How Does Gaining Coverage Affect People’s Lives? Access, Utilization, and Financial Security among Newly Insured Adults Rachel Garfield and Katherine Young In 2014, millions of people gained health insurance as the major coverage provisions of the Affordable Care Act (ACA) were implemented. While much attention has been paid to enrollment in new coverage options and changes in the number of uninsured over the past year, less is known about how this coverage has affected people’s lives. This report, based on the 2014 Kaiser Survey of Low-Income Americans and the ACA, aims to understand the impact that gaining coverage has had on the lives of the “newly insured” adult population. The survey of 10,502 non-elderly adults was fielded between September 2 and December 15, 2014, with the majority of interviews (70%) conducted prior to November 15, 2014 (the start of the second open enrollment period). Additional detail on the survey methods is available in the methods appendix available online. Based on the survey findings, approximately 11 million nonelderly adults were newly insured in 2014, meaning they reported that they obtained health coverage in 2014 and were uninsured before that coverage started. While many of these people gained coverage in the first quarter of 2014—which coincided with the “open enrollment period” for Marketplace coverage—most gained it after March 2014. Medicaid enrollment is available throughout the year, and some people were eligible to enroll in Marketplace coverage outside of open enrollment. In addition, people can gain non-ACA coverage at any time. The vast majority (95%) of adults who gained coverage in 2014 have family income below 400% of poverty, the income range for financial assistance under the ACA, with more than half (53%) in low-income families (at or below 138% of poverty) and more than one in four (42%) in middle-income families (139 to 400% of poverty). While this income profile is not significantly different than that for the remaining uninsured population, the newly insured population is significantly more likely than the previously insured to be low- or middle-income and significantly less likely to be higher income (greater than 400% of poverty). Because of these differences in income, we restrict the analysis in this brief to the population below 400% of poverty. Most newly insured adults are in working families, many with a part-time worker. Despite concerns about adverse selection into coverage, about half of newly insured adults are under age 35 (similar to those who remained uninsured), and newly insured adults are actually less likely to report fair or poor health than those who remained uninsured. Notably, newly insured adults were more likely to be female than their counterparts who remained without coverage, and they were also more likely to have insurance coverage for all their children (if they had any) than those who remained uninsured. In addition, half of newly insured adults are people of color, and more than half do not have dependent children—groups that have historically faced disparities in coverage rates or exclusions from coverage in the past. A primary goal of expanding health insurance coverage is to help people access the medical services that they need. The survey findings reinforce other findings that insurance facilitates access to health care, indicating that adults who gained coverage in 2014 are more likely to be linked to regular care, less likely to postpone care when they need it, and more likely to use preventive services than those who remained uninsured. While some newly insured adults changed where they regularly go for care and most see private doctor’s offices for their regular care, many continue to seek services from community clinics and health centers, which have historically served under-served populations such as the uninsured and may be the most available source of care in their area. Still, survey findings show that newly insured adults face some access barriers compared to adults who were insured before 2014. This finding may indicate that newly insured adults are not as settled into regular care as their previously insured counterparts; it may also reflect difficulty finding a provider, problems navigating the health system and health insurance networks, misunderstanding about how to use coverage and when to seek care, or concerns about out-of-pocket costs. Health care costs can be a major burden for low- and middle-income families. While many newly insured adults report difficulty affording their monthly premium, they also report lower rates of problems with medical bills and lower rates of worry about future medical bills than their uninsured counterparts. However, newly insured adults still face financial insecurity: they are more likely than those who had coverage before 2014 to worry about future medical bills, and they face general financial insecurity at rates similar to the uninsured. These patterns may indicate that while coverage can ameliorate some of the financial challenges that low- and moderate-income adults face, many will continue to face financial challenges in other areas of their lives. People’s views of their plan may affect not only their use of their coverage but also the likelihood that they re- enroll in coverage or change plans. Survey results reveal that newly insured adults were very sensitive to cost in choosing their plan, placing a priority on cost over benefits and provider networks. A minority of both newly insured and previously insured adults reported problems in using their plan. However, newly insured adults were more likely than previously insured to say they do not understand the details of their plan and were more likely to give their plan a low rating. These findings indicate that additional education may be needed to help people understand their coverage. As more and more evidence mounts to document coverage gains during the first year of the ACA, there is interest in understanding how these gains in coverage have affected the lives of the newly insured. Findings from the 2014 Kaiser Survey of Low-Income Americans and the ACA show, not surprisingly, that adults who gained coverage had better access to health care and better financial security from medical costs than those who remained without coverage. In addition, survey findings reveal few differences in outcomes among the Access, Utilization, and Financial Security among Newly Insured Adults 2 newly insured population by type of coverage, and the differences that do exist largely reflect Medicaid’s role in targeting the lowest income and most vulnerable. Still, comparison between newly insured adults and those who have had coverage since before 2014 shows some areas for ongoing attention as policymakers strive to translate coverage to care. Ongoing monitoring of newly insured adults’ access and utilization is important to assess whether this population continues to face challenges or whether these differences subside over time. Lack of health insurance coverage for millions of people has been a long-standing policy challenge in the United States. Historically, most Americans received health coverage as an employer benefit through a job, but not all workers and their families were covered. Some people purchased coverage on their own, but this “non- group” coverage was costly and could be difficult to obtain. Public coverage provided assistance to many low- and middle-income people, but gaps in eligibility left many without an affordable coverage option. To increase the number of people with access to affordable coverage, the Affordable Care Act (ACA) included several provisions to address these challenges. The major coverage provisions, which went into effect in January 2014, include the expansion of Medicaid in many states and the availability of premium tax credits to purchase coverage through newly-established Health Insurance Marketplaces. These provisions have the potential to improve the availability and affordability of insurance coverage in the United States, with the ultimate goal of helping people access needed health services and reducing the financial burden of medical costs on low- and middle-income families. While much attention has been paid to enrollment in new coverage options and changes in the number of uninsured since coverage provisions went into effect, less is known about how this coverage has affected people’s lives. To help understand the early impact of the ACA, the Kaiser Family Foundation is conducting a series of comprehensive surveys of the low- and moderate-income population. The 2013 Kaiser Survey of Low- Income Americans and the ACA, fielded prior to the start of open enrollment for 2014 ACA coverage, provided a baseline snapshot of health insurance coverage, health care use and barriers to care, and financial security among insured and uninsured adults at the starting line of ACA implementation.1 In Fall 2014, we conducted a second wave of the Kaiser Survey of Low-Income Americans and the ACA to understand how these factors have changed under the first year of the law’s main coverage provisions. The survey of 10,502 nonelderly adults was fielded between September 2 and December 15, 2014, with the majority of interviews (70%) conducted prior to November 15, 2014 (the start of open enrollment for 2015 Marketplace coverage; Medicaid enrollment is open throughout the year). Questions asked about coverage in 2014, costs and scope of coverage, access to health care services, and affordability and family budgets. Additional detail on the survey methods is available in the methods appendix available online. Access, Utilization, and Financial Security among Newly Insured Adults 3 Based on the survey findings, approximately 11 million nonelderly adults were newly insured in 2014, meaning they reported that they obtained health coverage in 2014 and were uninsured before that coverage started. While the ACA was leading to major changes in health insurance coverage in 2014, these changes were occurring against the backdrop of the normal Figure 1 cycles of health coverage that people experience Current Coverage Type Among Nonelderly Adults, by Newly as their employment and income circumstances Insured versus Previously Insured Status change. Therefore, though most people who 16% 18% report gaining coverage in 2014 did so through 12%* 3%* one of the pathways in place under the ACA 36% (Figure 1), some people gained other coverage Other such as employer coverage. In addition, some 22% 67%* Medicaid Marketplace people who were insured before 2014 also ESI 26% enrolled in ACA coverage options. For example, some people who were purchasing coverage on Newly Insured Previously Insured NOTE: Includes adults ages 19-64. “Previously Insured” includes people who were insured as of interview date and have been their own instead purchased that coverage insured since before January 2014. “Newly Insured” include people who were insured as of interview date and gained coverage since January 2014. People who reported that they were waiting for their coverage to start or who were uncertain about when their coverage started or their previous insurance status are not included. “Other” coverage includes Medicare, non-Marketplace through the new Marketplaces, and some people direct purchase, VA or military coverage, and other types of coverage. People who names a plan name that could not be identified as Medicaid, Marketplace, or employer coverage are also included in “other.” * Significantly different from Newly Insured at the p<0.05 level. who lost coverage and were low- and middle- SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. income took up Medicaid. Under the ACA, most people can only purchase Marketplace coverage during “open enrollment.” For coverage that started in 2014, open enrollment was between October 2013 and the end of March 2014; however, due to website glitches, people who started an application before March 31, 2014 were allowed to enroll through April 2014. In addition, “special enrollment periods” may be available for those undergoing certain life events (such as having a baby, getting married, or moving to a Figure 2 new state). Medicaid enrollment is open Timing of Enrollment in Coverage Among Low- and Middle- throughout the year, and enrollment in job-based Income Newly-Insured Adults, by Type of Coverage coverage is generally timed to start of a job or fall 9% open enrollment periods if the employer offers a 24%* choice of plans. While many (40%) newly insured 51% 62% 57% adults gained their coverage in the first quarter of Don't Know/Refused 2014, most gained it after March 2014. Not 65%* After 1st Quarter 2014 surprisingly, given enrollment periods, newly 40% 39% 31% insured Marketplace enrollees were most likely to gain coverage in the first quarter, whereas All Newly Newly Insured Newly Insured Newly Insured Insured Medicaid Marketplace ESI newly-insured adults with Medicaid or employer coverage were more likely to gain coverage NOTE: Includes adults ages 19-64. “Newly Insured” include people who were insured as of interview date and gained coverage since January 2014. Share of Newly Insured Medicaid, Marketplace, and ESI reporting “Don’t Know/Refused” not shown because throughout the year (Figure 2). they do not meet minimum standard for statistical reliability. * Significantly different from Medicaid at the p<0.05 level. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. The vast majority of adults who gained coverage in 2014 have family income below 400% of poverty, the income range for financial assistance under the ACA. More than half (53%) of adults who gained coverage in 2014 have family income at or below 138% of poverty, or about $27,300 for a family of three, and more than one in four (42%) has family incomes in the range for tax credits (139 to 400% of poverty). This income profile is not significantly different than that for the remaining uninsured population. However, the newly insured Access, Utilization, and Financial Security among Newly Insured Adults 4 population is significantly more likely than the previously insured to be low- and middle-income and significantly less likely to be higher income (greater than 400% of poverty). This pattern reflects the longstanding association between being low income and lacking insurance coverage. This report aims to understand the impact that gaining coverage has had on the lives of low- and middle- income “newly insured” adults. Based on the 2014 Kaiser Survey of Low-Income Americans and the ACA, it describes who was newly insured as of Fall 2014 and compares this population to their uninsured and previously insured counterparts (see text box below for definitions of these terms); provides information on how the newly insured view their coverage and any problems they have encountered, and examines how the newly insured fare with respect to access to medical care and financial burden. Because adults who were previously insured were more likely to be higher income, and because income is associated with many of the outcomes of interest, the analysis in this brief is restricted to only the population below 400% of poverty, who we call “low- and middle-income adults.” This approach enables us to compare the newly insured to the uninsured and previously insured with a similar income profile. Because timing of coverage may also affect some of the outcomes of interest, we also conducted sensitivity analysis to examine whether patterns among the newly insured differed by timing of coverage and, where relevant, report those as well. Throughout this report, we use the following terms to refer to people by whether they have insurance coverage and when they gained their coverage:  Uninsured: This group includes people who lacked insurance coverage at the time of the survey. While some of these people lost coverage during 2014, the vast majority (77%) lacked coverage since at least January 2014.  Newly Insured: This group includes people who were insured at the time of the survey, indicated that their coverage started on or after January 2014, and said that they lacked insurance coverage before their current coverage began.  Previously Insured: This group includes people who were insured at the time of the survey and had been insured since before January 2014. Some of these individuals may have changed the type of coverage they had in 2014, but they had no period of uninsurance before their current coverage began. In addition, to increase the comparability between coverage groups, we restrict this analysis to low- and middle-income nonelderly adults. Income groups are defined as:  Low-Income: People in families with incomes up to or including 138% of the poverty level. In 2014, 138% of poverty was $27,300 for a family of three.  Middle-Income: People in families with incomes between 139 and 400% of the poverty level. In 2014, 400% of poverty was $79,200 for a family of three. Access, Utilization, and Financial Security among Newly Insured Adults 5 In some ways, the low- and middle- income “newly insured” population (those who gained coverage in 2014 and were uninsured before gaining that coverage) and “uninsured” population (those who lacked coverage in fall 2014) resemble each other. For example, they are similar with respect to income, work status, age, and family type, and they differ from the low- and middle-income “previously insured” population (people who had coverage before 2014 and still had it in 2014) on these factors. However, the newly insured population differs from their counterparts who remained without coverage on some important factors, such as race/ethnicity, gender, and immigration status. These differences in part reflect ongoing barriers to coverage among some groups and in part reflect higher take-up among others. Even within the low- and middle-income population, newly insured adults are more likely to be lower-income than previously insured Figure 3 adults. More than half (56%) of adults in the Income Distribution Among Low- and Middle-Income income range for ACA financial assistance are in Nonelderly Adults, By Insurance Coverage in Fall 2014 families at or below 138% of poverty, a rate that is not statistically significantly different from the 41% 44% remaining uninsured. In contrast, previously 63%* insured adults in the low- and middle-income range are more likely to fall into the middle- 139-400% FPL 59% 56% income range, with 63% having family incomes ≤ 138% FPL 37%* between 139 and 400% of poverty (Figure 3). The fact that newly insured adults are more likely to Uninsured Newly Insured Previously Insured be in the lowest income group may have NOTE: Includes adults ages 19-64. The federal poverty level (FPL) in 2014 was $19,790 for a family of three. “Previously Insured” implications for their financial stability and includes people who were insured as of interview date and have been insured since before January 2014. “Newly Insured” include people who were insured as of interview date and gained coverage since January 2014. “Uninsured” includes people who lacked coverage as of the interview date. Totals may not sum to 100% due to rounding. ability to navigate the health system, as lower- * Significantly different from Newly Insured at the p<0.05 level. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. income individuals face more barriers to health care than higher-income people. Figure 4 Family Work Status Among Low- and Middle-Income Not surprisingly, adults who are newly insured Nonelderly Adults, by Insurance Coverage in Fall 2014 through Medicaid are significantly more likely to be in the lowest income group than adults who 29% 33% 33% gained Marketplace or other private coverage, who are more likely to be middle-income (data 10%* No Worker in Family 19% 20% not shown). Medicaid eligibility is targeted to Self or Spouse Working Part Time adults with the lowest incomes, with the ACA Self or Spouse Working Full Time extending eligibility to most adults with incomes 47% 45% 61%* at or below 138% in states that expanded. Some adults, such as pregnant women or working Uninsured Newly Insured Previously Insured adults with disabilities, may qualify for Medicaid NOTE: Includes adults ages 19-64. “Previously Insured” includes people who were insured as of interview date and have been insured since before January 2014. “Newly Insured” include people who were insured as of interview date and gained coverage at higher incomes through pathways in place since January 2014. “Uninsured” includes people who lacked coverage as of the interview date. Those who refused or did not know answers to work status questions not shown. * Significantly different from Newly Insured at the p<0.05 level. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. before the ACA. Access, Utilization, and Financial Security among Newly Insured Adults 6 Newly insured adults are more likely to be in a family working part-time (versus full-time) than their previously insured counterparts. A majority of low- and middle-income adults who gained coverage in 2014 live in a family with a worker, meaning either they or their spouse works full time (45%) or part time (20%), and a third (33%) are in a family with no worker (Figure 4). This distribution is not significantly different from the uninsured. However, previously insured adults are more likely than newly insured adults to have a full-time worker in the family and less likely to have a part-time worker. This pattern reflects the historical ties between work and health insurance, since most people who had coverage before the ACA obtained that coverage through a job and people without full-time employment had limited access to affordable coverage. With new coverage provisions in place as of 2014, there were more options for health insurance outside employment, particularly for people in states that expanded Medicaid. Within the newly insured population, those newly insured through Medicaid were less likely than adults with other coverage (including Marketplace) to be in a full-time working family (data not shown). This finding is not surprising given that Medicaid eligibility targets those in the lowest income bracket, and people with lower incomes are less likely to work full-time. However, compared to adults who had Medicaid coverage before 2014, those who gained Medicaid coverage were more likely to be in a family with a worker. With the expansion of Medicaid in many states, eligibility levels were raised to levels where one could work part-time and still meet income limits. Half of newly insured adults are under age 35. Despite concerns that many people who sign up for coverage would be older adults who were more at risk for health problems, half of newly insured adults were under age 35 (Appendix Table 1). Nearly a fifth (19%) were aged 19 to 25, the so-called “young invincible” group. The age distribution of the newly insured was similar to the remaining uninsured population but younger than the previously insured population. These differences likely reflect the fact that those who lacked coverage prior to 2014 were more likely to be young, since younger adults have looser ties to employment and lower incomes. Within the newly insured population, there were no significant differences in age distribution between Medicaid and Marketplace enrollees, though newly insured adults with employer coverage were less likely than those who gained ACA coverage to be age 45-64. The newly insured population is more likely to be female than their counterparts who remained without coverage. Nearly six in ten (58%) of the newly insured population is female, a share significantly higher than that among the remaining uninsured (45%) but not significantly different from the previously insured (Appendix Table 1). Women have historically had a lower uninsured rate than men,2 and the gender patterns in who gained coverage may reflect women taking up coverage at a higher rate than men. There were no significant differences in gender by coverage type within the newly insured population. Access, Utilization, and Financial Security among Newly Insured Adults 7 More than half of newly insured adults are adults without dependent children, a group that has generally been excluded from publicly-financed health coverage in the past. About six in ten (61%) newly insured adults do not have dependent children, and 72% are not married (Figure 5). These shares are similar to those among the remaining uninsured population. In the past, non-elderly adults without dependent children could only qualify for Medicaid if they were disabled or pregnant, and private coverage as an adult dependent was generally restricted to spouses. With new coverage expansions, some people who faced limits to accessing coverage due to family structure were able to gain coverage. Previously insured adults were most likely to be married, perhaps reflecting the availability of family coverage in the private market. Within the newly insured population, there were no significant differences by coverage in the share of adults who were not married without dependent children. Figure 5 Figure 6 Family Status of Low- and Middle-Income Nonelderly Adults, By Share of Low- and Middle-Income Parents Whose Children Are Insurance Coverage in Fall 2014 Insured, by Parent Insurance Coverage in Fall 2014 Share with all children insured: 39%* 52% 50% Not married, no dependent children Married, no dependent children 18%* Not married with 92% 96% 10% 11% dependent children 14%* Married with dependent 67%* children 22% 22% 29%* 16% 16% Uninsured Newly Insured Previously Insured Uninsured Newly Insured Previously Insured NOTE: Includes adults ages 19-64. “Previously Insured” includes people who were insured as of interview date and have been NOTE: Includes adults ages 19-64. “Previously Insured” includes people who were insured as of interview date and have been insured since before January 2014. “Newly Insured” include people who were insured as of interview date and gained coverage insured since before January 2014. “Newly Insured” include people who were insured as of interview date and gained coverage since January 2014. “Uninsured” includes people who lacked coverage as of the interview date. Children includes dependent since January 2014. “Uninsured” includes people who lacked coverage as of the interview date. children under age 19. * Significantly different from Newly Insured at the p<0.05 level. Share of newly insured with some or all * Significantly different from Newly Insured at the p<0.05 level. children uninsured not shown because estimate does not meet standard for statistical reliability. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. Among parents, newly insured adults were less likely to have uninsured children than adults who remained without coverage. The vast majority of uninsured children are eligible for coverage under the ACA: Medicaid and the Children’s Health Insurance Program (CHIP) are available to most children in low- income families, and children may be covered along with their parents in Marketplace coverage. Research has found that parent coverage in public programs is associated with higher enrollment of eligible children.3 Coverage patterns in 2014 support this finding: newly insured parents were less likely than uninsured parents to have uninsured children, and nearly all newly insured and previously insured parents had all of their children insured (Figure 6). Access, Utilization, and Financial Security among Newly Insured Adults 8 Over half of newly insured adults are people of color. Reflecting historical patterns of the uninsured being more likely to be people of color than the Figure 7 insured, the newly insured are less likely than Race/Ethnicity of Low- and Middle-Income Nonelderly Adults, the previously insured to be White, Non- By Insurance Coverage in Fall 2014 Hispanic, though they are no more or less likely 8% 9% 9% to be White, Non-Hispanic than adults who 23% 18% 31%* remained uninsured (Figure 7). Notably, the 12%* Other^ newly insured population is less likely to be 19% Hispanic 15% Hispanic than the remaining uninsured. This Black, Non-Hispanic pattern likely reflects a combination of factors, 61%* White, Non-Hispanic 49% including language barriers, immigration policy, 45% and work status, that led to the remaining uninsured being disproportionately Hispanic. Uninsured Newly Insured Previously Insured NOTE: Includes adults ages 19-64. “Previously Insured” includes people who were insured as of interview date and have been There were no significant differences in insured since before January 2014. “Newly Insured” include people who were insured as of interview date and gained coverage since January 2014. “Uninsured” includes people who lacked coverage as of the interview date. ^Comprises Asian, Pacific Islander, American Indian, Alaskan Native, “Other”, and “Don’t Know.” race/ethnicity of the newly insured population * Significantly different from Newly Insured at the p<0.05 level. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. by type of coverage gained. The vast majority of newly insured adults are U.S. citizens. Nearly nine in ten (87%) of newly insured adults are citizens, and 7% are legal immigrants (Appendix Table 1). The remainder is immigrants who are in the United States without a green card. While federal law bars undocumented immigrants from ACA coverage either through Medicaid or the Marketplace, as documented elsewhere, immigrants without green cards may acquire coverage through a job, directly from insurers outside the Marketplace, or through state-only programs.4,5,6 However, bans on coverage among undocumented immigrants are evident in the higher share (15%) of remaining uninsured who fall into this category. Among the previously insured, nearly all (97%) are U.S. citizens or legal immigrants. Within the newly insured population, there were no significant differences in the share of US citizens by type of coverage. Newly insured adults do not differ Figure 8 Health Status Among Low- and Middle-Income Nonelderly significantly from the previously insured Adults, by Insurance Coverage in Fall 2014 on most measures of health status, but Uninsured Newly Insured Previously Insured they are less likely than their uninsured counterparts to report fair or poor health. Nearly three in ten (28%) newly 49%* insured adults rate their overall health as fair or 39% 41% 37%* 36% poor, a share that is not significantly different 28% 25% 32% 25%* 20% 18% from the previously insured but is lower than 16% the remaining uninsured (Figure 8). Nearly a fifth (18%) reports their mental health is fair or Fair to Poor Overall Fair to Poor Mental Has Ongoing Condition Taking a Prescription^ Health Health poor and about four in ten (39%) report that NOTE: Includes adults ages 19-64. “Previously Insured” includes people who were insured as of interview date and have been insured since before January 2014. “Newly Insured” include people who were insured as of interview date and gained coverage they have an ongoing medical condition that since January 2014. “Uninsured” includes people who lacked coverage as of the interview date. ^Does not include birth control. * Significantly different from Newly Insured at the p<0.05 level. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. requires regular care, rates about equal to adults in other coverage groups. These findings refute the idea that those who gained coverage are more likely than those who did not to be in poor health or feel they need medical services. However, newly insured adults are Access, Utilization, and Financial Security among Newly Insured Adults 9 less likely than the previously insured and more likely than the uninsured to say they take a prescription on a regular basis. Within the newly insured group, adults with Medicaid are more likely say they receive care for an ongoing condition than those with Marketplace coverage (data not shown). Further, adults newly insured through Medicaid were more likely to report fair or poor overall or mental health, to have an ongoing condition, or to take a prescription drug than those newly insured through employer coverage. Several pre-ACA Medicaid eligibility pathways specifically target people with health problems, and some gaining coverage may have qualified through these routes. Many adults also enroll in Medicaid after coming in contact with the medical system, which may explain why these adults are more likely than other newly insured to have a chronic condition. The ultimate goal of expanding health insurance coverage is to help people access the medical services that they need. A large body of literature has documented that people with insurance are more likely to be linked to regular care, are less likely to postpone care when they need it, and have an easier time accessing services. The survey findings reinforce those findings, indicating that adults who gained coverage in 2014 have better access to care than those who remained without coverage. In addition, the survey findings provide insight into patterns of care among the newly insured and remaining insured. While some newly insured adults report changing where they regularly go for care, many say they continue to seek services from community clinics and health centers, which have historically provided care to under-served populations such as the uninsured. Adults who gained coverage are more likely to be linked to care than those who remained uninsured. Newly insured adults were more likely than those who remained uninsured in Fall 2014 to have a usual source of care, or a place to go when they are sick or need advice about their health (not counting the emergency room); they were also more likely to have a regular doctor at their usual source of care (Figure 9). Having a usual source of care or regular doctor is an indicator of being linked in to the health care system and having regular access to services. These patterns reinforce a large body of research that finds that gaining coverage is associated with improved access to Figure 9 Share of Low- and Middle-Income Insured Adults with a Usual Source care. However, results also indicate that the of Care or Regular Provider, by Insurance Coverage newly insured are less likely than the previously Uninsured Newly Insured Previously Insured insured to have a usual source of care or regular 79%* doctor. This finding may indicate that newly 66%* insured adults are still navigating the health care 63% system and are not as settled into regular care as 46%* 44% their previously insured counterparts. There were 25%* no differences in the share with a usual source of care by type of coverage among the newly insured, but adults newly insured through Has a Usual Source of Care Has a Regular Provider at a Usual Source of Care Medicaid were more likely than those newly NOTE: Includes insured adults ages 19-64. Respondents who indicate their usual source of care is the emergency department are not included. “Previously Insured” includes people who were insured as of interview date and have been insured since before insured through Marketplace or employer January 2014; some of these people may have switched coverage type. “Newly Insured” include people who were insured as of interview date and gained coverage since January 2014. * Significantly different from Newly Insured at the p<0.05 level. coverage to say they have a regular doctor at their SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. usual source of care. Access, Utilization, and Financial Security among Newly Insured Adults 10 Newly insured adults were more likely to change where they usually go for care than their uninsured or previously insured Figure 10 counterparts. A fifth of newly insured adults Change in Usual Source of Care Among Low- and Middle- Income Nonelderly Adults, by Insurance Coverage in Fall 2014 who have a usual source of care reported that Among those with a usual source of care, share who: they changed the place they usually go for care Uninsured Newly Insured Previously Insured since gaining their coverage (Figure 10). This rate is twice as high as the share of previously insured adults who changed their usual source of care in 20% 2014 (it is also higher than the share of uninsured adults, but the difference is not 13% 10%* 10% statistically significant). About half of newly 4%* 3%* insured adults who changed their site of care reported that it was due to their insurance, a Changed where they go for usual care Changed usual source of care due to insurance NOTE: Includes adults ages 19-64. “Previously Insured” includes people who were insured as of interview date and have been significantly higher rate than the other coverage insured since before January 2014. “Newly Insured” include people who were insured as of interview date and gained coverage since January 2014. “Uninsured” includes people who lacked coverage as of the interview date. * Significantly different from Newly Insured at the p<0.05 level. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. groups. Figure 11 Type of Place Used for Usual Source of Care among Low- While clinics remain an important source and Middle-Income Adults, by Insurance Coverage Among those with a usual source of care, share using: of care for the newly insured, most rely on Doctor’s Office or HMO Clinic or Health Center Other Place^ private doctor’s offices for their regular care. Among newly insured adults who have a Uninsured 31%* 49%* 20% usual source of care, about half (51%) say it is a doctor’s office or HMO, and more than a third Newly Insured 51% 34% 15% (34%) say it is a clinic or health center (Figure 11). In contrast, about half of uninsured adults with a usual source of care rely on a clinic or Previously Insured 60%* 25%* 15% health center, and less than a third use a doctor’s NOTE: Includes adults ages 19-64. “Other” includes urgent care centers, hospital outpatient departments, some other location, and office or HMO for their regular care. Previously don’t know/refused. Respondents who indicate their usual source of care is the emergency department are not included. “Previously Insured” includes people who were insured as of interview date and have been insured since before January 2014; some of these people may have switched coverage type. “Newly Insured” include people who were insured as of interview date insured adults were most likely to use a doctor’s and gained coverage since January 2014. * Significantly different from Newly Insured at the p<0.05 level. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. office or HMO and least likely to use clinics as Figure 12 their usual source of care. Historically, clinics Reason for Choosing Usual Source of Care among Low- and and health centers were crucial “safety net” Middle-Income Adults, by Insurance Coverage Among those with a usual source of care, share choosing providers for uninsured people. As newly insured because it is: Convenient Only Option Preferred Provider is There Good Reputation Affordable gain coverage, many continue to rely on these providers, but they are also more likely to change Uninsured 23%* 11% 21% 7%* 32% to a doctor’s office for their care. Newly Insured Like their previously insured 38% 7% 30% 14% counterparts, most newly insured adults choose their site of care based on Previously Insured 31% 8% 42%* 11% 5% convenience or providers, rather than NOTE: Includes adults ages 19-64. Respondents who indicate their usual source of care is the emergency department are not affordability or lack of options. In the past, included. Share of Newly Insured reporting “Affordable” not shown because does not meet minimum standard for statistical reliability. “Previously Insured” includes people who were insured as of interview date and have been insured since before January 2014; some of these people may have switched coverage type. “Newly Insured” include people who were insured as of interview many uninsured adults reported that they chose date and gained coverage since January 2014. * Significantly different from Newly Insured at the p<0.05 level. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. Access, Utilization, and Financial Security among Newly Insured Adults 11 their usual source of care because it was affordable, a pattern that is also seen among adults who were uninsured in 2014. In contrast, adults who gained coverage in 2014 were more likely to say they chose their usual source of care because it was convenient (38%), and many chose it because the provider they prefer to see is there (30%) (Figure 12). They were also more likely than the uninsured to choose their site of care because it has a good reputation. Previously insured adults were more likely than newly insured to choose their usual source of care because their preferred provider is there. These differences may indicate that the previously insured adults have stronger ties to their providers, having been linked to care for a longer period of time. Mirroring patterns of being linked to care, newly insured adults are more likely than their uninsured counterparts to have used medical services or received preventive care. Overall, nearly two-thirds (64%) of adults who gained coverage in 2014 said they used at least one medical service since gaining their coverage, and nearly half (47%) had received a preventive visit or check-up (Figure 13). These rates were significantly higher than those for the uninsured in 2014 but were lower than the previously insured reported for 2014. These patterns are not unexpected given the large body of research showing that people with insurance coverage are more likely than those without to use care, including preventive care. The differences between the newly insured and previously insured partially reflect the shorter period of time that the newly insured had their coverage, since most people’s Figure 13 coverage started at least several months into Use of Care Among Low- and Middle-Income Nonelderly Adults, 2014. Analysis of the type of care received (not by Insurance Coverage in Fall 2014 Uninsured Newly Insured Previously Insured shown) indicates that differences exist for 81%* outpatient services (well-care or sick care) and mental health services but not for hospital-based 64% 65%* services, including emergency care, indicating 52%* 47% that patterns differ for discretionary versus emergent or high-acuity services. Within the 27%* newly insured, adults with employer coverage were less likely than those with Medicaid to have used medical services since gaining coverage, and Used any medical services Had checkup or preventive care visit NOTE: Includes adults ages 19-64. “Previously Insured” includes people who were insured as of interview date and have been they were less likely than either Medicaid or insured since before January 2014. “Newly Insured” include people who were insured as of interview date and gained coverage since January 2014. “Uninsured” includes people who lacked coverage as of the interview date. * Significantly different from Newly Insured at the p<0.05 level. Marketplace enrollees to have received a SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. preventive visit since gaining coverage. Newly insured adults were less likely than uninsured adults to never receive needed care or face serious consequences of postponing care. While there were no significant differences between coverage groups in the share who postponed care, newly insured adults were significantly less likely than uninsured adults to say they never got the care they needed (22% versus 32%) (Figure 14). They were also less likely to report that postponing care led to a condition worsening or serious stress (there was no significant difference in the share who said postponing care led to time away from work or school). Still, the newly insured were more likely than the previously insured to report problems postponing and never receiving needed care, reflecting some unmet need among those who gained coverage in 2014. Access, Utilization, and Financial Security among Newly Insured Adults 12 Figure 14 Figure 15 Unmet Need for Care Among Low- and Middle-Income Reasons for Postponing Care Among Low- and Middle-Income Nonelderly Adults, by Insurance Coverage in Fall 2014 Nonelderly Adults, by Insurance Coverage in Fall 2014 Share who say they postponed care and did so because: Uninsured Newly Insured Previously Insured Uninsured Newly Insured Previously Insured 42% 34%* 35% 31% 32%* 29%* 21% 22% 20%* 18% 15%* 15%* 15% 16% 11% 10% 10% 8% 8% 9% 10% 8% 6% 6% Postponed Care Postponed Care & Postponed Care Led to Postponed Care Led to Postponed Care Led to Never Received It Condition Worsening Loss of Time at Work Serious Stress Could not afford cost Clinic or doctor's office was not Difficulty travelling to clinic or or School open when they could get there doctor's office NOTE: Includes adults ages 19-64. “Previously Insured” includes people who were insured as of interview date and have been NOTE: Includes adults ages 19-64. “Previously Insured” includes people who were insured as of interview date and have been insured since before January 2014. “Newly Insured” include people who were insured as of interview date and gained coverage insured since before January 2014. “Newly Insured” include people who were insured as of interview date and gained coverage since January 2014. “Uninsured” includes people who lacked coverage as of the interview date. since January 2014. “Uninsured” includes people who lacked coverage as of the interview date. * Significantly different from Newly Insured at the p<0.05 level. * Significantly different from Newly Insured at the p<0.05 level. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. Unmet need could be related to several factors, including difficulty finding a provider, problems navigating the health system and health insurance networks, misunderstanding about how to use coverage and when to seek care, or concerns about out-of-pocket costs. When asked why they postponed care, newly insured adults were less likely than uninsured adults to say cost was a factor (21% versus 34%), but they were more likely than previously insured adults (15%) to say cost was a factor (Figure 15). While Medicaid enrollees pay no or nominal cost-sharing, adults with Marketplace coverage may face out-of-pocket costs, particularly if they do not choose a silver plan (cost sharing subsidies for people with incomes below 250% of poverty are only available if they choose a silver plan).7 In addition, as discussed earlier in this brief, newly insured adults have lower incomes than previously insured adults, which means cost-sharing may pose a bigger burden for them. When asked whether being able to get to the provider when it was open or difficulty traveling to the provider were factors, there were no significant differences in the shares of uninsured, newly insured, and previously uninsured adults who said these things caused them to postpone care. Though most adults did not report problems getting medical appointments, newly insured adults were more likely than other adults to say a provider would not take them as a new patient. Compared to 7% of uninsured and 6% Figure 16 of previously insured adults, 15% of newly Problems Getting Medical Appointments Among Low- and insured adults say that a provider told them Middle-Income Nonelderly Adults, by Insurance Coverage in he/she would not take them as a new patient Fall 2014 (Figure 16). Most newly insured adults who Uninsured Newly Insured Previously Insured reported this problem said it was because the provider did not take their coverage, a rate higher than that for the previously insured. The lower rates among the uninsured likely reflect this 15% 12% 14% 14% group’s lower propensity to seek care, as detailed 7%* 6%* 3% 7% 5% 4% 5% 5% elsewhere. The higher rates among the newly Told could not get appt with Had to wait longer than Had to wait longer than Had to wait longer than insured may reflect problems with network a provider reasonable for any appointment reasonable for primary care reasonable for specialty care adequacy, outdated or inaccurate plan NOTE: Includes adults ages 19-64. “Previously Insured” includes people who were insured as of interview date and have been insured since before January 2014. “Newly Insured” include people who were insured as of interview date and gained coverage since January 2014. “Uninsured” includes people who lacked coverage as of the interview date. information, or disruptions in care patterns that * Significantly different from Newly Insured at the p<0.05 level. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. Access, Utilization, and Financial Security among Newly Insured Adults 13 led newly insured adults to be more likely to seek a new provider. Among adults who received care, newly insured adults were more likely than uninsured to report effective communication with their providers about their care. Once people get into care, health literacy—or “patients' ability to obtain, process, and understand the basic health information and services they need to make appropriate health decisions”8—plays an important role in how that care affects health outcomes. Health literacy depends on a range of factors related to patients (e.g., engagement in care), providers (e.g., how the information is communicated), service setting (e.g., the length of time of the interaction), and the nature of the visit (e.g., the complexity of health information). In general, it appears that adults with coverage are more likely than those without coverage to report effective communication with their provider, a finding that may be linked to having a Figure 17 regular doctor. Adults who were newly insured Views of Health Care Encounter Among Low- and Middle- were significantly more likely than their Income Nonelderly Adults, by Insurance Coverage in Fall 2014 Share saying happened “always” or “most of the time” they visited provider: uninsured counterparts to report effective Uninsured Newly Insured Previously Insured communication, including getting all the 84% 89% 87%* 91% 93% 83%* 79% 82% 79% information they wanted from the provider; 75%* 68%* 68%* feeling encouraged to ask questions; understanding their test results; and understanding how to take their medication (Figure 17). Within the group of newly insured adults, there were no significant differences by Provider gave all the Provider encouraged me Results of tests were Instructions about taking information I wanted to ask questions easy to understand medicine easy to coverage type. Further, the only outcome for understand NOTE: Includes adults ages 19-64 who had at least one provider visit. “Previously Insured” includes people who were insured as of which there was a significant difference between interview date and have been insured since before January 2014. “Newly Insured” include people who were insured as of interview date and gained coverage since January 2014. “Uninsured” includes people who lacked coverage as of the interview date. the newly and previously insured was * Significantly different from Newly Insured at the p<0.05 level. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. understanding test results. Health care costs can be a major burden for low-income families. While many newly insured adults report difficulty affording their monthly premium, they also report lower rates of problems with medical bills and lower rates of worry about future medical bills than their uninsured counterparts. However, newly insured adults still face financial insecurity: they are more likely than those who had coverage before 2014 to worry about future medical bills, and they face general financial insecurity at rates similar to the uninsured. These patterns may indicate that while coverage can ameliorate some of the financial challenges that low- and moderate- income adults face, many will continue to face financial challenges in other areas of their lives. Access, Utilization, and Financial Security among Newly Insured Adults 14 Many low- and middle-income insured Figure 18 Difficulty Affording Health Insurance Premiums among Low- and adults report difficulty paying their Middle-Income Insured Adults, by Insurance Coverage monthly premium. Among adults who say that Share reporting it is “somewhat difficult” or “very difficult” to pay premium: they pay a monthly premium for their health coverage, more than four in ten newly insured 56% 49% adults (44%) and over a third of previously 44% 41% 44% 35% insured adults (35%) say it is somewhat or very 29% difficult to afford this cost (Figure 18). While rates of difficulty varied by type of coverage among the newly insured, these differences by All Newly Marketplace ESI All Previously Marketplace Non- ESI Insured Insured Marketplace type of coverage were not statistically significant. Nongroup Newly Insured Previously Insured Notably, though a majority (85%) of Marketplace NOTE: Includes insured adults ages 19-64. “Previously Insured” includes people who were insured as of interview date and have enrollees receive premium subsidies,9 many (41% been insured since before January 2014; some of these people may have switched coverage type. “Newly Insured” include people who were insured as of interview date and gained coverage since January 2014. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. of the newly insured and 49% of the previously insured) still report difficulty affording their premium cost. However, coverage does provide financial protection from medical bills and eases concern over affording medical care. Compared to the uninsured, both newly insured and previously insured adults report lower rates of difficulty paying medical bills. Despite being less likely to use services, over a third (36%) of uninsured adults report a problem paying medical bills, a rate twice as high as either the newly insured or previously insured (Figure 19). Uninsured adults were also more likely to report serious consequences from medical bills, such as using up their savings, having difficulty paying for necessities, borrowing money, or being sent to collection. On all measures of problems from medical bills, there were no significant differences between the newly and previously insured. Figure 19 Figure 20 Problems Paying Medical Bills Among Low- and Middle-Income Financial Insecurity Over Medical Costs Among Low- and Nonelderly Adults, by Insurance Coverage in Fall 2014 Middle-Income Nonelderly Adults, by Insurance Coverage in Fall 2014 Uninsured Newly Insured Previously Insured Uninsured Newly Insured Previously Insured 82%* 68%* 59% 36%* 40%* 34% 24%* 27%* 21%* 24%* 17% 18% 18%* 15%* 10% 9% 8% 8% 10% 10% 16% 6% 6% 12% Any problem paying Problem with Problem with Problem with Problem with medical bills medical bills led to medical bills led to medical bills led medical bills led to Not Confident Can Afford Usual Not Confident Can Afford Major Worry About Medical Costs using up savings difficulty paying for borrowing money being sent to Medical Costs Medical Costs Affects Job Performance, Family basic necessities collection Relationships, or Ability to Sleep NOTE: Includes adults ages 19-64. “Previously Insured” includes people who were insured as of interview date and have been NOTE: Includes adults ages 19-64. “Previously Insured” includes people who were insured as of interview date and have been insured since before January 2014. “Newly Insured” include people who were insured as of interview date and gained coverage insured since before January 2014. “Newly Insured” include people who were insured as of interview date and gained coverage since January 2014. “Uninsured” includes people who lacked coverage as of the interview date. since January 2014. “Uninsured” includes people who lacked coverage as of the interview date. * Significantly different from Newly * Significantly different from Newly Insured at the p<0.05 level. Insured at the p<0.05 level. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. In addition to being less likely to report experiencing financial strain due to medical bills, insured adults are less likely than uninsured to report living with worry about their ability to afford medical care in the future. Newly insured adults were half as likely as uninsured to say they lack confidence in their ability to afford the cost of care for services they typically require (34% versus 68%), and they were also significantly less likely to Access, Utilization, and Financial Security among Newly Insured Adults 15 say they lack confidence in their ability to afford the cost of a major illness (59% versus 82%) (Figure 20). In some cases, this concern has implications for people’s level of stress and affects their daily lives: newly insured adults were less likely than uninsured to say that worry over affording medical costs has affected their job performance, family relationships, or ability to sleep. However, in contrast to reported problems with medical bills, newly insured adults were more likely than previously insured adults to report financial insecurity over future medical bills. Among the newly insured, there were no significant differences in lack of confidence by coverage type. It is possible that newly insured adults have less confidence in the protection offered by their coverage, or it is possible that their recent experience without coverage led them to be more concerned about future coverage and costs. Many newly insured adults still face financial insecurity in areas outside of health care costs. While coverage provides some financial protection from medical bills, newly insured adults are not less likely than uninsured adults to report facing general financial challenges in other areas of their lives. For example, there are no significant differences in the share of uninsured and newly insured adults reporting general financial insecurity or in the share reporting Figure 21 difficulty paying for necessities, saving money, or Financial Security Among Low- and Middle-Income Nonelderly paying off debt (Figure 21). However, previously Adults, by Insurance Coverage in Fall 2014 Uninsured Newly Insured Previously Insured insured adults were less likely than newly insured 82% 81% to report these financial challenges. 68%* 65% 67% 58% Within the group of newly insured adults, those 52% 51% 50%* 45% with Medicaid were more likely than those with 34%* 35%* other types of coverage to report that they were financially insecure and more likely to say they have difficulty paying for necessities (data not Generally financial Somewhat/very difficult Somewhat/very difficult Somewhat/very difficult shown). This finding is not surprising, given that insecure to pay for necessities to save money to pay off debt Medicaid is targeted to adults with the lowest NOTE: Includes adults ages 19-64. “Previously Insured” includes people who were insured as of interview date and have been insured since before January 2014. “Newly Insured” include people who were insured as of interview date and gained coverage since January 2014. “Uninsured” includes people who lacked coverage as of the interview date. * Significantly different from Newly incomes. Insured at the p<0.05 level. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. People’s views of their plan may affect not only their use of their coverage but also the likelihood that they re- enroll in coverage or change plans. Survey results reveal that newly insured adults were very sensitive to cost in choosing their plan, placing a priority on cost over benefits and provider networks. A minority of all insured adults reported problems in using their plan. However, newly insured adults were more likely than previously to say they do not understand the details of their plan and were more likely to give their plan a low rating. These findings indicate that additional education may be needed to help people understand their coverage. Access, Utilization, and Financial Security among Newly Insured Adults 16 Newly insured adults were less likely to prioritize scope of coverage in choosing their plan than previously insured adults. Among adults who say they had a choice of plans and made the choice themselves, under a quarter (24%) of newly insured adults say they chose their plan because of the benefits covered, compared to 35% of previously insured adults (Figure 22). Newly insured adults were most likely to say they chose their plan because of low cost (35%); while this share was higher than the previously insured (28%), the difference was not statistically Figure 22 significant. Newly insured adults may have been Main Reason for Choosing Health Plan, Among Low- and Middle- Income Insured Adults Who Had a Choice less likely to choose based on benefits because new regulations set a minimum scope of coverage Low cost Provider network Benefits covered Recommended Other reason across new plans (so called “essential health benefits”), but “grandfathered” pre-existing plans Newly Insured 35% 15% 24% 9% 18% are not held to the same requirement. Alternatively, newly insured adults may be more sensitive to price than their previously insured counterparts, even with the availability of Previously Insured 28% 19% 35%* 5% 14% financial assistance for coverage. Notably, more than half (56%) of newly insured Marketplace NOTE: Among insured adults ages 19-64 who had a choice of plans and made the choice themselves. “Previously Insured” includes enrollees say they chose their plan primarily people who were insured as of interview date and have been insured since before January 2014; some of these people may have switched coverage type. “Newly Insured” include people who were insured as of interview date and gained coverage since January 2014. *Significantly different from newly insured at the p<0.05 level. based on cost (data not shown). SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. Newly insured adults were more likely to say they had difficulty comparing services and provider networks across plans than previously insured adults. In contrast to Figure 23 comparing costs, which similar shares of the Views of Plan Selection Process Among Low- and Middle- Income Adults Who Chose a Health Plan newly insured (17%) and previously insured Share reporting it was “somewhat difficult” or “very difficult” to: (15%) said was difficult, newly insured adults Newly Insured Previously Insured who chose a plan were significantly more likely than previously insured to say they found it difficult to compare services (32% versus 19%) or 32% 34% provider networks (34% versus 22%) (Figure 23). 19%* 17% 22%* 15% Comparing the newly insured and previously insured by coverage type, it appears that these Compare services covered Compare costs Compare provider networks differences may be linked to coverage type. For example, newly insured adults with Marketplace NOTE: “Previously Insured” includes people who were insured as of interview date and have been insured since before January coverage were no more likely to report difficulty 2014; some of these people may have switched coverage type. “Newly Insured” include people who were insured as of interview date and gained coverage since January 2014. *Significantly different from newly insured at the p<0.05 level. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. than the previously insured with Marketplace coverage (data not shown). Access, Utilization, and Financial Security among Newly Insured Adults 17 Most newly insured adults give their health plan high ratings, but some report not understanding the details of their plan. Nearly three quarters (74%) of all newly insured adults rate their coverage as “excellent” or “good” (versus “not so good” or “poor”), and this rate did not differ significantly by type of coverage that people gained (Figure 24). While these findings show high rates of satisfaction, adults who had coverage before 2014 were more likely to give their plan a high rating, with 83% saying their coverage was excellent or good. Figure 24 Figure 25 Rating of Health Insurance Coverage among Low- and Understanding of Health Insurance Coverage among Low- Middle-Income Insured Adults, by Insurance Coverage and Middle-Income Insured Adults, by Insurance Coverage Share who say they understand “very well” or “somewhat well”: Share rating their coverage as “Excellent” or “Good”: 85%* 84% Services Covered Cost Sharing Rules 83%* 79% 85%* 74% 73% 75% 75% 79%* 71% 75% 67% All Newly Medicaid Marketplace ESI All Previously Medicaid Marketplace Non- ESI Insured Insured Marketplace Nongroup Newly Insured Previously Insured Newly Insured Previously Insured NOTE: Includes insured adults ages 19-64. “Previously Insured” includes people who were insured as of interview date and have been NOTE: Includes insured adults ages 19-64. “Previously Insured” includes people who were insured as of interview date and have been insured since before January 2014; some of these people may have switched coverage type. “Newly Insured” include people who were insured since before January 2014; some of these people may have switched coverage type. “Newly Insured” include people who were insured as of interview date and gained coverage since January 2014. * Significantly different from Newly Insured at the p<0.05 level. insured as of interview date and gained coverage since January 2014. * Significantly different from Newly Insured at the p<0.05 level. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. Lower plan ratings among the newly insured could reflect problems with coverage, but, as discussed below, newly insured were no more likely to report problems with their plans than their previously insured counterparts. However, newly insured adults were less likely than previously insured adults to say that they understand their plan (Figure 25). Just two thirds (67%) said they understand the services their plan covers “very well” or “somewhat well” (versus 79% of previously insured adults), and three quarters understand how much they would have to pay when they visit a health care provider (versus 85% of previously insured). These shares were not significantly different across coverage type within the newly insured. It is possible that newly insured adults face challenges in understanding the complexity of insurance coverage, and lower plan ratings could reflect confusion or misunderstanding Figure 26 about coverage. Problems with Current Coverage Among Low- and Middle- Income Insured Adults, by Insurance Coverage Newly insured adults were no more likely Share reporting problem: than previously insured to report a Newly Insured Previously Insured specific problem with their health plan. When asked specifically if they encountered various problems with their coverage, such as 26%* 26%* 23% 24% coverage, costs, or customer service, newly 20% 14% 14% 14% insured adults reported similar or lower rates than previously insured. Specifically, there were Plan would not pay for service you thought was Costs you had to pay for a Plan would not pay because service higher than expected had not met deductible Had difficulty getting question answered no significant differences in shares reporting covered being denied coverage for a service they thought NOTE: Shares exclude those who say they had even but it was not a problem for them. “Previously Insured” includes people who were insured as of interview date and have been insured since before January 2014; some of these people may have switched coverage type. “Newly Insured” include people who were insured as of interview date and gained coverage since January 2014. was covered or having difficulty getting a *Significantly different from newly insured at the p<0.05 level. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. Access, Utilization, and Financial Security among Newly Insured Adults 18 question answered (Figure 26). Newly insured adults were less likely than previously insured to say they faced higher than expected out-of-pocket costs or that they had not yet met their deductible. Again, within the newly insured group, there were no significant differences in rates of problems by type of coverage, with the one exception of newly insured adults with employer coverage being less likely to say their plan did not cover a service they thought was covered. In addition, there were no consistent patterns in the share of newly insured adults reporting problems by when their coverage started. As more and more evidence mounts to document coverage gains during the first year of the ACA, there is interest in understanding how these gains in coverage have affected the lives of the newly insured. Findings from the 2014 Kaiser Survey of Low-Income Americans and the ACA show, not surprisingly, that adults who gained coverage had better access to health care and better financial security from medical costs than those who remained without coverage. Still, comparison to adults who have had coverage since before 2014 show some areas for ongoing attention as policymakers strive to translate coverage to care. The ACA created new coverage options for people who were left out of coverage in the past. Many people who gained coverage in 2014 were from groups that have historically lagged in access to health insurance, including part-time workers, single adults, and people of color. These groups had high uninsured rates in the past for a variety of reasons, including limited access to coverage through a job, limits on publicly- financed coverage, and low incomes that made affording coverage difficult. With the ACA, some of these barriers to coverage were eased. However, socio-demographic differences between the newly insured and remaining uninsured do reveal some remaining barriers to coverage. For example, the newly insured population is more likely than the remaining uninsured to be female—perhaps indicating a need for more outreach to men—and is more likely to be US citizens or legal immigrants—indicating ongoing restrictions to coverage for some immigrants. Further, while many who gained coverage in 2014 were people of color, indicating advances in addressing longstanding racial and ethnic disparities in health coverage, most of the remaining uninsured are people of color, with more than a quarter identifying as Hispanic. Continued expansion of coverage may be key to further efforts to address ongoing disparities in coverage. There is limited evidence of selection or a “surge” among newly insured adults. Newly insured adults were no more likely than those who remained without coverage to be older or in poor physical or mental health. In fact, the newly insured adult population reports better health on average than the remaining uninsured population. In addition, compared to those who had coverage since before 2014, there were no differences in self-reported health status, and newly insured adults were less likely to have used medical services. The differences in utilization patterns between the newly insured and previously insured partially reflect the shorter period of time that the newly insured had their coverage, since most people’s coverage started at least several months into 2014. Notably, newly insured adults were no more likely to use emergency care than those who had coverage since before 2014. Newly insured adults have protection from medical costs but still face some financial difficulty. Compared to their counterparts who remained uninsured, adults who gained coverage in 2014 had better protection from medical bills and less worry about future medical costs. However, newly insured adults still face financial insecurity: they are more likely than those who had coverage before 2014 to worry about future Access, Utilization, and Financial Security among Newly Insured Adults 19 medical bills, and they face general financial insecurity at rates similar to the uninsured. Notable shares of both newly insured and previously insured adults report problems paying their monthly premium, and newly insured adults were particularly cost-sensitive in choosing their health plan. These patterns may indicate that while coverage can ameliorate some of the financial challenges that low- and moderate-income adults face, many will continue to face financial challenges in other areas of their lives. Coverage facilitates access to care, but some newly insured adults need additional support in navigating the health system and getting linked to care. Like outcomes related to medical costs, survey results show that newly insured adults fared better than uninsured adults in access to care, including having a regular provider, receiving preventive care, not postponing care, and have effective communication with their provider. However, on some measures, newly insured adults reported more problems than their counterparts who have had coverage since before 2014: for example, they were less likely to have a regular provider, more likely to not get needed care, and more likely to say a provider would not take them as a patient due to insurance. These differences likely reflect a range of factors, including limited networks, problems navigating the health system, misunderstanding about how to use coverage and when to seek care, or concerns about out- of-pocket costs. While coverage facilitates access to care, it may not automatically or immediately link newly insured adults into care in the same way that adults who have had insurance for quite some time are. Ongoing monitoring of newly insured adults’ access and utilization is important to assess whether this population continues to face challenges or whether these differences subside over time. Among the newly insured population, there were few differences in outcomes by type of coverage. The ACA builds on the existing employer-based system to create coverage options for people across the income spectrum, including Medicaid (for people at the lowest incomes) and subsidies for Marketplace coverage (for people with middle-income). Medicaid is designed to serve a low-income population, with very limited cost sharing and broad benefits; Marketplace coverage is designed to serve those with middle incomes, with premium and cost-sharing support for people with income at the lower range of eligibility. Through some have expressed concern that some gaining coverage under the ACA are required to enroll in Medicaid versus Marketplace coverage, survey findings indicate very few differences in outcomes for these two groups. For example, there were no differences in plan ratings or problems with coverage, protection from medical bills, or access to care. The differences that were seen (for example, that newly insured adults with Medicaid are sicker, less likely to be in a working family, and are more generally financially insecure) largely reflect Medicaid’s role in targeting lowest income and most vulnerable. However, on measures of how coverage works for enrollees, Medicaid and Marketplace coverage fared about equally well and generally as well as employer-based coverage. Access, Utilization, and Financial Security among Newly Insured Adults 20 Uninsured Newly Insured Previously Insured < 138% FPL 59% 56% 37% * 139 - 400% FPL 41% 44% 63% * Full Time Working Family 47% 45% 61% * Part Time Working Family 19% 20% 10% * Unemployed Family 33% 33% 29% Hispanic 31% * 23% 18% White, Non-Hispanic 45% 49% 61% * Black, Non-Hispanic 15% 19% 12% * Other 8% 9% 9% Female 45% * 58% 53% Male 55% * 42% 47% Citizen 77% * 87% 94% * Legal Immigrant 7% 7% 3% Undocumented 15% * 5% 2% * 19-25 24% 19% 18% 26-34 29% 31% 20% * 35-44 20% 19% 22% 45-64 26% 31% 40% * Married with dependent children 16% 16% 29% * Married, no dependent children 10% 11% 18% * Not married with dependent children 22% 22% 14% * Not married, no dependent children 52% 50% 39% * Doesn’t have Children 62% 62% 57% All Children are insured 25% * 35% 41% Some or all children are uninsured 12% -- 2% Excellent/Good Health 62% * 71% 75% Fair/Poor Health 37% * 28% 25% Excellent/Good Mental Health 79% 80% 84% Fair/Poor Mental Health 20% 18% 16% Has Ongoing Condition 32% 39% 41% Taking Rx 25% * 36% 49% * Quarter 1 NA 40% NA Quarter 2 NA 20% NA Quarter 3 NA 22% NA Quarter 4 NA 9% NA DK/RF NA 9% NA Coverage started prior to 2014 NA NA 87% Had same plan, but renewed in 2014 NA NA 11% Had other plan, same coverage type NA NA -- Had other type of coverage NA NA 13% Notes: NA: Not applicable. “--“: Estimates with relative standard errors greater than 30% or with cell sizes less than 100 are not provided. * Estimate statistically significantly different from newly insured estimate at the 95% confidence level. Source: 2014 Kaiser Survey of Low- Income Americans and the ACA. Access, Utilization, and Financial Security among Newly Insured Adults 21 1 Garfield, R. R. Licata, and K. Young. The Uninsured at the Starting Line: Findings from the 2013 Kaiser Survey of Low-Income Americans and the ACA. February 2014. Available at: http://kff.org/uninsured/report/the-uninsured-at-the-starting-line-findings- from-the-2013-kaiser-survey-of-low-income-americans-and-the-aca/. 2 Salganicoff, A., U. Ranji, A. Beamesderfer, N. Kurani. Women and Health Care in the Early Years of the ACA: Key Findings from the 2013 Kaiser Women's Health Survey. (Washington, DC: Kaiser Family Foundation), May 15, 2014. Available at: http://kff.org/report- section/women-and-health-care-in-the-early-years-of-the-aca-key-findings-from-the-2013-kaiser-womens-health-survey-coverage- access-and-affordability/. 3 Sommers BD. “Insuring children or insuring families: do parental and sibling coverage lead to improved retention of children in Medicaid and CHIP?” J Health Econ. 2006 Nov;25(6):1154-69. Epub 2006 Jun 5. 4 Zuckerman, S., T.A. Waidmann, E, Lawton. “Undocumented Immigrants, Left Out Of Health Reform, Likely To Continue To Grow As Share Of The Uninsured.” Health Affairs. October 2011 30:1997-2004. 5 Passel, J.S., and D. Cohn. A Portrait of Unauthorized Immigrants in the United States. Pew Hispanic Center, April 14, 2009. Available at: http://www.pewhispanic.org/2009/04/14/iv-social-and-economic-characteristics/. 6 Wallace, S.P. et al. Undocumented Immigrants and Health Care Reform. (Los Angeles, CA: UCLA Center for Health Policy Research), August 31, 2012. Available at: http://healthpolicy.ucla.edu/publications/Documents/PDF/undocumentedreport-aug2013.pdf. 7 Claxton C., C. Cox, and M. Rae. The Cost of Care with Marketplace Coverage. (Washington, DC: Kaiser Family Foundation), February 11, 2015. Available at: http://kff.org/health-reform/issue-brief/the-cost-of-care-with-marketplace-coverage/. 8 Agency for Healthcare Quality and Research. CAHPS Item Set for Addressing Health Literacy. Available at: https://cahps.ahrq.gov/surveys-guidance/item-sets/literacy/index.html. 9 Addendum to Health Insurance Marketplace Summary Enrollment Report, October 1, 2013 - March 31, 2014, Office of the Assistant Secretary for Planning and Evaluation (ASPE), Department of Health and Human Services (HHS); May 1, 2014. Available via: http://kff.org/other/state-indicator/marketplace-enrollees-by-financial-assistance-status-2014/ The Henry J. 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