The Uninsured at the Starting Line: Findings from the 2013 Kaiser Survey of Low-Income Americans and the ACA

Conclusion & Policy Implications

The survey findings related to: i) patterns of insurance coverage, ii) the process of enrolling in and choosing health coverage, iii) interactions with the health care system, iv) financial security, and v) readiness for ACA coverage expansions have implications for early implementation of the ACA. Below, we summarize the implications how this pre-ACA baseline data can inform outreach and enrollment, plan selection and scope of coverage, providers and health systems.

Reaching Eligible Uninsured Adults

Outreach and enrollment will be an ongoing process. While there is much focus on the initial push to enroll people in coverage under the ACA, enrollment is not a “one shot” effort that will be completed in the first few months of implementation. The survey findings reveal that millions of people lose and gain coverage throughout the year, either due to job changes, income fluctuations, or problems at renewal. It also demonstrates that low-income individuals are particularly vulnerable to gaps in coverage that can result from such changes. Thus, implementing the ACA will require ongoing efforts to enroll and keep people in coverage.

Some eligible uninsured adults have little or no connection to pre-ACA health or social services systems and may be hard to reach. Many people targeted for coverage expansions are not currently connected to the health care system, have been outside the health insurance system for quite some time, or are not linked to social services programs. The survey shows that nearly half of uninsured adults have lacked coverage for five years or longer, most uninsured do not have a regular source of care, and many uninsured have no health care visits over the course of a year. Further, while many low-income (<138% FPL) uninsured adults have a family connection to a social services program, the majority of moderate-income (139-400% FPL) uninsured adults do not. Public outreach campaigns are likely important avenues for reaching these individuals. In addition, policymakers may pursue new outreach avenues to find and reach out to the “unconnected” uninsured.

Many eligible uninsured have experience with pre-ACA health care, health insurance, or social services systems, but there is great need for continued education of new coverage options. Others targeted for coverage expansions have experience with the health care system and health insurance but may be unaware that eligibility and costs have changed under the ACA. Notable shares reported in the survey that they were unaware of new coverage options at the start of open enrollment, and many report experiences of trying to get coverage and encountering cost or eligibility barriers.  It will be important to reach out to people who have tried to apply for coverage in the past to let them know coverage options for them may have changed. While awareness of coverage under the ACA has likely increased in recent months, given heavy media attention to the rollout of health reform, it is important to make sure the information they receive is accurate. In addition, with currently 25 states having not expanded their Medicaid programs, having left millions of low-income adults in a “coverage gap,”¹ new coverage options will need to be state-specific. Efforts to reach people through “fast track” enrollment may be particularly fruitful for low-income uninsured in expansion states, as these approaches require limited paperwork and reach people with known eligibility.

Connecting People to Suitable Coverage

In addition to technical issues with websites, it will be important to monitor whether other challenges in enrolling in health coverage that existed prior to the ACA are addressed by ACA simplification provisions. Policymakers have made strides in addressing many of the website glitches that plagued early enrollment efforts under the ACA, and they continue to focus attention on addressing these technical issues. However, there are other challenges to enrolling in coverage and picking a plan that policymakers may need to address. Survey results indicate that, before the ACA, some insured people reported challenges in comparing plan information or in compiling required paperwork. While most Medicaid applicants reported that they found the process to be not difficult, Medicaid enrollees were more likely than adults with other types of coverage to report challenges in selecting a plan. The ACA includes provisions to ease the plan selection process for people purchasing coverage through the Marketplaces and to simplify the application process for Medicaid. It will be important to track implementation of these simplifications to ensure that challenges that some people faced in the past do not carry over to ACA enrollment.

Early assessments of plan choice under the ACA may account for the fact that cost is only one factor in people’s preferences for health coverage. Much focus in early coverage of ACA enrollment has been on the premiums and deductibles that people will face under their new coverage. These features provide concrete measures that people can examine, and certainly costs are a key concern for new enrollees. However, the survey shows that people also value other aspects of their coverage, such as benefits and networks, sometimes even more than low out-of-pocket costs. Evaluations of coverage therefore may consider how well new plans are meeting the full range of priorities and preferences for health coverage, and future changes to plan offerings under the law may consider people’s priorities for their coverage.

Even once people have insurance, they may face issues in scope of coverage for benefits they need. Survey findings reveal that the vast majority of enrollees in various types of coverage report being satisfied with their plan, but notable shares report a problem with their scope of coverage. Many adults on Medicaid report needing coverage for dental services that are not included in their plan, and people with private coverage also report gaps in ancillary services. Future assessments of the impact of the ACA should gauge whether the scope of coverage people have under the law, and early implementation can work to educate people about both what is and what is not included in their coverage.

While the ACA could ameliorate the financial burden of health care for many, affordability of health services may remain a challenge.  In addition to the goal of facilitating access to health care services, a goal of coverage expansions is to provide financial protection from medical expenses. As survey findings show, even once people gain insurance, health care costs can be a challenge. Though less likely than their uninsured counterparts to have difficulties with medical costs, low-income insured adults report challenges in paying premiums, copayments, out-of-pocket costs for uncovered services, and other health care expenses. In addition, all low-income families, regardless of insurance coverage, face financial hardship in making ends meet. While affordability provisions in the ACA may address some of the challenges that low-income insured individuals face in affording medical care, it will be important to track ongoing financial barriers and financial instability even among those who have coverage. Further, efforts to “bend the cost curve” in health care may be a promising approach to addressing not only costs to financing sources but also to individuals.

Adapting the Health System and Patterns of Care to Meet New Needs

Based on demonstrated need and barriers to care among the uninsured prior to the ACA, health care providers may see increases in adults seeking care. Ultimately, the goal of coverage expansions under the ACA is to help people access needed health care services. Thus, once people gain coverage, providers and health systems will need to be prepared to serve newly-insured people. Survey findings reinforce conclusions from prior research that gaining health coverage is likely to alter the way that people interact with the health system. Compared to their insured counterparts, uninsured adults face barriers to care, despite many having a demonstrated need. Some uninsured adults have ongoing health conditions yet still are not receiving regular care, and others have postponed preventive or other services, primarily due to cost. These findings indicate that there is likely to be some pent-up demand for health care services among the newly-covered. Outreach and education may be needed to link the newly-insured to a regular provider and help them establish a pattern of regular preventive care.

Changes in insurance coverage may lead people to use new or different providers, but safety net providers will continue to serve many vulnerable populations. Many are concerned about shifting patterns of care under the ACA, as changes where people receive care may alter revenue streams for providers. The effect of changing revenue streams for different types of providers is unclear at this point. Based on the survey findings, the uninsured are likely to have more options for where to receive their care once they obtain coverage under the ACA. Compared to their insured counterparts, prior to the ACA, they were more likely to seek care in clinics, hospitals, or urgent care centers and to report limited options for where to get medical care. As people gain coverage, they may shift their service locations to more closely resemble that of people with private or Medicaid coverage. However, clinics and hospitals may continue to see high levels of the uninsured, particularly in states that do not expand their Medicaid programs. As uncompensated care funds diminish over time, these safety net providers may be strained to meet demand in the face of shrinking resources.

As implementation unfolds, providers may continue to be on the front lines of not only service delivery but also outreach and enrollment. Providers are one avenue that policymakers are using to reach out to uninsured adults who may be eligible for coverage expansions under the ACA. Survey findings indicate that emergency rooms and hospitals may be promising avenues for reaching eligible individuals with episodic interactions with the health system, and community health centers can reach a share of the uninsured who use them for ongoing care.

Moving Forward in ACA Implementation

As enrollment in new coverage options grows and people begin to use their coverage, survey findings point to several issues that can inform ongoing efforts to implement the ACA. Future reports using the 2013 Kaiser Survey of Low-Income Americans and the ACA will continue to delve into these issues and provide state-specific findings, and future surveys can assess whether and how coverage, access, and family finances change under the law.