Over 115 million individuals live in the American South today, and together, they make up over a third of the U.S. population. The South, as defined by the U.S. Census Bureau, includes 17 states, stretching from Oklahoma, Texas, and Arkansas on the West to the Atlantic Ocean on the East, and northward to Delaware, Maryland, Kentucky, and West Virginia (Figure 1). This brief provides an overview of health coverage and care in the South today and the potential impact of the Affordable Care Act (ACA) health coverage expansions. It includes key findings in several areas including the following:

Demographics. The southern population is large and growing rapidly. The region’s population is racially and ethnically diverse and also diverse across a number of factors including citizenship status, age, urban-rural composition, and income. Southerners are significantly more likely than those in the Northeast and Midwest to be poor, and the South includes states with some of the highest poverty rates.

Health Coverage and Care Today. The South has faced longstanding disparities in health coverage, health status, and health care relative to the rest of the United States. Compared to those in other regions, Southerners are more likely to be uninsured, less likely to have access to needed health services, and more likely to experience a number of chronic health conditions such as diabetes and heart disease.

The Impact of the ACA Coverage Expansions. The ACA has the potential to extend health coverage to many uninsured Southerners through an expansion of Medicaid and the creation of new Health Insurance Marketplaces with tax credit subsidies. However, most southern states are not moving forward with the Medicaid expansion, and many poor uninsured Southerners will not gain a new coverage option and may remain uninsured. Even with these gaps in coverage, millions of uninsured Southerners are now eligible for coverage, and effective outreach and enrollment efforts are key for ensuring that they are enrolled.

Translating Coverage to Care: Delivery Systems and the Safety Net. Improving health outcomes in the long-term will take more than expanding coverage. It will be important to ensure that insured individuals as well as Southerners who remain uninsured are connected to care. Ongoing development of provider capacity and delivery system innovation in the South will be important for addressing health care needs and challenges.

As of 2012, 115 million individuals lived in the 17 southern states, accounting for over a third (37%) of US residents nationally (Figure 2). Over half (56%) of the southern population resides in just four states – Texas, Florida, Georgia, and North Carolina. These four most populous southern states also include more than a fifth (21%) of the total US population.¹  The southern population is growing rapidly, largely due to high domestic and international migration to the South. The Census Bureau estimates that over half (52%) of the increase in the U.S. population by 2030 will be a result of population growth in the South.² 

The southern population is racially and ethnically diverse. People of color make up 41% of the total southern population (Figure 3). However, the share of the population who are people of color varies across southern states from less than 15% in Arkansas and West Virginia to over half of residents in the District of Columbia and Texas (see Appendix Table 1).

Moreover, more than four in ten (41%) of all people of color reside in the South. However, the share of people residing in the South varies across racial and ethnic groups, with nearly six in ten Blacks residing in the South (58%) compared to about one in five Asians and Pacific Islanders (22%)  (Figure 4).

The southern population is also diverse across a number of other characteristics, including citizenship status, age, educational attainment, and urban-rural composition. Similar to other regions, the large majority (89%) of Southerners are U.S.-born citizens, while about one in ten (11%) are immigrants, who include both naturalized citizens and non-citizens. The age distribution of the southern population is similar to that of other regions as well. About one-quarter (26%) of the region’s residents are children and 14% are elderly individuals. Young adults aged 19-34 account for 21% of the population. While the large majority (89%) of Southerners live in metropolitan settings, Southerners are more likely than those in the Northeast and West to live in a rural area (see Appendix Table 2).

Overall, three-quarters (77%) of nonelderly individuals in the South live in a household with at least one full-time worker. The majority of southern workers (62%) are in blue-collar jobs, most commonly in the service, trade, health services, and manufacturing industries.³  More than 15% of all workers have jobs in services, arts, or entertainment, and almost 14% of workers are in wholesale or retail trade.⁴  One in four workers in the South (25%) are employed by small firms or businesses with fewer than 50 employees, and 9% of Southern workers are self-employed (Figure 5).  These work patterns in the South are similar to those of the general US population and other regions. ⁵ 

The South includes states with some of the nation’s highest poverty rates. Overall, the poverty rate for the South is not significantly different from the nation’s poverty rate, with just over one in five nonelderly southern residents (22%) living in a poor household.⁶  However, Southerners are significantly more likely than those in the Northeast and Midwest to be poor.⁷  Further, poverty rates vary widely across the southern states, and the region includes several states, including Louisiana, Mississippi, Arkansas, and the District of Columbia, that have among the highest rates of poverty in the nation (Table 2).

Southerners are less likely to have private coverage and more likely to be uninsured compared to individuals in the Northeast and Midwest. The low rate of private coverage among nonelderly Southerners likely reflects the fact that a large share of southern adults work in low-wage, blue collar jobs or small firms that often do not offer health coverage, and private coverage on the individual market has historically been unaffordable for many families. As a result of their lower rate of private coverage, nonelderly Southerners are more likely than those in the Northeast and Midwest to be uninsured, with more than one in five (21%) lacking coverage (Figure 6). In particular, Texas and Florida have some of the highest uninsured rates in the country at 27% and 25%, respectively (see Appendix Tables 3 and 4). Moreover, the majority of uninsured individuals in the South live in Texas, Florida, and Georgia, which together account for two-thirds (65%) of all nonelderly uninsured Southerners and 44% of the uninsured nationwide.⁸  

People of color make up the majority of uninsured people in the South (58%), although more than four in ten uninsured Southerners (42%) are White (Figure 7). Nearly one-third of uninsured Southerners are Black, and about one in five are Hispanic.

As in other regions, most uninsured Southerners are low-income working adults (Figure 8). Four in ten uninsured Southerners have income below the poverty limit ($11,670 for an individual in 2014), and nine in ten have income below 400% of poverty ($46,680 for an individual). Most uninsured Southerners are also in working families. Nearly two-thirds (65%) are in households with at least one full-time worker. Moreover, a large majority (84%) of nonelderly uninsured individuals in the South are adults. Over half (57%) are adults without dependent children, and about a quarter (27%) are parents. Children account for 16% of the uninsured in the region. These coverage patterns reflect the fact that states have significantly expanded Medicaid and CHIP eligibility for children, helping to fill their gap in private coverage, while Medicaid eligibility for adults has historically been very limited in most states.

Reflecting their limited coverage rates, adults in the South are more likely than those in other regions to report difficulty accessing needed health care services. Nearly one-quarter of Southerners report that they do not have a usual source of care, which is significantly higher than the share of adults without a usual source of care in the Midwest and Northeast. Compared to adults in other regions, particularly the Northeast, Southerners are also more likely to report having postponed seeking care or gone without needed care or drugs due to cost (Figure 9).

Access to health coverage and care is important for Southerners, especially given the high prevalence of chronic health conditions in the South. Most of the states with the highest rates of diabetes are in the South (Figure 10). Similarly, the South includes states with the highest heart disease death rates, infant mortality rates, and cancer death rates in the country.⁹  Adults in the South are also significantly more likely than those in the Northeast and West to be overweight or obese.¹⁰  While a broad array of factors contributes to the relatively high chronic disease rates and poor health outcomes in the South, a key step in addressing these disparities is to ensure that individuals have health coverage that enables them to access preventive and primary care and ongoing treatment and services to meet their health needs.

The Impact of the Affordable Care Act Coverage Expansions

A key goal of the ACA is to reduce the number of uninsured individuals through the creation of new coverage options that will allow individuals to access needed health care services. The ACA established a continuum of new coverage options including an expansion of Medicaid eligibility to nearly all adults with incomes at or below 138% FPL ($16,105 for an individual or $27,310 for a family of three in 2014) and the creation of Health Insurance Marketplaces with premium tax credit subsidies to help individuals with incomes up to 400% FPL ($46,680 for an individual or $79,160 for a family of three in 2014) purchase coverage. The ACA also includes provisions designed to provide consumers a streamlined, coordinated enrollment experience across health coverage programs. The combined effects of the coverage expansions, streamlined enrollment system, and broad outreach and enrollment efforts are expected to bring many uninsured individuals into coverage.

The majority of southern states (11 of 17) are relying on the Federally-facilitated Marketplace in 2014, although three (DC, KY, and MD) elected to establish their own State-based Marketplaces. Three additional southern states (AR, DE, and WV) are operating a Marketplace in partnership with the federal government (Figure 11). Marketplace enrollment varies across the southern states. As of April 19, 2014, after the initial annual open enrollment period, nearly 3.5 million Southerners had enrolled health coverage through a Marketplace– about 27% of the potential Marketplace population in the region.¹¹  However, enrollment varied significantly by state, from 16% of the eligible population in Oklahoma to 39% of potential enrollees in Florida (Figure 12).

The ACA offers the potential to significantly increase coverage in the South, especially for low-income adults, but gaps in coverage will remain, as many southern states are not implementing the Medicaid expansion. As enacted, the Medicaid expansion was to apply to all states, setting a national income floor of 138% FPL for all adults, but the Supreme Court ruling on the ACA effectively made the expansion a state option. Just over half of the states (27 states, including DC), including 6 of the 17 Southern states, are implementing the expansion in 2014 (Figure 13).¹²  There is no deadline by which states must implement the Medicaid expansion, so additional states may choose to expand in the future.

Overall, southern states experienced a 7% increase in Medicaid enrollment in April 2014, compared to the monthly average in the states during the three months prior to open enrollment. This was similar to enrollment growth in the Northeast (7%) and Midwest (8%), but much lower than the Medicaid enrollment growth rate in the West during the same period (19%). The six southern states that are implementing the Medicaid expansion experienced much higher enrollment growth compared to states that are not expanding (26% vs. 4%). However, some southern non-expansion states experienced notable growth, including South Carolina, where Medicaid enrollment increased by 14% between Summer 2013 and April 2014.[endnote 109111-11]

State Medicaid expansion decisions have significant fiscal implications for state spending on uncompensated care costs and indigent care programs, state economies, and for providers.¹³  If all states expanded Medicaid, southern states could experience the largest percentage increase in federal funds with the Medicaid expansion, compared to states in other regions (Figure 14).

If all states expanded Medicaid, southern states could also experience a 25 percent increase in Medicaid payments to hospitals relative to no expansion – the highest percentage increase of any region (Figure 15).

Without the Medicaid expansion, Medicaid eligibility for adults remains very limited in the South. The ACA Medicaid expansion was designed to fill longstanding gaps in Medicaid eligibility for parents and other non-disabled adults. In the absence of the expansion, adults without dependent children in 11 of the 17 southern states remain ineligible for Medicaid regardless of how low their incomes are. Moreover, eligibility limits for parents remain below 50% FPL ($9,895 per year for a family of three) in eight southern states (see Appendix Table 5). Overall, the median Medicaid eligibility limits for parents (52% FPL) and childless adults (0% FPL) in the South are far lower than the median limits for other regions (Figure 16). In addition, even though Medicaid and CHIP eligibility limits for children and pregnant women in the South remain higher than those for adults, they are still low compared to other regions.

Nearly 4 million poor uninsured Southerners fall into a coverage gap because they remain ineligible for Medicaid but do not earn enough to qualify for the premium tax credits for Marketplace coverage. Because the ACA envisioned that low-income people would receive coverage through Medicaid, the tax credit subsidies to help people purchase private coverage through the Marketplace are only available to people with incomes at or above the poverty level ($11,670 for and individual and $19,790 for a family of three in 2014). Consequently, in states that do not expand Medicaid, uninsured adults with incomes above Medicaid eligibility limits but below poverty fall into a “coverage gap.” These individuals earn too much to qualify for Medicaid but not enough to qualify for the premium tax credits. Over half (51%) of uninsured adults in the South who would be eligible for Medicaid if their states implemented the expansion fall into this coverage gap (Table 3). These 3.8 million poor uninsured adults in the South, nearly half of whom (46%) reside in Texas, Florida, and Georgia, make up nearly eight in ten of the 4.8 million poor uninsured adults who fall into the coverage gap nationwide (Figure 17).

People of color are disproportionately affected by the coverage gap. Within the South, the impact of the coverage gap varies across racial and ethnic groups, reflecting the fact that Blacks are more likely than Hispanics to live in the South and to be uninsured. Overall, among uninsured adults in the South who would be eligible for Medicaid under the ACA expansion, 54% of adults of color and 56% of Blacks fall into the coverage gap, compared to less than half (47%) of Whites (Figure 18).

However, White adults are the largest racial or ethnic group in the coverage gap in the South. Four in ten poor adults in the South who fall into the coverage gap are White, compared to 31% who are Black, and about one quarter (24%), who are Hispanic (Figure 19). In total, 1.5 million poor, White adults and 2.3 million people of color in the South fall into the coverage gap.

Even with these gaps in coverage, nearly half (48%) of the 21 million uninsured Southerners are eligible for financial assistance for health coverage in 2014 (Figure 20). About 30% of uninsured Southerners are eligible for premium tax credits to purchase Marketplace coverage and 18% are eligible for Medicaid or CHIP, including those newly eligible in the states implementing the Medicaid expansion as well as individuals who were already eligible but not yet enrolled, who are mostly children. Nearly one in five uninsured Southerners (18%) fall into the coverage gap because they reside in a state that is not implementing the Medicaid expansion. The remaining third (34%) of uninsured Southerners are not eligible for assistance for health coverage. About one in five (21%) do not qualify for the premium tax credits because they have incomes above 400% FPL or have access to affordable coverage through their employer. These individuals can still purchase unsubsidized coverage through the Marketplaces. The other 13% are not eligible to enroll in Medicaid and are barred from purchasing coverage through the Marketplaces due to their immigration status; they will likely remain uninsured.¹⁴ 

Connecting Individuals to Coverage Through Outreach and Enrollment

Effective outreach and enrollment efforts are key to ensuring that the millions of uninsured Southerners who are eligible for coverage are enrolled. Even with remaining coverage gaps, millions of uninsured individuals in the South have gained access to new coverage options under the ACA. Effective outreach and enrollment efforts will be important for successfully enrolling these individuals, including targeted efforts to reach people of color, immigrant families, rural populations, low- and moderate-income families, and people with serious health needs. Regardless of state decisions to expand Medicaid, the ACA requires all states to adopt new approaches to simplify enrollment and renewal that make it easier for individuals to apply for and retain coverage. These include providing multiple application avenues for families (including online, by phone, and in person) and moving to technology-driven eligibility verification processes.¹⁵  Through previous experience with Medicaid and CHIP, a number of southern states have demonstrated that these and other strategies can be effective ways to enroll eligible populations into coverage while improving efficiency and minimizing burdens on state agencies (see Box 1). Looking forward, these state experiences provide key lessons for improving access to coverage in the South.

To improve health outcomes in the long term, it will also be important to ensure that newly-insured individuals are able to obtain needed primary and specialty care services. As uninsured individuals in the South gradually gain coverage and seek care, health resources in these communities may be further stretched. The ACA includes a number of provisions to help states improve health system capacity, including increased funding to expand community health centers and a temporary increase in Medicaid payment rates for primary care physicians.²¹  Increases in physician capacity will be especially important in areas with historically limited health resources.

Provider Capacity in the South

Many Southerners live in a primary care Health Professional Shortage Area (HPSA), meaning that they reside in a region with a documented shortage of primary care providers. As of 2012, nearly one-quarter (22%) of southern residents were residing in a primary care HPSA. In four southern states (AL, DC, LA, and MS), more than one in three residents lived in a primary care HPSA, and in Mississippi, over half of the state population lived in a primary care HPSA—the highest share in the country (Table 4). As coverage expands and the demand for care increases, expanding provider capacity will be key to ensuring that coverage translates into access to care.

Medicaid payment rates are one lever for increasing provider supply and access in the program, but additional measures are needed to overcome provider shortages. In 2012, state Medicaid programs overall paid physicians just 66% of Medicare fee levels. Notably, though, 13 of the 17 Southern states paid Medicaid rates equal to at least 75% of Medicare rates, including eight southern states that paid 80% or more of Medicare fee levels (Figure 21). Under the ACA, Medicaid payment rates to primary care physicians (PCP) for most of their services must be at least equal to Medicare rates in 2013 and 2014 (the difference is fully funded by the federal government); in 2013, this provision increased PCP fees by at least 40% in half of the southern states, including Florida, where they more than doubled.

Although paying providers fee-for-service rates closer to Medicare and private insurance rates may attract more provider participation in Medicaid, absolute shortages in the supply of physicians, particularly in rural and low-income communities, are system-level capacity constraints that Medicaid payment rates cannot  correct. Broader strategies and investments to develop a more adequate health care workforce are called for. The ACA includes numerous provisions along those lines, but they will take time to bear fruit. A more immediate strategy for expanding access (especially access to primary care) is to expand the role of nurse practitioners (NP), physician assistants (PA), and other health professionals in delivering care. A large body of evidence on NPs shows that the care they provide is of equal or, in some cases, better quality than physician-provided care for the same conditions. In many states, including 11 states in the South, state regulations that restrict NP scope of practice are a major obstacle to this strategy. These restrictions prevent NPs from diagnosing and treating illness and prescribing drugs without physician supervision.²²  Of the southern states, only DC, Maryland, and Delaware extend full autonomy to NPs to practice independently at the “top of their license” (Figure 22).

Medicaid managed care programs can also expand the role of NPs by including them in their primary care provider panels. A 2009 RAND study that estimated potential health care savings associated with expanding the role of NPs and PAs in Massachusetts assumed in its model that NPs and PAs could provide care for six simple acute conditions (e.g., cough, fever, earache) that are among those commonly treated at retail clinics staffed by these providers. Care for these six conditions, plus well-baby visits and general medical examinations, which the model also assumed NPs and PAs could provide, represent nearly one in five of all office-visits nationally.²³  This analysis suggests that expanding the use of NPs and PAs in the South – in effect, increasing the supply could increase the availability of routine primary care.

Medicaid managed care

Nationwide, a large and growing share of Medicaid beneficiaries receive their care in capitated managed care plans. Increasingly, state Medicaid programs across the country are contracting with private managed care plans to deliver Medicaid benefits to Medicaid enrollees. Under these contracts, states pay a fixed “capitation” rate to plans for each person enrolled, and the plans are at financial risk for all the services specified in their Medicaid contracts. Enrolled beneficiaries receive all or most of their care from their plan’s network of providers. Under the other major (though much smaller) model of Medicaid managed care, known as primary care case management (PCCM), states retain fee-for-service payment, but provide a small monthly fee to primary care providers to coordinate primary care for their Medicaid patients. Some states’ PCCM programs involve partial capitation payment.As of July 2011, over half of all Medicaid beneficiaries nationally were enrolled in risk-based managed care, but the proportion varied considerably across the country. A number of factors may contribute to the variation. Some states or areas lack sufficient population to attract risk-based plans. Organized medicine and managed care interests may influence Medicaid policy choices. Some states have abandoned risk-based contracting because of plan exits from the market, budget pressures, or a preference for managing their Medicaid programs themselves by contracting directly with providers, rather than shifting responsibility and financing for services to insurers.

Most states in the South have some share of their Medicaid population enrolled in risk-based managed care. In 2011, 5 of the 17 states in the South had no risk-based Medicaid managed care (Alabama, Arkansas, Louisiana, North Carolina, and Oklahoma). However, the other 12 had risk-based programs that, with a few exceptions, covered at least half their Medicaid population, and substantially more in the District of Columbia (77%), Maryland (75%) and Tennessee (97%) (Figure 23). Notably, Louisiana more recently adopted risk-based managed care statewide, Alabama is slated to do so later this year, and under Arkansas’ proposed “private option” for implementing the ACA Medicaid expansion, adults newly eligible for Medicaid are to be enrolled in the same managed care plans offered in the new insurance Marketplaces.

PCCM programs are prevalent in the South as well, operating in 12 of the 17 states in the region. In four states – Arkansas, Louisiana, North Carolina, and Oklahoma – over 60% of Medicaid beneficiaries were enrolled in these arrangements as of 2011. Interestingly, while the Medicaid trend nationally is for states to move away from the fee-for-service toward risk-based managed care, in the mid-2000s, both North Carolina and Oklahoma terminated their risk-contracting programs and implemented PCCM statewide.

Trends suggest a continued movement toward managed care within the South going forward. In a recent 50-state survey, nearly all states in the South reported that they undertook Medicaid managed care initiatives in 2013 or planned to in 2014, including expansions of managed care to new geographic areas or groups, mandatory managed care enrollment, implementation or expansion of managed long-term care, and measures to improve quality.

Delivery system innovation

State Medicaid programs, including many in the South, are in a period of dynamic innovation in health care delivery and payment. Medicaid programs have historically been a source of new approaches to improving care for some of the nation’s most medically complex and low-income populations. Now, new options, demonstration programs, and funding opportunities provided by the ACA are catalyzing increased activity, including Medicaid participation in multi-payer initiatives designed to leverage broader systemic change, as well as reforms within Medicaid programs themselves.

Consistent with a broader trend nationally, most states in the South have undertaken medical home initiatives designed to provide comprehensive and continuous patient-centered care to Medicaid beneficiaries. In addition, both Alabama and North Carolina have taken up a new Medicaid option under the ACA to establish health homes to provide comprehensive care coordination for Medicaid beneficiaries with chronic conditions, and Arkansas, Delaware, the District of Columbia, Maryland, Oklahoma, and West Virginia are planning such programs. Alabama and North Carolina have also taken steps to establish accountable care organizations (ACO) in Medicaid. In ACOs, participating providers, plans, and hospitals are collectively responsible for the care of a defined population, encompassing the continuum of care across different settings. The participating providers agree to achieve specified financial and quality outcomes and may share in savings associated with their performance. The following selected initiatives in Arkansas, North Carolina, South Carolina, and Texas illustrate the diversity of service delivery and payment innovation underway in Medicaid:

The Safety Net

Safety net providers will continue to be an important part of the health care system in the South. Historically, uninsured and low-income individuals have relied on safety net providers such as community health centers and clinics when seeking care, and even with broad-scale efforts to expand physician capacity and improve the delivery of services to low-income populations, these providers will likely remain a primary source of care for millions of newly-insured Southerners and many low-income individuals who will likely remain uninsured. As of 2011, there were 388 federally-funded federally qualified health centers (FQHCs) in the South that served over six million patients.²⁴  The number of FQHCs available to serve the low-income population in the South varies by state from 5.6 per million low-income people in Florida to nearly 17 FQHCs per million people with low incomes residing in Mississippi (Figure 24). In addition, as of 2011, there were over 1,500 Medicare-certified rural clinics in the South serving the 20 million Southerners residing in rural areas²⁵  and 448 public hospitals, which saw nearly 2.5 million patient visits in the year.²⁶ 

Community health centers and other safety net providers serve many vulnerable populations in the South. In addition to providing free or low-cost services to those with low incomes, community health centers are often seen as a trusted source for care within the community and are able to offer culturally and linguistically appropriate services that meet the needs of the diverse populations they serve. In the South, over 90% of patients in federally-funded community health centers are low-income. Over half (56%) are people of color, nearly four in ten are uninsured, 12% are better served in a language other than English, and 5% are homeless (Figure 25). Health centers provide an array of services to their patients, including primary and preventive care, professional services such as dental and mental health care, and enabling services such as case management, health education, and interpretation and translation services.²⁷  As coverage expands, some of these health centers may experience revenue gains as more patients obtain coverage. However, they will continue to serve as a key source of care for individuals who remain uninsured or who have historically relied on their services, requiring adequate resources to support this role.

Historically, the South has faced longstanding disparities in coverage and care. Yet, access to health coverage and care is particularly important for Southerners given a high prevalence of chronic health conditions and poor health outcomes in the region. The ACA offers the potential to connect many currently uninsured Southerners to coverage, serving as a key first step in enabling individuals in the region to access needed care and manage their health conditions.

To date, the ACA has expanded coverage options for many Southerners, particularly through the new Marketplaces. However, millions of poor Southerners who could gain access to coverage through the ACA Medicaid expansion fall into a coverage gap and are left without a new coverage option in states that are not implementing the Medicaid expansion at this time. If additional states in the South opt to expand in the future there will be even greater coverage gains within the region.

Looking ahead, helping uninsured Southerners who have gained access to new coverage options to enroll successfully will help boost coverage. Regardless of state decisions to expand Medicaid, all states must implement new simplified enrollment processes, which will help connect eligible individuals to coverage. Even with simpler processes in place, effective outreach and enrollment efforts will be key. Across the South, in communities that have historically faced restrictions in coverage and barriers to enrollment, using targeted strategies and one-on-one assistance are available to help eligible individuals enroll and access the health care services they need will be required.

Furthermore, to improve health outcomes in the South, newly-insured individuals need to be able to access health services. The ACA includes a number of provisions to help expand the availability of primary and specialty services in underserved communities, including an increase in Medicaid fees to primary care physicians. Separately, many southern states are adopting a number of innovative approaches to provide comprehensive and patient-centered care to Medicaid beneficiaries including an expansion of managed care and reform of delivery systems to improve care coordination for medically-complex low-income populations. Even with these efforts, safety net providers will likely remain a primary source of care for millions of newly-insured Southerners and for many low-income individuals in the South who remain uninsured.

Given the growing and diverse population in the South, changing patterns of health coverage and care in the region have important implications nationally and for people of color. As such, continued attention to health coverage and care in the South for those gaining coverage and those remaining uninsured will be important for understanding the impact of the ACA and implications for longstanding efforts to reduce disparities in coverage, care, and health outcomes.

1. KCMU/Urban Institute analysis of 2013 and 2012 ASEC Supplements to the CPS. ↩︎
2. United States Census Bureau. 2005 Interim State Population Projections. “Percent change in population by region of the United Stats for five-year periods: 2000 to 2030.”  http://www.census.gov/population/projections/data/state/projectionsagesex.html ↩︎
3. KCMU/Urban Institute analysis of 2013 and 2012 ASEC Supplements to the CPS. ↩︎
4. Urban Institute tabulations of 2013 ASEC Supplement to the CPS. ↩︎
5. KCMU/Urban Institute analysis of 2013 and 2012 ASEC Supplements to the CPS. ↩︎
6. Ibid. ↩︎
7. Ibid ↩︎
8.  Ibid. ↩︎
9.  KCMU analysis of the Center for Disease Control and Prevention (CDC)’s Behavioral Risk Factor Surveillance System (BRFSS) 2012 Survey Results. ↩︎
10.  Ibid. ↩︎
11. Based on data from Health Insurance Marketplace: March Enrollment Report, October 1, 2013 – March 1, 2014, Office of the Assistant Secretary for Planning and Evaluation (ASPE), Department of Health and Human Services (HHS); March 11, 2014 and State-by-State Estimates of the Number of People Eligible for Premium Tax Credits Under the Affordable Care Act, Kaiser Family Foundation, November 5, 2013. https://modern.kff.org/health-reform/state-indicator/marketplace-enrollment-as-a-share-of-the-potential-marketplace-population/# ↩︎
12. Kaiser Family Foundation. “State of State Action on the Medicaid Expansion Decision, 2014” https://modern.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/. ↩︎
13. For more detail on the fiscal implications of the Medicaid expansion see: Kaiser Commission on Medicaid and the Uninsured. “The Cost of Not Expanding Medicaid.” July 2013. https://modern.kff.org/medicaid/report/the-cost-of-not-expanding-medicaid/ ↩︎
14. For more detail on Medicaid coverage for immigrants, see: http://modern.kff.org/disparities-policy/fact-sheet/key-facts-on-health-coverage-for-low/. ↩︎
15. Kaiser Commission on Medicaid and the Uninsured. “Medicaid Eligibility, Enrolment Simplification and Coordination under the Affordable Care Act: A Summary of CMS’s March 23, 2012 Final Rule.” December 2012. https://modern.kff.org/medicaid/issue-brief/medicaid-eligibility-enrollment-simplification-and-coordination-under-the-affordable-care-act-a-summary-of-cmss-march-23-2012-final-rule/ ↩︎
16. Heberlein, M. et al. “Performing Under Pressure: Annual Findings of a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2011-2012. https://modern.kff.org/medicaid/report/performing-under-pressure-annual-findings-of-a/ ↩︎
17. “Supra, J. “South Carolina’s Experience Implementing Express Lane Redeterminations.” Presentation. November 1, 2011. http://www.insurekidsnow.gov/professionals/events/2011_conference/ele-jsupra.pdf ↩︎
18. Kaiser Commission on Medicaid and the Uninsured. “Using Data and Technology to Drive Process Improvement in Medicaid and CHIP: Lessons from South Carolina.” March 2012. https://modern.kff.org/medicaid/fact-sheet/using-data-and-technology-to-drive-process/ ↩︎
19. Batts, D. “Improving Retention in Louisiana.” Presentation for Kaiser Family Foundation Webinar, Stop the Drop: Profiles of Innovative Medicaid Renewal Initiative and Lesson for 2014 and Beyond. May 14, 2013. https://modern.kff.org/medicaid/event/stop-the-drop-profiles-of-innovative-medicaid-renewal-initiatives-and-lessons-for-2014-and-beyond/ ↩︎
20. Guyer, J. et al, “Fast Track to Coverage: Facilitating Enrollment of Eligible People into the Medicaid Expansion,” Kaiser Commission on Medicaid and the Uninsured, November 2013. ↩︎
21. Riley, P., J. Berenson, and C. Dermody. “How the Affordable Care Act Supports a High-Performance Safety Net.” Commonwealth Fund. January 2012. http://www.commonwealthfund.org/Blog/2012/Jan/Affordable-Care-Act-Safety-Net.aspx ↩︎
22. AANC 2012 ↩︎
23. Controlling Health Care Spending in Massachusetts: An Analysis of Options, RAND, 2009. http://www.rand.org/content/dam/rand/pubs/technical_reports/2009/RAND_TR733.pdf ↩︎
24. National Association of Community Health Centers, 2012. Population data based KCMU/Urban Institute analysis of 2013 and 2012 ASEC Supplements to the CPS. ↩︎
25. Centers for Medicare and Medicaid Services, Rural Health Center, Medicare Certified Rural Health Clinics as of 1/9/201 ↩︎
26. HCUP Nationwide Inpatient Sample (NIS), 2011, Agency for Healthcare Research and Quality (AHRQ), based on data collected by individual States and provided to AHRQ by the States. ↩︎
27. National Association of Community Health Centers, 2012. Population data based KCMU/Urban Institute analysis of 2013 and 2012 ASEC Supplements to the CPS.   ↩︎

Over 115 million individuals live in the American South today, and together, they account for over one-third (37%) of the total U.S. population. The South is racially and ethnically diverse and home to a large share of the nation’s people of color. As such, efforts to improve health in the South have significant implications for the advancement of health and health equity nationwide.

The South has faced longstanding disparities in health and health care, although significant variation exists between southern states. As a group, compared to those in other regions, Southerners are more likely to be uninsured, less likely to have access to needed health services, and more likely to experience a number of chronic health conditions. Yet, many southern states have also adopted innovative approaches to improve their health systems, particularly in the delivery of care, that provide key lessons for improving access to health coverage in the South more broadly.

Health Coverage and Care in the South: A Chartbook provides key data on the demographic and economic characteristics of the southern population as well as their health status, health insurance coverage, and access to care today.

Together, these data offer a snapshot of health care in the South, highlighting both opportunities for advancement and challenges relating to improving health care and health equity looking forward.

Section 1: Demographics

Section 2: The Southern Economy

Section 3: Health Status

Section 4: Health Insurance Coverage

Section 5: Access to Care, Delivery Systems, and the Safety Net

Section 6: Medicaid’s Broader Role

Over one third of the total U.S. population resides in the 17 southern states, and the population has been growing over time. The southern population is racially and ethnically diverse, although the racial and ethnic composition varies by state. Overall, over four in ten of all people of color in the U.S. reside in the South, including over half of Blacks in the United States. The region is also diverse across a number of factors including citizenship status, age, urban-rural composition, and income.

The southern states play an important role in the national economy, contributing 35 percent of the total U.S. gross domestic product. Work patterns in the South are similar to those in other regions, although Southerners are less likely than those in other regions to be unemployed. Overall, Southerners earn less per capita than individuals in other regions of the U.S. However, income varies significantly by state, and, in four states, per capita earnings are higher than the national average. Earnings also vary widely within states, and several southern states have among the highest levels of income inequality in the country.

While measures of health status vary by state, Southerners as a group are generally more likely than those in other regions to have a number of chronic illnesses and experience worse health outcomes. For example, most of the states with the highest rates of obesity and diabetes are in the South, and many southern states are among those with the highest infant mortality rates and cancer death rates in the country. As in other regions, health status within the South also varies by race and ethnicity, and Blacks in particular, are more likely than Whites to report having fair or poor health.

While a broad array of factors contribute to the relatively high chronic disease rates and poor health outcomes in the South, a first step in addressing these disparities is ensuring that individuals have health coverage that enables them to access preventive and primary care and ongoing treatment to meet their health needs. Health insurance coverage facilitates timely access to health services, and being uninsured affects people’s ability to obtain needed medical care as well as their financial security. Compared to individuals in other regions, Southerners are more likely to be uninsured. Further, within the South, people of color are more likely than Whites to be uninsured. Coverage rates in the South vary by state, however, reflecting variation in demographics and the availability of health coverage options.The Affordable Care Act has the potential to extend health coverage to many currently uninsured Southerners through an expansion of Medicaid to low-income individuals and the creation of new health insurance Marketplaces with financial assistance to help moderate-income individuals purchase private coverage. Because many southern states are not implementing the Medicaid expansion, many uninsured adults in the South will not gain a new coverage option. However, nearly half of uninsured individuals are eligible for some financial assistance to obtain coverage in 2014, largely through the Marketplace, and millions of eligible individuals have already enrolled.

To improve health outcomes in the long term, it will be important to ensure that all individuals are able to obtain needed primary and specialty health care services. Southerners have historically been more likely than those in other regions to report difficulty accessing and paying for needed care.

States are increasingly relying on a number of tools to improve provider capacity and reform the delivery of care including expanding the use of Medicaid managed care, increasing payment to providers, and revising scope of practice laws to allow nurse practitioners to treat patients with fewer restrictions. Even with improvements to the delivery and coordination of care, however, community health centers and other safety net providers in the South will likely continue to serve an important role in providing care to some of the region’s most vulnerable low-income populations including the uninsured, people of color, homeless individuals, and those with limited English proficiency.

Medicaid is both an expenditure and a source of federal revenue in state budgets. The program is funded jointly by states and the federal government through a matching formula based on a state’s personal income, and in many southern states, where per capita personal income is less than the national average, the federal government pays at least two dollars for every dollar states spend on their programs. Overall, the federal government funds the majority of Medicaid costs in the South, although the way in which states finance their share of spending on Medicaid and its impact on their budgets varies by state.

As in other regions and in the United States generally, Medicaid spending in the South is concentrated among a small number of high-need enrollees. Children and adults in the South account for a large majority of Medicaid enrollees but less than 40 percent of expenditures. The elderly and disabled, who make up only about one quarter of Medicaid enrollees, account for nearly two-thirds of spending. Looking forward, efforts to improve care and control costs in Medicaid will likely focus on these high-need, high-cost beneficiaries.

Given the growing and diverse population in the South, changing patterns of health coverage and care in the region have important implications nationally and for people of color. As such, continued attention to health coverage and care in the South for those gaining coverage and those remaining uninsured will be important for understanding the impact of the ACA and implications for longstanding efforts to reduce disparities in coverage, care, and health outcomes.

January 1, 2014 marked the beginning of several provisions of the Affordable Care Act (ACA) making significant changes to the non-group insurance market, including new rules for insurers regarding who they must cover and what they can charge, along with the opening of new Health Insurance Marketplaces (also known as “Exchanges”) and the availability of premium and cost-sharing subsidies for individuals with low to moderate incomes. Data from the Department of Health and Human Services and others provide some insight into how many people purchased insurance using the new Marketplaces and the types of plans they picked, but much remains unknown about changes to the non-group market as a whole.

The Kaiser Family Foundation Survey of Non-Group Health Insurance Enrollees is the first in a series of surveys taking a closer look at the entire non-group market. This first survey was conducted from early April to early May 2014, after the close of the first ACA open enrollment period. It reports the views and experience of all non-group enrollees, including those with coverage obtained both inside and outside the Exchanges, and those who were uninsured prior to the ACA as well as those who had a previous source of coverage (non-group or otherwise).

The ACA motivated many non-group enrollees to get coverage, and nearly six in ten Exchange enrollees were previously uninsured

The survey finds that roughly two-thirds of those with non-group coverage are now in ACA-compliant plans, while three in ten have coverage they purchased before the ACA rules went into effect (referred to as “non-compliant plans” throughout this report). About half of all non-group enrollees now have coverage purchased from a Health Insurance Exchange, and nearly six in ten (57 percent) of those with Exchange coverage were uninsured prior to purchasing their current plan. Most of this previously uninsured group reports having gone without coverage for two years or more, and for many the ACA was a motivator in seeking coverage; seven in ten of those who were uninsured prior to purchasing a Marketplace plan say they decided to buy insurance because of the law, while just over a quarter say they would have gotten it anyway.

Enrollees in ACA-compliant plans report somewhat worse health than those in pre-ACA plans

While government data have provided some basic demographic information about Exchange plan enrollees, there has been no reliable information to date about the demographics of those enrolling in non-Exchange plans, or about the health status of either of these groups. The survey finds that the age and gender distribution is similar for those in ACA-compliant plans purchased inside and outside the Marketplace; overall, a third (34 percent) of adults with compliant plans are under age 35 and half (47 percent) are male. The survey does, however, find a difference in self-reported health status that may have implications for insurance market risk pools: those in compliant plans are more likely than those in non-compliant plans to report being in fair or poor health (17 percent versus 6 percent). This difference is largely driven by those with Exchange coverage, among whom 20 percent rate their health as fair or poor.

Majority gives positive ratings to their new insurance plans and says they are a good value, though four in ten find it difficult to afford their monthly premium

Overall, the majority of non-group enrollees rate their coverage as excellent or good, believe it is a good value for what they pay for it, and say they are satisfied with various aspects of their plans. Satisfaction is highest for choice of providers but somewhat lower for plan costs, and among those in compliant plans, about a third say they are not satisfied with their premiums and deductibles. Most feel well-protected by their plans and express confidence in their ability to pay for their usual medical costs, but some evidence of financial strain remains. Nearly half of those in ACA-compliant plans say they’re not confident they would be able to afford to pay for a major illness or injury, over four in ten say it is difficult to afford their monthly premiums, and over six in ten say they are worried that their premiums will become unaffordable in the future.

Among plan switchers, as many report paying less as paying more for their new plans, but survey shows some signs of a trend toward narrower provider networks

Among those who previously bought non-group insurance and have switched to a new, ACA-compliant plan (referred to as “plan switchers” throughout this report), nearly half (46 percent) say their current premium – taking into account government subsidies – is lower than it was under their previous plan, while four in ten (39 percent) say it is higher. This group’s responses to other survey questions suggest that the coverage they are getting is, on average, similar to what they had before. There is, however, some evidence of a trend toward plans with narrower provider networks. While over half of plan switchers say their choice of providers is “about the same” under their new plan as under their old plan, those who report a change in the amount of choice available are more likely to say they have less choice than more choice when it comes to primary care doctors (32 percent versus 10 percent) and specialists (24 percent versus 11 percent).

Plan switchers are less likely to be satisfied with plan costs, maybe because half of them report having their previous plan cancelled

Despite the fact that plan switchers are just as likely to say their premiums went down as went up under their new plan, this group stands out as being less satisfied with their plan costs and less likely to perceive their coverage as a good value compared to those in compliant plans who were previously uninsured. This may be related to the fact that about half of plan switchers report having received a cancellation notice from their previous insurer.

Half got help with enrollment; most say the shopping process was easy, but a third say it was difficult to set up a Marketplace account

Early problems with Healthcare.gov and many Exchange websites were widely reported in the media, and the survey finds that the Internet was the most commonly reported method of shopping and enrollment. However, it was not the only method; about a third of those with Exchange coverage and over half of those with compliant coverage purchased off-Exchange say they spent no part of the shopping and enrollment process on the Internet, and substantial shares report completing at least part of the enrollment process on the telephone or in person with someone helping them out. Overall, half of those in ACA-compliant plans say they got help with the enrollment process. Despite media reports of website and enrollment problems, most people in ACA-compliant plans purchased both on and off the Exchanges say it was at least somewhat easy to compare costs and coverage when shopping for plans. Still, 35 percent of Exchange enrollees in states using Healthcare.gov and 30 percent of those in states with their own Exchange websites say it was at least somewhat difficult to set up an account with the marketplace.

In the non-group market, those most likely to feel they have benefited from the ACA are people getting subsidies, those most likely to feel negatively impacted are those who had their plans cancelled

As a whole, non-group enrollees are more likely than the public overall to have a favorable view of the ACA – they are roughly evenly split between positive and negative views (47 percent favorable, 43 percent unfavorable), while views among 18-64 year-olds nationally are more negative than positive (38 percent favorable, 46 percent unfavorable¹ ). Like it is nationally, opinion of the ACA among non-group enrollees is strongly divided along party lines. About equal shares of non-group enrollees feel their families have benefited (34 percent) and been negatively affected (29 percent) by the ACA. However, these averages mask substantial differences within the non-group market. Those who are most likely to feel they have benefited from the law are people receiving government financial assistance for Exchange plan premiums (60 percent benefited), while those most likely to feel they have been negatively affected by the law are people who experienced a plan cancellation in the past year (57 percent negatively affected).

About The Groups Described In This Report

This survey reports on the views and experiences of all people purchasing health insurance coverage in the non-group market. However, because of the complexities of the market and the changes brought about by the ACA, much of this report breaks out responses by different subgroups based on how they obtained their coverage and their previous insurance status. The ACA made major changes to the non-group insurance market, including new rules that standardize coverage, guarantee access to those with pre-existing conditions, and provide subsidies based on income for those buying coverage through new Health Insurance Exchanges (also known as Marketplaces; these terms are used interchangeably throughout this report).

Those rules took effect for coverage beginning on or after January 1, 2014. People were able to purchase this “ACA-compliant” coverage either through an Exchange or directly from an insurance company during an open enrollment period that began October 1, 2013 and ended March 31, 2014 (with some opportunities for special enrollment periods after that). This survey includes individuals who purchased these new ACA-compliant plans, as well as people who are currently enrolled in “non-compliant” plans, including those who were grandfathered under the ACA because they were purchased before the law went into effect, those who renewed policies last year or bought coverage that began before January 1, and those who have been able to keep their old policies for a period of time under a federal transition policy at the discretion of states.

A more detailed breakdown of the main groups described in this report is provided below.

Total non-group market: All individuals ages 18-64 whose primary source of health insurance coverage is a plan they purchased themselves, either directly from an insurance company or through a state or federal Health Insurance Marketplace, regardless of plan start date (see Survey Methodology for more details on inclusion criteria).

ACA-compliant plans (68% of total non-group market2 ): Allplans that took effect on or after January 1, 2014, including those purchased through a state or federal Marketplace and those purchased directly from an insurance company.

Exchange plans (48% of total non-group market): Plans that were purchased from a state or federal Health Insurance Exchange, including Exchange plans purchased through a health insurance agent or broker.

Compliant, non-Exchange plans (16% of total non-group market): Plans that took effect on or after January 1, 2014 that were purchased directly from an insurance company, including non-Exchange plans purchased through a health insurance agent or broker.

ACA-compliant plans by prior insurance status3 :

Previously uninsured, now in ACA-compliant plan (34% of total non-group market): Those with ACA-compliant plans who say they were uninsured immediately prior to purchasing their current plan.

Plan switchers (those who switched from a non-compliant to a compliant plan, 13% of total non-group market): Those with ACA-compliant plans who say they were covered by a different non-group plan (presumably, a non-compliant plan) immediately prior to purchasing their current plan, including those who chose to switch and those who had their prior plans cancelled.

Previously employer-sponsored insurance/COBRA (12% of total non-group market): Those with ACA-compliant plans who say they were covered by an employer-sponsored plan or COBRA immediately prior to purchasing their current plan.

Non-compliant plans (31% of total non-group market): Plans purchased outside the Health Insurance Exchange that took effect before January 1, 2014.

Section 1: Basic Demographics Of The Non-Group Market

Among the entire non-group market, about half of individuals (48 percent) report having coverage obtained from a state or federal Health Insurance Exchange, 16 percent have ACA-compliant coverage purchased outside of the Exchanges, and three in ten (31 percent) have non-ACA-compliant plans (those that have been in effect since before January 1, 2014).

One of the questions that has yet to be answered by state and federal data is what share of enrollees in ACA-compliant plans were previously uninsured. The survey finds that half of all those with compliant plans report being uninsured just prior to purchasing their current plan, while about one in five each say they were previously covered by another non-group plan (19 percent) or had employer coverage or COBRA (18 percent), and 9 percent previously had Medicaid or other public coverage. Exchange enrollees are more likely to say they were previously uninsured (57 percent), while those buying ACA-compliant plans outside the government marketplace are more likely to report having previous employer coverage (30 percent) or other non-group coverage (27 percent).

Among those who were previously uninsured and enrolled in a Marketplace plan, most say the reason they previously lacked coverage was because they couldn’t afford it or had no access to employer-sponsored insurance. Most of this group had been uninsured for a long time – seven in ten (71 percent) say that before buying their current plan they had been uninsured for two years or more, including 45 percent who say they were uninsured for at least five years. Seven in ten (72 percent) of the previously uninsured in Exchange plans say they decided to buy their own health insurance because of the ACA, while just over a quarter (26 percent) say they would have gotten insurance anyway, even without the law. These shares are similar when based on all those in ACA-compliant who were uninsured prior to purchasing their current plan.

Data from the Department of Health and Human Services provide some basic demographics, including the age and gender distribution, for individuals who signed up for Exchange plans.4  However, so far there has been no reliable information about the demographics of those enrolling in non-Exchange plans as well, or about the health status of either of these groups. The survey finds that the age and gender distribution is similar for those in ACA-compliant plans purchased inside and outside the Marketplace; overall, a third (34 percent) of adults with compliant plans are under age 35 and slightly fewer than half (47 percent) are male. By comparison, those with non-compliant plans are somewhat younger (44 percent under age 35) and more likely to be male (56 percent). Nearly two-thirds (64 percent) of those with ACA-compliant plans report having individual coverage, while those with non-compliant plans are more evenly split between individual (47 percent) and family coverage (53 percent). (See Appendix Table 1 for more details.)

The health status of enrollees has particular significance because it has implications for whether premiums this year will be adequate to cover the health expenses of enrollees and how much insurers may increase premiums for next year. Since people are now guaranteed coverage regardless of their health, there has been an expectation that some people with pre-existing conditions who were previously denied access to insurance will enroll. However, there has been substantial uncertainty about whether healthier people will enroll as well, motivated by premium subsidies and the ACA’s requirement that people have coverage or pay a penalty.

While the majority of individuals in non-group plans report being in good health, the survey finds that those with ACA-compliant plans – which insurers rate as a single risk pool – are more likely than those with non-compliant plans to report their health as “only fair” or “poor” (17 percent versus 6 percent). This suggests that people in new, ACA-compliant plans are somewhat sicker than those in the non-group market previously, some of whom have been able to retain their non-compliant coverage under transition policies. What this might mean for premiums in the non-group market is still uncertain, however, since many insurers anticipated a sicker-than-average mix of enrollees when they set their premiums for this year.

Section 2: How Do People In Different Groups Feel About Their Coverage?

The large majority of those with ACA-compliant plans purchased both inside and outside the Exchanges rate their coverage as excellent or good (72 percent of those with Exchange plans and 70 percent of those with non-Exchange plans). Those in non-compliant plans are even more likely to give high marks to their plans (85 percent), though this is offset by a larger share of those in compliant plans saying they don’t know how to rate their plans rather than a larger share giving their coverage poor marks, likely a reflection of the fact that most of those in compliant plans had only recently purchased coverage when the survey was conducted. Responses to this question are also similar to those given by people with employer-sponsored insurance in a separate national survey conducted in May.5  (See Appendix Table 2 for more details.)

More than half of those in compliant plans say their insurance is an excellent or good value for what they pay for it, though roughly four in ten rate the value as “only fair” or “poor,” similar to the shares among those with non-compliant plans. By comparison, those with employer-sponsored coverage interviewed in a separate national survey were more likely to rate their plan as an excellent or good value, likely reflecting the fact that for most of them, the employer pays a large portion of the premium.6 

Majorities of those with ACA-compliant coverage report being satisfied with various aspects of their plans, including their choice of providers and plan costs such as premiums, deductibles, and copays. Satisfaction with choice of doctors and hospitals is higher than with plan costs, and among those in compliant plans, about a third report being unsatisfied with their premiums (33 percent) and deductibles (34 percent). While the large majority of those in compliant plans say they are satisfied with their choice of providers, about one in five say they are unsatisfied with their choice of specialists (20 percent), primary care doctors (19 percent), and hospitals (15 percent). Dissatisfaction with provider choice is somewhat higher among those in ACA-compliant plans than among those in non-compliant plans or among people with employer-sponsored coverage interviewed as part of a separate national survey (in the range of 5-7 percent for each of these measures, see Appendix Table 3 for more details).

More specifically when it comes to premiums, the survey finds that among those who previously bought non-group insurance and have switched to a new, ACA-compliant plan (referred to here as “plan switchers”), nearly half (46 percent) say their premium is lower under their current plan than it was under their previous plan, and about four in ten (39 percent) say it is higher.

Survey responses for plan switchers also indicate that their deductibles and level of coverage are, on average, similar to what they had in their previous plans. Roughly a third each of this group says their current deductible is higher, lower, and about the same as under their previous non-group plan. Similarly, when asked about the range of covered services and level of financial protection offered under their new plans, about four in ten plan switchers say these things are about the same, while roughly equal shares say they are better and worse.

Responses among plan switchers do offer some evidence of a trend toward plans with narrower networks. While over half say their choice of providers is “about the same” under their new plan as under their old plan, those reporting a change in the degree of choice are more likely to say they have less choice versus more choice when it comes to primary care doctors (32 percent versus 10 percent) and specialists (24 percent versus 11 percent).

Despite the fact that most plan switchers report paying similar premiums and getting similar coverage compared to their previous plans, this group stands out as being less satisfied with their plan costs and less likely to perceive their coverage as a good value compared to those in compliant plans who were previously uninsured. For example, 51 percent of plan switchers say the value of their coverage for what they pay for it is “only fair” or “poor”, compared with 32 percent of those who were previously uninsured. Similarly, plan switchers are twice as likely to say they are not satisfied with their premium compared with those who were previously uninsured (51 percent versus 25 percent). These differences may be related to the fact that about half of plan switchers report having received a cancellation notice from an insurer in the past year, compared with very small shares of those who were uninsured or had employer coverage before purchasing their current plan (see Appendix Tables 2 & 3 for more details).

What People Know And Don’t Know About Their Coverage

Health insurance is complicated, and many previous studies have documented gaps in health insurance literacy among consumers. The survey finds evidence of this among those who purchase their own coverage, with many respondents unable to answer some basic questions about their plans. For example, nearly one in five non-group enrollees (18 percent) say they don’t know the amount of their monthly premium and almost four in ten (37 percent) don’t know the amount of their annual deductible. Among those with ACA-compliant plans, three in ten (30 percent) say they don’t know the metal level of their plan (platinum, gold, silver or bronze)7 , and among those who report getting a government subsidy to defray their premium cost, nearly half (47 percent) couldn’t say what the amount of the subsidy is.

Some groups are more knowledgeable than others, including college graduates, those with higher incomes, and small business owners. Plan switchers, who likely have more experience buying coverage in the non-group market, are also more likely than those who were previously uninsured to be able to report the metal level of their plan and their premium and deductible amounts.

In addition to knowledge gaps about their own plans, a third (33 percent) of those with non-group coverage are unaware that the ACA provides financial assistance to help low- and moderate-income Americans purchase coverage. Those in compliant plans purchased outside the Exchanges (53 percent) are the least likely to know that the ACA provides these subsidies, while awareness is somewhat higher among those in non-compliant plans (66 percent) and highest among those with Exchange coverage (76 percent).

Despite these gaps in knowledge, most people with non-group coverage feel they have a pretty good idea of what their plan covers (75 percent say they understand this “very” or “somewhat” well) and what they will have to pay out-of-pocket when they use services (83 percent). This is true even among those who were uninsured before purchasing their current plan (See Appendix Table 4).

Section 3: Affordability And Financial Protection

Health insurance brings with it a measure of financial security. Among those with ACA-compliant coverage, more than half (56 percent) say they feel well-protected by their health plans, including 59 percent of those who were previously uninsured. Still, this leaves over a third saying they feel vulnerable to high medical bills, rising to 51 percent in the “plan switchers” group. Those with non-compliant plans are more likely to say they feel well-protected, with the difference between the compliant and non-compliant groups largely driven by the “plan switchers” (see Appendix Table 5 for more details). By comparison, people with employer-sponsored coverage interviewed as part of a separate national survey are also more likely than those in compliant plans to say they feel well-protected (again, not surprising due to the fact that employer plans tend to have lower patient cost-sharing than non-group coverage and employers generally cover a portion of the premium).

Feelings of vulnerability may stem more from worries about unexpected medical costs rather than concerns about paying for routine care. Nearly two-thirds (63 percent) of those with compliant plans say they feel confident about paying for “usual” medical costs, but a somewhat smaller share (52 percent) say they feel confident about paying for a serious illness. This leaves nearly half (46 percent) feeling “not too confident” or “not at all confident” that they would have enough money or insurance to pay for a major illness or injury. Those with non-compliant plans are more likely to feel confident about paying for both types of costs, perhaps related to the fact that they report their previous year’s income as higher than those with compliant plans. Health status may also play a role; enrollees in non-compliant plans are more likely to report they are in excellent or good health status compared to those in compliant plans. Looking at the non-group market as a whole (including those in compliant and non-compliant plans), those in fair or poor health are less likely to say they are confident about paying for routine care than their healthier counterparts (55 percent versus 71 percent). (See Appendix Table 6 for more details.)

Despite the fact that most people report being satisfied with their premiums, cost pressures remain. Overall, forty-three percent of those with ACA-compliant plans say it is “very” or “somewhat” difficult for them to afford to pay their premium each month.

The ACA’s premium tax credits were designed to help alleviate affordability concerns for people with low and moderate incomes. The survey finds that nearly half (46 percent) of Exchange enrollees say they are getting financial help from the government to help pay their monthly premium, which is substantially lower than official data (according to the Department of Health and Human Services, 85 percent of those selecting a plan in the Marketplace qualified for a premium tax credit).8  Multiple factors may be contributing to this apparent under-reporting on the survey, but it is likely that at least some individuals receiving government financial help may be unaware that the government is paying a portion of their premium. As noted in the section above on health literacy, insurance concepts are complicated and many people have trouble reporting detailed information about their plans. During the enrollment process, some people may have been focused on the bottom line question of “What do I pay?” and less focused on whether that amount was subsidized or not. Still, the vast majority (85 percent) of those who do report getting assistance – representing 39 percent of all Exchange enrollees – say they would not have been able to afford insurance without this financial help.

Most people with non-group insurance also express at least some level of worry about their future ability to afford and access care and insurance. For example, about six in ten (62 percent) say they are “very” or “somewhat” worried that their insurance company will raise their premium so much that they will no longer be able to afford insurance. Among those who report receiving government subsidies, over half (54 percent) say they are worried that their income will change and they will no longer be eligible for this financial help.

Section 4: The Process Of Shopping For And Obtaining Coverage

Early problems with Healthcare.gov and many state Exchange websites were widely reported in the media, and the survey finds that about two-thirds of Exchange enrollees and nearly half (47 percent) of those with compliant coverage purchased outside the Exchanges spent at least some part of the shopping and enrollment process on the Internet. Other methods of shopping and enrollment were also common, however. Roughly half of Exchange enrollees and about four in ten non-Exchange purchasers report spending at least part of the process on the phone, while just over a quarter (27 percent) of those with Exchange plans and more than four in ten (43 percent) of those with non-Exchange plans say they spent time in person with someone helping them sign up for coverage. Internet enrollment required the biggest time investment for the largest share of people, with 18 percent of Exchange enrollees and 16 percent of non-Exchange purchasers saying they spent at least 5 hours shopping and enrolling on the web.

Overall, half of those in ACA-compliant plans say they got outside help with the enrollment process, while the other half say they completed the process on their own. The most common source of help for people with Exchange coverage was an Exchange representative (24 percent), while the most common source of help for those with coverage obtained outside the Exchanges was a health insurance broker or agent (24 percent).

Perhaps surprisingly given the extent to which Exchange website problems were reported in the media, most people in ACA-compliant plans purchased on and off the Exchanges say it was at least somewhat easy to compare costs and coverage when shopping for plans.9  Still, 35 percent of Exchange enrollees in states using Healthcare.gov and 30 percent of those in states with their own Exchange websites say it was at least somewhat difficult to set up an account with the marketplace, and roughly three in ten say it was difficult to figure out if their income qualified them for financial assistance.

When it comes to choosing their current plan, those with compliant coverage report considering a variety of factors as important to their health plan choice, with costs rising to the top of the list. Among those who considered multiple plans, eight in ten (80 percent) say the monthly premium was a “very” or “extremely” important factor in choosing their current plan over other choices available, and seven in ten (72 percent) say the same about the plan’s copay and deductible. Somewhat fewer – though still sizeable shares – report placing a lot of importance on provider choice and covered benefits (63 percent each), while far fewer say recommendations from friends or family were an important factor (24 percent).

Section 5: How Do Non-Group Enrollees Feel About The ACA?

Overall, those with non-group insurance coverage are more likely to have a favorable view of the ACA than the public at large. Views among non-group enrollees are roughly evenly split between favorable (47 percent) and unfavorable (43 percent), while among adults nationwide in the same age range, more have an unfavorable view of the law (46 percent) than a favorable one (38 percent).10 

However, the average above masks some differences within the non-group market. Majorities have a favorable view of the ACA among those with Exchange plans (58 percent) and those who were previously uninsured (53 percent). On the other side, majorities of those in non-compliant plans and those who switched from a non-compliant to a compliant one (the “plan switchers”) express an unfavorable view of the law (52 percent and 53 percent, respectively).

As has been the case nationally since the passage of the ACA, partisanship plays a major role in people’s views of the ACA among those in the non-group market as well, with a large majority of Republicans (78 percent) expressing an unfavorable view of the law, a large majority of Democrats (69 percent) expressing a favorable view, and independents almost evenly split (44 percent favorable, 48 percent unfavorable).

On balance, those with ACA-compliant plans are about twice as likely to say the law has made it easier rather than harder for them to shop and compare health plans (41 percent easier, 19 percent harder) and to find affordable coverage (44 percent easier, 20 percent harder). Similarly, about twice as many say the law has increased (38 percent) rather than decreased (19 percent) the health plan choices available to them. In each of these areas, those with Exchange coverage and those who were uninsured prior to purchasing their current plan are more likely to say the law has made things easier, while those with non-Exchange coverage are more likely to say the law hasn’t made a difference and plan switchers are more mixed as to the law’s impact.

When asked about the overall impact of the ACA on their own families, similar shares of non-group enrollees report that they’ve benefited (34 percent) and been negatively affected (29 percent) by the law. Among the 34 percent who report benefiting, the main ways in which they feel the law has helped them are lower costs and expanded access to care and insurance. The 29 percent who feel they’ve been negatively affected are most likely to cite increased costs, followed far behind by a range of concerns like opposition to the individual mandate, cuts to benefits or choices, and policy cancellations.

Again, these averages mask some important differences within the non-group market. Those most likely to feel their families have benefited from the law include those with Exchange plans who report receiving government subsidies (60 percent), Exchange enrollees overall (54 percent), and the previously uninsured (50 percent). Those most likely to say the law has had a negative impact on their families include those who report experiencing a coverage cancellation in the past 12 months (57 percent), those who purchased ACA-compliant plans outside the Exchanges (48 percent), and the “plan switchers” who previously had other non-group coverage and are now in a compliant plan (47 percent).

Conclusion and Implications

The Affordable Care Act changes the non-group health insurance market substantially, requiring insurers to accept all applicants regardless of their health, standardizing coverage, creating new health insurance Exchanges to facilitate shopping for insurance, and providing income-based premium and cost-sharing subsidies. The Exchanges, along with expanded eligibility in Medicaid, are the primary mechanism for reducing the number of uninsured Americans under the ACA.

Currently, about two-thirds of non-group enrollees are in plans that meet all of the new rules (“ACA-compliant plans”), most of whom have purchased coverage through an Exchange. Three in ten remain in non-compliant plans, which includes those who were grandfathered under the ACA because they were purchased before the law went into effect, those who renewed policies last year or bought coverage that began before January 1, and those who have been able to keep their old policies for a period of time under a federal transition policy at the discretion of states. Over time, fewer people will remain in non-compliant plans as they lose or drop their coverage, and the only new plans available in the marketplace are those that comply with the ACA’s rules.

The new rules in the non-group market not only create new coverage opportunities for those who were previously uninsured, but they also mean changes for people who were buying their own coverage before the ACA took effect, in some cases creating disruption and in others better coverage at lower cost. The survey findings illustrate some of the real and perceived impacts of these changes on different groups.

For example, the survey finds that nearly six in ten of those now covered by Exchange plans were uninsured prior to signing up. The previously uninsured are one of the groups most likely to believe they have benefited from the ACA, and seven in ten of them say they would not have gotten coverage without the law. On the other side, people who were previously covered by non-group insurance and switched to an ACA-compliant plan (including those whose previous policies were cancelled because they didn’t meet the requirements of the health law and those who switched for other reasons) are one group that is more likely to feel they have been negatively affected by the law. However, in spite of reports last year about some people having plans cancelled and facing higher premiums, the survey finds that plan switchers are about as likely to report paying less for their new plan than their old one as to say they are paying more. This is likely due in part to the availability of tax credits for low- and moderate-income people who buy Marketplace coverage.

The survey also provides the first look at the health status of enrollees in ACA-compliant plans, which has implications for whether premiums this year will be adequate to cover the health expenses of enrollees and how much insurers may increase premiums for next year. While the majority of individuals in non-group plans report being in good health, those with ACA-compliant plans – which insurers rate as a single risk pool regardless of whether coverage was purchased on or off the Exchange – are more likely than those with non-compliant plans to report their health as “only fair” or “poor.” This suggests that people in new, ACA-compliant plans are somewhat sicker than those in the non-group market previously, some of whom have been able to retain their non-compliant coverage under transition policies. What this might mean for premiums in the non-group market is still uncertain, however, since many insurers anticipated a sicker-than-average mix of enrollees when they set their premiums for this year.

The survey’s findings about shopping and enrollment also have implications for future enrollment periods. While most of those who enrolled in coverage found it easy to compare plans, many spent significant time on the shopping process and half sought help with enrollment. This survey only looked at the experiences of those who successfully enrolled, and it’s likely that those who attempted to enroll but were unsuccessful encountered more problems with the process.

The non-group market will continue to undergo significant changes as people shift from non-compliant plans and more people enter the market in the years ahead. Though non-group enrollees represent a relatively modest share of the population, their experiences in the market have significant implications for whether the ACA is perceived as a success or not. This survey is the first in a series that the Foundation plans to conduct tracking the views and experiences of this important group.

Survey Methodology

The Kaiser Family Foundation (KFF) Survey of Non-Group Health Insurance Enrollees is the first in a series of surveys examining the views and experiences of people who purchase their own health insurance, either directly from an insurance company or through a state or federal Health Insurance Exchange created by the Affordable Care Act (ACA). The survey was designed and analyzed by researchers at KFF. Social Science Research Solutions (SSRS) collaborated with KFF researchers on sample design and weighting, and supervised the fieldwork.

The survey was conducted by telephone from April 3 through May 11, 2014 among a nationally representative random sample of 742 adults who purchase their own insurance. Computer-assisted telephone interviews conducted by landline (333) and cell phone (409, including 219 who had no landline telephone) were carried out in English and Spanish by SSRS. Respondents were considered eligible for the survey if they met the following criteria:

• Between the ages of 18-64
• Currently covered by health insurance that they purchase themselves
• Not covered by health insurance through an employer, COBRA, Medicare, Medicaid, or the U.S. military or VA
• If purchase insurance from a college or university, the insurance covers health services received both within and outside the university setting
• If a small business owner, the health insurance they purchase is only for themselves and/or their family, and does not cover non-related employees of their business
• If purchase from a trade association, respondent pays the entire premium themselves
• Respondent was able to answer a question about whether insurance was purchased directly from an insurance company, from a state or federal health insurance marketplace, or through a health insurance agent or broker (Q35 in questionnaire)

Because the study targeted a low-incidence population, the sample was designed to increase efficiency in reaching this group, and consisted of three parts: (1) respondents reached through RDD landline and cell phone dialing to previously uncalled (“fresh”) sample (N=179); (2) respondents reached by re-contacting those who indicated in a previous RDD survey that they either purchased their own insurance or were uninsured (N=186); (3) respondents reached as part of the SSRS Omnibus survey (N=377), a weekly, nationally representative RDD landline and cell phone survey. All RDD landline and cell phone samples were generated by Marketing Systems Group. The “fresh” sample was designed to oversample areas with a lower-income population in order to complete more interviews with respondents who were uninsured prior to the ACA open enrollment period (since being uninsured is negatively correlated with income).

A multi-stage weighting process was applied to ensure an accurate representation of the national population of non-group enrollees ages 18-64. The first stage of weighting involved corrections for sample design, including accounting for the low-income oversample used in the “fresh” sample, the likelihood of non-response for the re-contact sample, number of eligible household members for those reached via landline, and a correction to account for the fact that respondents with both a landline and cell phone have a higher probability of selection. In the second weighting stage, demographic adjustments were applied to account for systematic non-response along known population parameters. No reliable administrative data were available for creating demographic weighting parameters for this group, since the most recent Census figures could not account for the changing demographics of non-group insurance enrollees brought about by the ACA this year. Therefore, demographic benchmarks were derived by compiling a sample of all respondents ages 18-64 interviewed on the SSRS Omnibus survey during the field period (N=4,312) and weighting this sample to match the national 18-64 year-old population based on the 2013 U.S. Census Current Population Survey March Supplement parameters for age, gender, education, race/ethnicity, region, population density, marital status, and phone use. This sample was then filtered to include respondents qualifying for the current survey, and the weighted demographics of this group were used as post-stratification weighting parameters for the “fresh” sample (including gender, age, education, race/ethnicity, marital status, income, and population density). A final adjustment was made to the full sample to adjust for previous insurance status (estimated based on the combined “fresh” and omnibus samples), to address the possibility that the criteria used in selecting the prescreened sample could affect the estimates for previous insurance status.

Weighting adjustments had a minor impact on the overall demographic distribution of the sample, with the biggest adjustments being made based on age (this is common in all telephone surveys, as younger respondents are the most difficult to reach and convince to participate). Weighted and unweighted demographics of the final sample are shown in the table below.

All statistical tests of significance account for the effect of weighting. The sample size and margin of sampling error (MOSE) for key subgroups are shown in the table below.

1. Kaiser Health Tracking Poll: May 2014. https://modern.kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-may-2014/ ↩︎
2.  Three percent of non-group enrollees overall are in ACA-compliant plans that were purchased through a broker but were unsure if their plan was purchased through an Exchange or not. These respondents are not included in either the “Exchange” or “Compliant, non-Exchange” groups. ↩︎
3.  Nine percent of non-group enrollees overall are in ACA-compliant plans and either say they were covered by some other type of insurance (including Medicaid) before purchasing their current plan or did not answer the question about previous insurance status. These respondents are not included in any of the breakout groups of ACA-compliant plans by prior insurance status. ↩︎
4. DHHS Office of the Assistant Secretary for Planning and Evaluation Issue Brief, “Health Insurance Marketplace: Summary Enrollment Report For The Initial Annual Open Enrollment Period,” May 1, 2014. http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib_2014Apr_enrollment.pdf ↩︎
5. Kaiser Health Tracking Poll: May 2014. https://modern.kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-may-2014/ ↩︎
6. Kaiser Health Tracking Poll: May 2014. https://modern.kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-may-2014/ ↩︎
7. Among those in Marketplace plans who report a metal level, the distribution of self-reported responses in the survey looks somewhat different from administrative data released by the Department of Health and Human Services (http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib_2014Apr_enrollment.pdf). Silver is the most common metal tier in both data sources, but the survey finds a somewhat lower share reporting Silver plans (48 percent versus 65 percent) and a somewhat higher share reporting Bronze plans (30 percent versus 20 percent) compared with HHS. Differences between self-reported data from surveys and administrative data are not uncommon, particularly when it comes to a complicated topic like details about one’s health insurance plan. ↩︎
8. DHHS Office of the Assistant Secretary for Planning and Evaluation Issue Brief, “Health Insurance Marketplace: Summary Enrollment Report For The Initial Annual Open Enrollment Period,” May 1, 2014. http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib_2014Apr_enrollment.pdf ↩︎
9. Since this is a survey of people who are enrolled in health plans, it only includes those who successfully completed the enrollment process and may not fully represent the ease or difficulty of the process for all those who tried to enroll. ↩︎
10. Kaiser Health Tracking Poll: May 2014. https://modern.kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-may-2014/ ↩︎