47% of Uninsured Americans Did Not Explore ACA, Medicaid Options

Uninsured Americans may not be examining all of their options in Medicaid or on the Affordable Care Act marketplace, a Robert Wood Johnson Foundation and Urban Institute study discovered.

In 2019, the uninsured population was 2.2 million higher than it was in 2016. However, many of the uninsured population have not enrolled in Medicaid or Affordable Care Act marketplace coverage--or even looked into enrollment--although they may be eligible.

“Lack of awareness or understanding of publicly subsidized coverage options among the uninsured may result in people not enrolling in programs for which they qualify,” suggested the report. “This may be especially true for those newly losing ESI, who may have little prior experience with subsidized coverage.”

The researchers leveraged data from the Urban Institute’s Coronavirus Tracking Survey, specifically, data from the second wave of the survey which was conducted for a little over two weeks in September 2020. The report focused on the 437 respondents who were uninsured.

A little over half of the uninsured survey participants (53.9 percent) responded that they had heard a lot or some about the Affordable Care Act marketplaces, but 64.9 percent of the participants had heard nothing or a little about marketplace financial aid options.

Meanwhile, among the uninsured individuals who had heard of marketplace health plans, nearly 50 percent did not consider a marketplace plan. Seven in ten respondents in this category reported that they did not explore marketplace options due to the perceived cost.

Less than a third of uninsured adults tried to enroll in Medicaid or Children’s Health Insurance Program (CHIP) coverage. Of the remaining 70 percent of uninsured individuals who did not attempt to obtain Medicaid or CHIP coverage, most indicated that they did not think they would be eligible.

A little under half of the uninsured adult respondents did not explore Affordable Care Act marketplace coverage or Medicaid (47 percent).

Around 20 percent of the uninsured looked into both the Affordable Care Act marketplace and about 30 percent had considered one of the two.

The report acknowledged that for those within a certain income bracket—300 to 400 percent of the federal poverty level—the Affordable Care Act marketplace premiums could consume up to 10 percent of their family income. Thus, for families with a moderate income, the Affordable Care Act marketplace premiums could in fact be out of reach financially.

Similarly, the perception that they may not qualify for Medicaid could be a reasonable conjecture. Twenty percent of all uninsured adults found that they did not qualify for Medicaid. This is a strong possibility in states that have not adopted Medicaid expansion, where certain populations cannot receive Medicaid coverage regardless of income.

Still, Medicaid and Affordable Care Act coverage could have been accessible to some of the newly uninsured. Early on in the pandemic, Urban Institute estimated that 14 million individuals in vulnerable industries were eligible for Medicaid or subsidized Affordable Care Act marketplace health plans.

“As the pandemic continues, the new administration, Congress, and state officials could enact several policies to improve awareness and accessibility of Marketplace and Medicaid/CHIP coverage,” the researchers recommended.

First, the researchers called on the Biden administration to expand outreach and enrollment support through resources such as navigators, adding their voices to the Kaiser Family Foundation’s commentary.

Second, improving general knowledge about the income range for subsidies on the Affordable Care Act marketplace could help inform potentially eligible uninsured individuals about their options. The Biden administration has also included higher subsidies on the Affordable Care Act marketplace and higher COBRA subsidies in his latest stimulus package proposal.

Third, the researchers urged more states to adopt Medicaid expansion along with more relaxed restrictions regarding immigrant eligibility. In a previously published study, Urban Institute found that if every state had adopted Medicaid expansion during the last three quarters of 2020, 4.4 million people might have been spared from uninsurance.

Fourth, policymakers and Medicaid officials can work to reduce complexities around enrollment processes, which often dissuade people from enrolling in Medicaid or Affordable Care Act marketplace plans. About 40 percent of adults who tried to enroll in Medicaid or renew their Medicaid coverage during the pandemic found the enrollment process challenging.

There is still time to address this issue and the need remains pressing, the researchers indicated.

“Though some losing ESI during the pandemic have enrolled in coverage through Medicaid and the ACA Marketplaces to avoid becoming uninsured, eroding ESI rates mean increases in uninsurance are unlikely to reverse, and could accelerate, during the current recession,” the report noted.