Survey of Non-Group Health Insurance Enrollees
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).