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


In January 2014, the major coverage provisions of the 2010 Affordable Care Act (ACA) went into full effect. These provisions include the creation of new Health Insurance Marketplaces where low and moderate income families can receive premium tax credits to purchase coverage and, in states that opted to expand their Medicaid programs, the expansion of Medicaid eligibility to almost all adults with incomes at or below 138% of the federal poverty level (FPL) ($15,856 for an individual or $26,951 for family of three in 2013). With these coverage provisions, ACA has the potential to reach many of the 47 million Americans who lack insurance coverage, as well as millions of insured people who face financial strain or coverage limits related to health care.

Though ACA implementation is underway and people are already enrolling in coverage, policymakers continue to need information to inform coverage expansions. Reports of difficulties in enrolling in coverage, continued confusion and lack of information about the law point to challenges in the early stages of implementation. In the future, data will be needed to assess whether and how the ACA is helping low- and moderate-income families gain affordable coverage, access needed care, and obtain financial security. Detailed data on the population targeted for coverage expansions’ experience with health coverage, current patterns of care, and family situation can help policymakers target early efforts, provide insight into some of the challenges that are arising in the first months of new coverage, and evaluate the ACA’s longer-term affects.

To that end, the Kaiser Family Foundation has launched a new series of comprehensive surveys of the low and moderate income population. This report, based on the baseline 2013 Kaiser Survey of Low-Income Americans and the ACA, provides a snapshot of health insurance coverage, health care use and barriers to care, and financial security among insured and uninsured adults across the income spectrum at the starting line of ACA implementation. It also provides a baseline for future assessment of the impact of the ACA on health coverage, access, and financial security of low- and moderate-income individuals nationwide. Future reports using this baseline survey will provide additional in-depth analysis of issues in ACA implementation, such as differences between states expanding their Medicaid programs and those not expanding; in-depth analysis of issues in affordability of health care and family finances; Medicaid’s role in facilitating access to care; and challenges facing part-time workers, among others. Forthcoming separate state reports focusing on California, Missouri, and Texas will analyze these issues in the context of state-specific efforts to implement the law.

This report examines how findings from the baseline survey can help policymakers understand and address early challenges in implementing health reform.  Throughout sections that focus on findings related to i) patterns of insurance coverage, ii) the process of selecting and enrolling in health coverage, iii) interactions with the health care system, iv) financial security, and v) readiness for ACA coverage expansions, the report highlights findings that can inform outreach and enrollment workers, health plans, and providers and health systems. A detailed explanation of the methods underlying the survey and analysis is available in the Methods section of the report.

Executive Summary Background: The Challenge of Gaining Insurance Coverage Prior to the ACA

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