that the state would implement workarounds and incremental fixes when it faced early problems or glitches with its system, which allowed for continuous improvement. Medicaid and kynect officials also pointed to the importance of using data and feedback loops to understand how the system was functioning and identify problems. During the initial launch, officials reported that they closely tracked statistics to monitor system operations and would target fixes or changes as necessary when the data pointed to problems.

The state continued to refine and enhance the system over time. The system did face some early technological glitches, but stakeholders generally agreed that many were resolved by the end of the first open enrollment period. The state implemented several enhancements to the system prior to the second open enrollment period. These enhancements included allowing consumers to see premium costs with the advance premium tax credits applied when shopping for plans. In addition, the system was adjusted to display silver plans at the top of the plan list for people who qualify for cost-sharing reductions, given that these plans have the best value for these consumers by providing access to the cost-sharing reductions. Stakeholders reported that the system functioned very smoothly during the second open enrollment period, which allowed more individuals to self-enroll and freed up assistance resources to address more complex cases. As of the end of the second open enrollment period, the state was planning for continued improvements and enhancements, including addressing system problems affecting enrollment for immigrants and refugees and consumers changing plans at renewal. The state was also planning to move all Medicaid determinations, including disability-based determinations, as well as determinations for other social service programs into the new system and to launch a tablet-based application.

The kynect website included features to assist individuals seeking health insurance. These features included informational videos, a countdown clock to the end of open enrollment, an option to subscribe to email updates, a toll-free number, and information about how to obtain local in-person assistance. The website provided resources in other languages as well as a toll-free number for language assistance and a full Spanish version of the website was available. Kynect also launched a mobile app through which individuals could identify enrollment events, find an agent or assister, complete a pre-screen for eligibility, and anonymously shop. It planned to enhance the app over time to allow individuals to create an account, take images of documentation, and browse for plans, including Medicaid managed care plans (Figure 1).

Outreach and Marketing

Kentucky used state-specific branding for kynect, which helped detach the coverage expansions from the ACA or “Obamacare.” This state-specific branding was particularly important in Kentucky, since many residents are distrustful of government programs and not politically supportive of the ACA. Kentucky directed all residents seeking health insurance to “kynect, Kentucky’s Health Care Connection.” It also created animated characters that were representative of different types of Kentuckians who could benefit from the new coverage options, to which stakeholders felt consumers responded well (Figure 2). The effectiveness of the state-specific branding is supported by survey results that show that, although Kentucky residents lean negative in their views of the ACA law as a whole, they are more positive towards the programs the law has created in the state. For example, about half (49%) of residents have an unfavorable view of the health care law, but 42% have a favorable view of kynect and 63% have a favorable view of the Medicaid expansion. However, there remain large gaps in knowledge and understanding of these components of the law, with about 30% saying they don’t know enough to say their view on kynect and 13% not reporting a view on the Medicaid expansion.

I think the approach that the Governor took on this whole thing was to not talk about it in terms of Obamacare or the Affordable Care Act. He talked about it in terms of…Kentucky’s health… it’s not about politics…. It’s about improving the health of our state, so that kind of takes the argument out of it. – kynect official

Kentucky conducted statewide marketing across diverse channels. The state launched an extensive statewide marketing campaign to educate individuals about the new coverage options and used diverse channels, including television, radio, print, billboards, and social media. Messaging during the early part of the initial open enrollment period conveyed a simple, straightforward message about the availability of new coverage options and focused on raising brand awareness of kynect. In year two, outreach messaging shifted away from raising awareness to providing personal testimonials and emphasizing the importance and value of coverage. Stakeholders also indicated that messaging focused more on the availability of financial help and affordable coverage options during year two. For example, kynect’s advertising included the phrase, “If you think you can’t afford to be insured, think again” (Figure 3).

In addition to a broad marketing campaign, the state and other stakeholders engaged in an expansive range of local level enrollment efforts. For example, kynect and Medicaid officials and assisters attended events throughout the state, including the state fair, where they distributed information about coverage options and encouraged people to enroll (see Box 1). They distributed reusable shopping bags at these events, which were viewed as highly effective in raising awareness of kynect. Additionally, kynect officials travelled across the state in branded RVs to promote coverage and get people enrolled. During the initial open enrollment period, kynect also established an enrollment storefront in the community that was staffed with assisters, brokers, and kynect and Medicaid staff. Stakeholders noted that this storefront was enormously successful and particularly helpful for handling complex cases because all of the people with the needed expertise were in the same room. Building on this success, kynect provided two enrollment storefronts during year two as well as enrollment kiosks in various locations. The state and assisters also hosted local enrollment events. For example, kynect promoted a “Sign-up Saturday” event at local libraries. In some cases, assisters used local media outlets to reach large numbers of consumers. For example, some assisters participated in a weekly local news station call-in show, during which consumers could call in with coverage questions.

The state and assisters utilized targeted enrollment efforts to connect with hard-to-reach populations. Stakeholders described focused efforts to reach the Latino community, including utilizing more Spanish-speaking assisters and volunteers and marketing through Spanish media channels. Assisters also targeted outreach to the immigrant community, African Americans, young adults, veterans, and the LGBT community. In addition, the state launched an initiative to enroll individuals in coverage as they re-enter the community upon release from prison or jail.

Enrollment Assistance

Kentucky established an extensive consumer assistance network that drew on existing assistance networks, including those providing Medicaid and CHIP enrollment assistance, health clinics, community-based organizations, hospitals, and advocacy organizations. Kynectors, as enrollment assisters are called in Kentucky, had varied backgrounds and were able to provide personalized assistance to the communities they served. Some kynectors also said that, because of their personal ties to the community, local organizations, schools, and other groups were often willing to work closely with them and sometimes offered resources, such as space and equipment, to support enrollment. Recruiting trusted members of the community to serve as kynectors was particularly important in rural eastern Kentucky where kynectors achieved significant enrollment success. In addition to kynectors, insurance brokers played an important role in enrollment. Kynect undertook significant efforts to engage brokers in enrollment and, despite some early fears and concerns among brokers, a large number of brokers were certified and often worked collaboratively with assisters to enroll uninsured people. This relationship between kynectors and brokers became increasingly strong over time. Providers, particularly community health centers (CHCs), also played a key role in outreach and enrollment by conducting both in-reach to their uninsured patients as well as outreach to the broader community.

Agents felt very threatened about it, so very early on, both the Commissioner of Insurance and our folks assured agents that they’re going to have a role and they’re going to have a very important role. And so when we set up the advisory board, we established several subcommittees and one of them was a subcommittee called Agents and Navigators. … The idea was that we were going to put the two competing forces … together and see if we couldn’t work out some kind of agreed to relationship. – kynect official

Kentucky utilized a regionally-based hub and spoke structure to organize and coordinate assister activities. Under this model, several lead regional organizations helped organize and coordinate activities of kynectors in their area, disseminated updates and information from the state to kynectors, and provided feedback on implementation to the state. In some areas, broader coalitions of stakeholders also helped coordinate and organize activities. For example, in Louisville, the local Board of Health established an outreach and enrollment coalition that coordinated efforts, shared best practices, and provided feedback on experiences in the field to the state. Kynectors also used shared online calendars to indicate where and when they were planning events, which helped prevent gaps and overlaps in outreach and enrollment efforts.

The state provided readily available support to consumer assisters. Kentucky established resources for kynectors and brokers to obtain support when they had questions or needed assistance while helping a consumer. Kynectors had dedicated telephone lines to reach call center staff, which helped reduce long waits when they needed support. Kentucky also maintained close and regular communication with kynectors to both share updates and information and receive feedback on implementation.

Access to and Utilization of Care

There have been efforts underway at multiple levels to help increase health insurance and health care literacy among individuals. For example, kynect created a “how to kynect” brochure that provides a glossary, information on how to find a primary care provider and how to use care, and healthy living tips. Kynectors have also developed educational materials to help improve health and health care literacy among newly covered individuals.

Medicaid enrollees are accessing needed care. An independent analysis of the first year of the Medicaid expansion in Kentucky found that, compared to previously eligible parents, those in the Medicaid expansion group accessed providers at a higher rate and had increased utilization of preventive services.⁷  Stakeholders suggest that part of this pattern might be due to the previous lack of health insurance leading to first-time screenings and appointments particularly for diabetes, heart disease, and other chronic conditions. In addition, there has not been a spike in overall emergency room use as had been anticipated.

There are some access challenges for certain types of services and providers. These challenges include access to certain specialties and behavioral health services and access in rural areas. However, stakeholders pointed out that these challenges are reflective of overall provider shortages and not specific to Medicaid. Kentucky engaged in efforts to expand access to behavioral health providers by allowing Medicaid to contract with individual providers (rather than through community mental health centers) and additional provider types (such as licensed drug alcohol counselors) and adding new services to Medicaid (such as additional services for substance use treatment). Stakeholders in Kentucky also pointed to challenges recruiting dental providers, although they noted that access varies across the state, with greater provider availability in Louisville where there is a dental school. As of the end of the second open enrollment period, Kentucky was focused on increasing care management for Medicaid enrollees who are super-utilizers of emergency department care. In addition, Kentucky added behavioral health services into the Medicaid managed care contract in 2014, and was holding regular meetings with the plans and educational forums with behavioral health providers to support integration of these services.

Overall, Kentucky residents, particularly those enrolled in Medicaid, view the program as working well for low-income residents. Among all residents, about two-thirds (67%) feel that the Medicaid program is working well for most low-income people in the state. This share rises to 84% among adults who are actually covered by Medicaid (Figure 5).

Access to care for individuals enrolled in QHPs varies based on their choice of plan. For example, a number of stakeholders noted that some individuals who selected lower cost plans with limited networks experienced challenges getting appointments and finding providers. They suggested that some of these challenges have moderated over time as individuals have adjusted their expectations and some plans have made adjustments to better accommodate member needs.

Economic Impact of Medicaid Expansion

The state has achieved cost savings as a result of the expansion. Overall, estimates show savings resulting from the Medicaid expansion. One analysis estimated a net positive fiscal impact from the Medicaid expansion of $919.1 million from SFY 2014 through SFY 2021 compared to what the state would have spent had it not expanded. These net positive impacts resulted from increased employment, increased revenues to providers, and decreased uncompensated care.⁸  The analysis also found that the state’s health care system and overall economy realized an infusion of $1.16 billion driven by new federal payments to health care providers for Medicaid expansion enrollees in calendar year 2014.⁹ 

What changes are being made to kynect and Medicaid?

In December 2015, newly elected Governor Bevin took office in Kentucky. Consistent with his election campaign, he has begun making changes to Kentucky’s health coverage system. These changes include transitioning from the fully state-run Marketplace, kynect, to a federally-supported State-Based Marketplace and proposing to make changes to the Medicaid expansion through a waiver.^10 ,11  A Kaiser Family Foundation survey of the views of Kentucky residents completed just after the Governor’s election in 2015 found that about half (52%) of residents would prefer to keep kynect, while roughly a quarter (26%) would prefer to switch to the federal marketplace. Nearly three in four (72%) Kentuckians said they would prefer to keep the state’s Medicaid program as it is rather than scale it back it to cover fewer people (Figure 6).

What are the potential impacts of these changes?

Changes to kynect

When the state transitions to a federally-supported State-Based Marketplace, the federal government will handle all eligibility and enrollment functions for Marketplace coverage through Healthcare.gov. The state will retain responsibility for consumer assistance and will maintain review of plans to include in the Marketplace, but certification of the plans will become a federal government responsibility. Some key questions to consider about the potential effects of this change include the following:

• How will the Medicaid and Marketplace enrollment experience be affected? With this change, there will no longer be an integrated eligibility determination and enrollment system for Medicaid and Marketplace coverage. On February 29, 2016, Kentucky launched Benefind, its new online portal for individuals to apply for Medicaid. Individuals may also apply for the Children’s Health Insurance Program and other programs, including the Supplemental Nutritional Assistance Program (SNAP, formerly food stamps) and Temporary Assistance for Needy Families, through Benefind. The Benefind system now serves as the state’s Medicaid eligibility determination system, while Marketplace determinations will occur through Healthcare.gov beginning in 2017. Once the transition is complete, timely and effective data transfers between Benefind and Healthcare.gov will be key for providing a seamless enrollment experience and preventing delays in eligibility determinations and gaps in coverage. Early experience with Benefind has indicated that system glitches have led to confusion and disruptions in coverage that could compromise enrollment.¹² 
• How will outreach and enrollment assistance be affected? As a federally-supported State-Based Marketplace, the state will retain responsibility for running the navigator (kynector) program. However, funding and other decisions will have important implications for the availability of consumer assistance in the future. For example, the transition to Benefind limited the role kynectors can play in assisting individuals with Medicaid coverage since only state eligibility workers can access the Benefind system.¹³  In addition, the state ended its advertising campaign that was targeted at raising consumer awareness about coverage options for kynect as of December 2015.¹⁴ 
• How will this transition affect insurer participation and plan offerings in the Marketplace? The state will continue to play a leading role in negotiating with insurers and will make recommendations to the FFM regarding insurer contracts. The state will also continue to regulate the insurers. However, plans will contract with the federal government rather than the state, which may influence their participation decisions. In addition, insurers that were considering entering the market for 2017 may choose to wait out this transition year.
• How much will the transition cost? The specific costs associated with the transition to a federally-supported State-Based Marketplace are uncertain. However, there are costs associated with decommissioning kynect, standing up the new Benefind eligibility system, and building functionalities to connect with Healthcare.gov. At the same time, there are savings related to foregone maintenance and operations costs for kynect and other potential savings that could accrue from reduced funding for consumer assistance and the call center.

From Medicaid Expansion to Waiver

The Governor plans to seek a waiver to make changes to the Medicaid expansion and has noted that he is looking to Indiana’s Medicaid expansion waiver as a potential model. The Governor hopes to have a plan proposed by the middle of 2016 and to implement changes at the start of 2017. To date, six states (AR, IA, MI, IN, NH, and MT) have Section 1115 waivers to implement the ACA Medicaid expansion in ways that extend beyond the law. While the waivers are each unique, they include some common provisions, including use of premium assistance, charging premiums, eliminating coverage of non-emergency medical transportation, and use of healthy behavior incentives.¹⁵  Most of the states with approved expansion waivers used the waiver to expand coverage to the uninsured population, resulting in new coverage. Since Kentucky already has its expansion in place, how the waiver affects individuals with existing coverage will be a key consideration. As more details on changes the Governor might seek through a waiver become available, it will be important to consider their impacts on enrollees, providers, costs, and program administration and complexity.

Conclusion

As a leader in implementing the ACA coverage expansions, Kentucky’s experience provides useful lessons about key components that have contributed to its success. These components include strong leadership and collaboration; a high-functioning integrated eligibility system; broad outreach and marketing efforts; a strong and diverse network of enrollment assistance; and initiatives to strengthen access to care for Medicaid enrollees as more individuals enroll. The newly elected Governor is moving forward with changes to transition from the fully state-run Marketplace, kynect, to a federally-supported State-Based Marketplace and plans seek a waiver to make changes to the Medicaid expansion. These changes have the potential to reshape coverage in Kentucky and will be important to track and assess over time.

Appendix: Related Resources

Survey of Kentucky Residents on State Health Policy, December 2015, https://www.kff.org/health-reform/poll-finding/survey-of-kentucky-residents-on-state-health-policy/

Year Two of the ACA Coverage Expansions: On-the-Ground Experiences from Five States, June 2015, https://www.kff.org/health-reform/issue-brief/year-two-of-the-aca-coverage-expansions-on-the-ground-experiences-from-five-states/

The Effects of the Medicaid Expansion on State Budgets: An Early Look in Select States, March 2015, https://www.kff.org/medicaid/issue-brief/the-effects-of-the-medicaid-expansion-on-state-budgets-an-early-look-in-select-states/

What Worked and What’s Next? Strategies in Four States Leading ACA Enrollment Efforts, July 2014, https://www.kff.org/health-reform/issue-brief/what-worked-and-whats-next-strategies-in-four-states-leading-aca-enrollment-efforts/

How Will the Uninsured in Kentucky Fare Under the Affordable Care Act?, January 2014, https://www.kff.org/health-reform/fact-sheet/state-profiles-uninsured-under-aca-kentucky/

Getting into Gear for 2014: An Early Look at Branding and Marketing of New Health Insurance Marketplaces, September 2013, https://www.kff.org/health-reform/issue-brief/getting-into-gear-for-2014-an-early-look-at-branding-and-marketing-of-new-health-insurance-marketplaces/

1. Kaiser Family Foundation analysis of the 2014 and 2015 Current Population Survey, Annual Social and Economic Supplements. ↩︎
2. Governor Matthew Bevin, 2016 State of the Commonwealth and Budget Address Transcript, January 26, 2016, https://www.ket.org/content/uploads/2016/01/Gov.-Matt-Bevin-2016-SOTC-Budget-Address-Transcript-01.26.16.pdf ↩︎
3. Ibid. ↩︎
4. Kaiser Family Foundation analysis of the 2014 and 2015 Current Population Survey, Annual Social and Economic Supplements. ↩︎
5. Kaiser Family Foundation, State Health Facts. “Total Medicaid and CHIP Child Enrollment, Summer 2013 to December 2015” Data source: CMS, Medicaid & CHIP Monthly Applications, Eligibility Determinations, and Enrollment Reports: February 2014 – December 2015 preliminary), as of February 29, 2016, https://modern.kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/. ↩︎
6. Kaiser Family Foundation, State Health Facts. “Marketplace Plan Selections as a Share of the Potential Marketplace Population.” Data Source: Addendum to the Health Insurance Marketplaces 2016 Open Enrollment Period:Final Enrollment Report for the period November 1, 2015 – February 1, 2016, Office of the Assistant Secretary for Planning and Evaluation (ASPE), Department of Health and Human Services (HHS), March 11, 2016; and Kaiser Family Foundation analysis based on 2015 Medicaid eligibility levels and 2015 Current Population Survey, https://modern.kff.org/health-reform/state-indicator/marketplace-plan-selections-as-a-share-of-the-potential-marketplace-population/ ↩︎
7. Deloitte Commission by the Commonwealth of Kentucky, “Medicaid Expansion Report 2014,” February 2015, http://jointhehealthjourney.com/images/uploads/channel-files/Kentucky_Medicaid_Expansion_One-Year_Study_FINAL.pdf ↩︎
8. Ibid. ↩︎
9. Ibid. ↩︎
10. Melissa Patrick and Al Cross, “Bevin Administration Will Still Have State Health-Insurance Exchange but Use Federal Exchange for Enrollment; Cost Debated” Kentucky Health News, March 6, 2016, http://www.thenewsjournal.net/8094-2/ ↩︎
11. Associated Press, “Gov. Matt Bevin: Medicaid Overhaul Will Be In Place by Start of 2017,” Lexington Herald Leader, December 30, 2015, http://www.kentucky.com/news/politics-government/article52259315.html ↩︎
12. Deborah Yetter, “New KY benefits system disruption aid for many,” Courier Journal, March 25, 2016, http://www.courier-journal.com/story/news/politics/2016/03/25/new-ky-benefits-system-disrupting-aid-many/82206656/ ↩︎
13. Ibid. ↩︎
14. Deborah Yetter, “State Ends Kynect Advertising Campaign,” Courier Journal, December 23, 2015, http://www.courier-journal.com/story/news/politics/2015/12/23/state-ends-kynect-advertising-campaign/77769562/ ↩︎
15. Robin Rudowitz and MaryBeth Musumeci, The ACA and Medicaid Expansion Waivers (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, November 2015), https://modern.kff.org/medicaid/issue-brief/the-aca-and-medicaid-expansion-waivers/ ↩︎