AARP Public Policy Institute INSIGHT on the Issues Monitoring the Impact of Health Care Reforms on Americans 50–64: Awareness and Coverage Expectations Gerry Smolka and Olivia Dean AARP Public Policy Institute Kyle J. Caswell, Timothy A. Waidmann, and Adam L. Weiss Urban Institute An Urban Institute and AARP survey conducted in December 2013 found widespread awareness among Americans ages 50 to 64 about the new health insurance Marketplace that had been created by the Affordable Care Act (ACA). Those with the most to gain from the ACA—the uninsured and those with nongroup (individual) insurance—expressed the greatest interest in using the Marketplace to learn about new coverage options. Most of those already insured expected to keep their same source of coverage in 2014, whereas the uninsured had mixed expectations. This paper is part of a series that looks at the experiences of 50- to 64-year-olds during the ACA’s first open enrollment period. A key goal of the Affordable Care Act In December 2013, on the eve of ACA (ACA) is to reduce the number of unin- implementation, AARP and the Urban sured Americans by expanding access Institute surveyed Americans ages to affordable health care coverage. This 50 to 64 about their awareness of the is particularly important for Americans Marketplaces and their experiences dur- who are ages 50 to 64, who do not have ing the initial phase of open enrollment. access to employment-based or Medicaid See the box at the end of this paper for coverage, and who have preexisting con- more details. ditions that prevented them from gaining coverage prior to the new law. Most Adults Ages 50 to 64 Were The ACA aims to make health insur- Aware of the Health Insurance ance more accessible and affordable Marketplaces for this population and others through a variety of health insurance reforms, The survey showed that nearly 9 in 10 including guaranteed issue of insurance, adults ages 50 to 64 were aware of the limited age rating, Medicaid expan- Marketplaces (figure 1). Awareness was sion, and subsidized coverage options. lower among those who: The ACA also created health insurance Marketplaces in each state to help con- ■■ Were uninsured or were on sumers purchase insurance coverage and Medicaid, compared with those who apply for subsidies. had employer-sponsored coverage. Monitoring the Impact of Health Care Reforms on Americans 50–64: Awareness and Coverage Expectations Figure 1 Nearly 9 in 10 Adults 50–64 Were Aware of the Marketplaces Unaware 11.6% Aware 88.4% Source: Authors’ calculations using the HRMS-AARP Survey, December 2013. ■■ Had a low or middle income, status and income showed variation, as compared with those who had higher in the following: incomes. ■■ The uninsured and those insured ■■ Reported that cost was a barrier in the nongroup market were to care, compared with those not much more likely to be interested reporting cost barriers. in looking for information about insurance in the Marketplace It is notable that the populations report- than were those insured through ing lower awareness are also among employers (figure 2). those most likely to benefit from ■■ Adults who had incomes below 400 Medicaid expansion or from ACA Marketplace subsidies. percent of the federal poverty level and who could qualify for Medicaid Interest in Using the Marketplaces or subsidies were more likely than Varied among 50- to 64-Year-Olds were those with high incomes to have used or planned to use the High levels of Marketplace awareness Marketplace (appendix table 2). among 50- to 64-year-olds did not nec- ■■ Adults who had reported having essarily translate into interest and use. problems paying medical bills in the The survey found wide variation in those past year or unmet medical needs reporting that they used or planned to caused by costs were also more use the Marketplace. Current insurance likely to express interest in using the 2 Monitoring the Impact of Health Care Reforms on Americans 50–64: Awareness and Coverage Expectations Figure 2 Interest in Using the Marketplace Varied by Insurance Status among Adults Ages 50–64 70% 62.2% 59.4% 60% 50% 20.7% 40% 31.1% 30% 21.8% 19.6% 20% 10% 0 Uninsured Nongroup Medicaid or Medicare Employer- insurance medical assistance sponsored insurance Source: Authors’ calculations using the HRMS-AARP Survey, December 2013. Marketplace than were those who expected to continue to have coverage had not experienced those problems from the same source in 2014, although (appendix table 2). responses varied by type of coverage (figure 3). These findings indicate that adults ages 50 to 64 who could benefit most Uninsured 50- to 64-Year-Olds Had from accessing coverage through the Mixed Coverage Expectations Marketplace showed the greatest interest in using it. A majority (57 percent) of uninsured adults ages 50 to 64 reported that they Most Insured Expected Their thought they would have insurance in Source of Coverage to Remain 2014 (figure 4). Of this group, most Unchanged in 2014 expected to be covered by Medicaid or through the nongroup insurance market In general, the new health law is ex- (see appendix table 3). Smaller shares pected to affect only a small share of expected to obtain coverage through an adults ages 50 to 64, because many in employer, Medicare, or another source. this age group already have health insur- Close to half did not expect to gain ance coverage and would not qualify coverage. for subsidized coverage through the Marketplaces or Medicaid. The survey Low-income uninsured adults ages 50 confirms that the vast majority of those to 64 living in states that chose to ex- who had health care coverage in 2013 pand Medicaid were twice as likely 3 Monitoring the Impact of Health Care Reforms on Americans 50–64: Awareness and Coverage Expectations Figure 3 Most Insured Adults Ages 50–64 Expected to Continue to Have the Same Type of Health Coverage in 2013 and 2014 100% 92% 93% 84% 80% 80% 60% 40% 20% 0 Employer sponsored Nongroup Medicaid or Medicare insurance medical assistance Source: Authors’ calculations using the HRMS-AARP Survey, December 2013. Figure 4 A Majority of Uninsured Adults Ages 50–64 Expected to Gain Coverage in 2014 Do not expect to gain coverage 42.8% Expect to gain coverage 57.2% Source: Authors’ calculations using the HRMS-AARP Survey, December 2013. 4 Monitoring the Impact of Health Care Reforms on Americans 50–64: Awareness and Coverage Expectations Figure 5 Low-Income Uninsured Adults Living in Expansion States Were More Likely to Expect to Receive Medicaid in 2014 35 30.4% 30 25 20 14.6% 15 10 5 0 Expansion state Nonexpansion state Source: Authors’ calculations using the HRMS-AARP Survey, December 2013. to say they expected to be covered by benefit from the reforms were not aware Medicaid in 2014 than were those liv- of the Marketplace. This finding points ing in non-Medicaid expansion states to the importance of strengthening re- (30 percent and 15 percent, respectively; sources and support for education and see figure 5). outreach. For the reforms to reach the Continued Education and intended populations missed by earlier Outreach Is Needed outreach and enrollment efforts, state and federal policy makers need to focus Millions of adults ages 50 to 64 could on the following: benefit from using the Marketplace to ■■ Identify, target, and reach groups find out if they qualify for coverage and subsidies to help reduce their health care that remain unaware of the new costs.The survey showed widespread opportunities for coverage. awareness of the new health insurance ■■ Encourage those who are aware Marketplace among 50- to 64-year-olds who had nongroup coverage or were un- of the Marketplace and who may insured—the groups most likely to ben- qualify for coverage or subsidies to efit from the 2014 health reforms. explore their options through the Marketplace. This conclusion indicates that public ■■ Help people who enrolled in new education and outreach efforts during the 2013–14 open enrollment period were health care coverage in 2014 to generally effective. However, some 50- maintain coverage in 2015, update their to 64-year-olds who should be able to information to determine eligibility 5 Monitoring the Impact of Health Care Reforms on Americans 50–64: Awareness and Coverage Expectations for assistance, and review their plan people fell during the first few months choices during open enrollment. of ACA enrollment. Nevertheless, the ■■ Extend coverage to low-income fact that a large share of uninsured older adults in states that have not yet adults (42 percent) expected to remain expanded Medicaid. uninsured in 2014 suggests that getting more uninsured people to sign up for Results from the March 2014 survey health care coverage may require greater showed that the number of uninsured effort over the long term. This work is based on the Health Reform Monitoring Survey’s oversample of individuals ages 50 to 64 (referred to as the HRMS-AARP) and was from December 2013 and March 2014. The Health Reform Monitoring Survey (HRMS) is a quarterly Internet survey of individuals ages 18 to 64 that is designed to produce rapid feedback on ACA implementation before the federal government’s survey data are available (Long et al. 2013). It was developed by the Urban Institute (hrms.urban.org); fielded by GfK (www .gfk.com); and jointly funded by the Robert Wood Johnson Foundation (www.rwjf.org), the Ford Foundation (www.fordfound.org), and the Urban Institute (www.urban.org). AARP funded the 50- to 64-year-old oversample, which is designed to produce nationally representative statistics of individuals ages 50 to 64. The December 2013 survey includes approximately 8,200 respondents, most of whom completed the survey in the first three weeks of December 2013. For more information on the HRMS survey instrument, go to http://hrms.urban.org/survey-instrument/index.html. See appendix table 1 for a summary of the HRMS-AARP sample for December 2013. Reference Long, Sharon K., Genevieve M. Kenney, Stephen Zuckerman, Dana E. Goin, Douglas Wissoker, Fredric Blavin, Linda J. Blumberg, Lisa Clemans-Cope, John Holahan, and Katherine Hempstead. 2013. “The Health Reform Monitoring Survey: Addressing Data Gaps to Provide Timely Insights into the Affordable Care Act.” Health Affairs 3 (1), 161–67. 6 Monitoring the Impact of Health Care Reforms on Americans 50–64: Awareness and Coverage Expectations Appendix Table 1 Summary of HRMS-AARP Sample, December 2013 % of respondents with characteristic Family income 400% of the federal poverty level (FPL) or greater 48.0 139% to less than 400% FPL 33.7 At or below 138% FPL 18.3 Insurance status at the time of the survey Employer-sponsored insurance 66.3 Nongroup coverage 7.2 Medicaid or medical assistance 6.1 Medicare 7.2 Other 1.6 Uninsured 11.6 Unmet medical need or problems paying medical bills Any unmet medical need due to costs in past 12 monthsa 22.6 No unmet medical need 77.4 Missing data on unmet medical need 0.1 Problems paying or unable to pay medical bills in past 12 months 19.6 No problems paying medical bills 80.0 Missing data on problems paying medical bills 0.4 Health status Very good or excellent 47.5 Good 34.6 Fair or poor 17.6 Not reported 0.3 Age 50–54 36.5 55–59 34.4 60–64 29.1 Gender Male 48.1 Female 51.9 Race or ethnicity White, non-Hispanic 72.2 Black or other race or ethnicity, non-Hispanic 17.3 Hispanic 10.5 7 Monitoring the Impact of Health Care Reforms on Americans 50–64: Awareness and Coverage Expectations Table 1 (continued) Summary of HRMS-AARP Sample, December 2013 % of respondents with characteristic Education College graduate 31.4 High school graduate or some college 60.9 Less than high school 7.7 Marital status Married 63.4 Not married 36.6 Employment status Employed 53.5 Self-employed 8.5 Not working, retired 15.2 Not working, other 22.8 Region Northeast 19.2 Midwest 25.0 South 34.1 West 21.8 Urban In metropolitan area 82.6 Not in metropolitan area 17.4 Missing data on metropolitan area 0.1 Medicaid expansion state of residence Expansion state 51.4 Nonexpansion state 48.6 Exchange type Federal 66.1 State 33.9 Sample size (respondents) 8,208 Source: Authors’ calculations using the HRMS-AARP, December 2013. a. Unmet medical needs include any of the following categories: prescription drugs, medical care, general physician care, specialist care, medical tests or follow-up care, and mental health care. 8 Monitoring the Impact of Health Care Reforms on Americans 50–64: Awareness and Coverage Expectations Table 2 Awareness of ACA Marketplace among Adults 50–64, December 2013 (percent) Has heard about Has heard about Marketplace and Marketplace and looked or planned did not plan to to look for look for information on information on insurance in insurance in Has not heard Marketplace Marketplace about Marketplace All adults, 50–64 28.4 60.0 11.6 At or below 138% FPL 33.8** 54.2** 11.9** 139% to less than 400% FPL 38.2** 41.8** 20.0** 400% FPL or greater (R) 20.9 71.0 8.1 Uninsured 62.2** 22.9** 14.9** Nongroup 59.4** 29.6** 11.0 Medicaid or medical assistance 31.1** 41.7** 27.2** Medicare 21.8 62.9** 15.3** Employer-sponsored insurance (R) 19.6 71.4 9.0 Had problems paying medical bills 42.9** 44.0** 13.1 No problems paying medical bills (R) 24.8 64.0 11.2 Any unmet need caused by costs 46.3** 38.9** 14.9** No unmet medical need caused by costs (R) 23.2 66.2 10.6 Source: Authors’ calculations using HRMS-AARP, December 2013. Note: Respondents that did not answer the survey questions relevant to the statistics above were excluded (total of 32), resulting in an overall sample of 8,176 respondents. Health insurance categories are mutually exclusive, and those who indicated they had insurance, but not a discernible type, are not reported (1.6 percent of the entire sample). Estimate is statistically different from the reference group marked with “R” using a two-tailed test. Significance level: * = 5 percent, ** = 1 percent. 9 Monitoring the Impact of Health Care Reforms on Americans 50–64: Awareness and Coverage Expectations Table 3 Expected Health Insurance Coverage in 2014 among Adults Ages 50–64, December 2013 (percent) Employer- Medicaid or INSIGHT on the Issues sponsored medical insurance Nongroup assistance Medicare Uninsured Other At or below 15.0** 5.5** 31.0** 23.6** 15.9** 6.6** 138% FPL 139 to less 58.5** 13.4** 5.1** 10.4** 6.8** 4.7** Family than 400% income FPL 400% FPL or 82.9 8.7 0.7 3.0 1.3 2.2 greater (R) Employer- 91.5 2.3 0.7 2.1 0.9 1.7 sponsored insurance (R) Health Nongroup 7.0** 80.2** 2.1** 3.9** 1.2 4.2** insurance Medicaid 0.8** 2.8 84.4** 4.9* 1.6 3.8 status or medical assistance Medicare 0.6** 0.7** 4.7** 93.0** 0.0** 0.5** Uninsured 5.8** 16.5** 14.2** 5.0** 42.8** 11.0** Expansion 3.5 8.4 30.4 5.7 39.6 8.1 state (R) and income at or Medicaid below 138% expansion FPL and state of uninsured residence, income up Non- 4.4 6.4 14.6** 3.5 50.1 14.8* to 138% of expansion FPL and state and uninsured income at or below 138% FPL and uninsured Source: Authors’ calculations using the HRMS-AARP, December 2013. Note: Expected health insurance categories are mutually exclusive, and those who reported “other” coverage at the time of the survey are not reported among the health insurance status groups above (1.6 percent of entire sample). Respondents who did not respond to the survey question on expected health insurance in 2014 are included in the statistics above yet not reported, and equal the residual for each row. Estimate is statistically different from the reference group marked with “R” using a two-tailed test. Significance level: * = 5 percent, ** = 1 percent. Insight on the Issues 96, December 2014 Written by Gerry Smolka, Olivia Dean, Kyle J. Caswell, Timothy A. Waidmann, and Adam L. Weiss AARP Public Policy Institute 601 E Street, NW, Washington, DC 20049 www.aarp.org/ppi 202-434-3890, ppi@aarp.org © 2014, AARP. Reprinting with permission only. AARP Public Policy Institute 10