AARP Public Policy Institute INSIGHT on the Issues Monitoring the Impact of Health Reform on Americans 50–64: Use of Insurance Marketplaces 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 that, despite widespread awareness of the new health insurance Marketplace among 50- to 64- year olds, relatively few who knew about the Marketplace were interested in using it to acquire new coverage. The survey also found that 50- to 64-year-olds’ use of the Marketplace varied widely by health insurance status and income. This paper is part of a series that looks at the experiences of 50- to 64-year-olds during the first open enrollment period of the Affordable Care Act. A key goal of the Affordable Care Act vey). The survey also asked people how (ACA) is to reduce the number of unin- they engaged or planned to engage with sured Americans by expanding access to the Marketplace. health care coverage. The ACA created a health insurance Marketplace in every Health Insurance Status and state to help individuals assess and ac- Income Influenced the Use of the cess new coverage options and subsidies. Marketplace among Adults Ages 50 to 64 Until implementation of the ACA, many people ages 50 to 64 found themselves Reasons for having used or planned to unable to purchase insurance in the in- use the Marketplace varied by health in- dividual market because of high cost or surance status, as follows: preexisting health problems. In addition, ■■ Just over half (52 percent) of the those able to purchase nongroup insur- uninsured 50- to 64-year-olds ance often faced burdensome premiums. planned to use the Marketplace In December 2013, on the eve of ACA to determine their eligibility for implementation, AARP and the Urban subsidies or Medicaid, and nearly Institute surveyed Americans ages 50 to half (46 percent) planned to use it to 64 about their interest in connecting with purchase insurance. the Marketplace to learn about available ■■ The majority (61 percent) of those insurance options (see box at the end of who had nongroup insurance and this paper for more details about the sur- who were interested in using the Monitoring the Impact of Health Reform on Americans 50–64: Use of Insurance Marketplaces Figure 1 Reasons Adults 50–64 Looked or Planned to Look for Health Insurance Information in the Marketplaces, by Health Insurance Status 51.8% Know if eligible for 39.6% subsidies or Medicaid 55.2% 45.6% Purchase insurance 42.1% 23.3% 7.9% Compare current health insurance plan to 60.5% Marketplace plans 20.4% 8.1% Know more about health insurance options 9.2% for retirement 20.3% 0 10 20 30 40 50 60 70 Uninsured Nongroup insurance Medicaid or medical assistance Source: Authors’ calculations using the HRMS-AARP, December 2013. Note: Statistics are limited to respondents who were aware of the health insurance Marketplace and who either looked or planned to look for information about insurance plans in the Marketplace. Respondents who indicated that they have health insurance but not a discernible type are omitted and represent 1.6 percent of the total weighted HRMS-AARP sample. Reason categories are not mutually exclusive. Health insurance categories are mutually exclusive. Respondents who did not indicate why they looked or planned to look for Marketplace plans are not reported and represent 1.1 percent of the weighted subpopulation. Marketplace planned to use it to to receive help with coverage costs compare their current insurance had a particular incentive to use the with that available through the Marketplace (see figure 2). We, there- Marketplace (figure 1 and appendix fore, anticipated that this group would table 2). However, less than half of use the Marketplace more than other those with nongroup coverage—just groups. As expected, the following find- 42 percent—said they wanted to use ings were seen among those who had the Marketplace to buy coverage, looked or planned to look for informa- and 40 percent wanted to find out if tion in the Marketplaces: they were eligible for subsidies or ■■ Nearly half (49 percent) of adults Medicaid in 2014. with incomes at or below 138 percent ■■ Over half (55 percent) of those of the federal poverty level (the income range eligible for Medicaid with Medicaid planned to use the coverage under Medicaid expansion) Marketplace to determine their said they wanted to find out if they eligibility for subsidies or Medicaid. qualified for subsidies or Medicaid. Because the Marketplace is a pathway ■■ Of those with incomes between to new financial assistance, those with 139 percent and 400 percent of the income in the range that qualifies them federal poverty level (the income 2 Monitoring the Impact of Health Reform on Americans 50–64: Use of Insurance Marketplaces Figure 2 Reasons Adults Ages 50–64 Looked or Planned to Look for Health Insurance Information in Marketplaces, by Income 27.4% Purchase insurance 31.5% 19.2% 48.8% Know if eligible for 42.4% subsidies or Medicaid 17.4% Compare current health 17.6% insurance plan to 39.2% Marketplace plans 49.7% Know more about health 11.6% insurance options 12.6% for retirement 22.3% 0 10% 20% 30% 40% 50% 60% 70% ≤ 138% FPL 139–399% FPL ≥ 400% FPL Source: Authors’ calculations using the HRMS-AARP, December 2013. Note: Statistics are limited to respondents who were aware of the health insurance Marketplace and either looked or planned to look for information on insurance plans in the Marketplace. Reason categories are not mutually exclusive. Health insurance categories are mutually exclusive. Respondents who did not indicate why they looked or planned to look for Marketplace plans are not reported and represented 1.1 percent of the weighted subpopulation. range eligible for subsidies), Marketplace to look for health insurance. 42 percent wanted to find out if they (See Monitoring the Impact of Health qualified for subsidies or Medicaid. Care Reforms on Americans 50–64: ■■ Of those with incomes at or above Awareness and Coverage Expectations 400 percent of the federal poverty [Insight on the Issues 96].) However, in- level (the income cut-off for terest was also limited among some who qualifying for subsidies), 17 per­ were uninsured or in the nongroup mar- cent said they wanted to find out ket (figure 3). Respondents in that group if they were eligible for subsidies provided several reasons for their limited or Medicaid. However, half of this interest: higher-income group planned to use ■■ Close to a quarter of uninsured 50- to the Marketplace to compare their current health insurance plan with 64-year-olds were not interested in Marketplace plans. the Marketplace because they didn’t want insurance or thought the cost of 50- to 64-Year-Olds Did Not Plan to insurance was too high. Use the Marketplace for Multiple ■■ Among those with nongroup Reasons insurance who said they were not Because the vast majority of survey going to use the Marketplace, the respondents had employer or public overwhelming majority (84 percent) coverage, most did not plan to use the said it was because they were already 3 Monitoring the Impact of Health Reform on Americans 50–64: Use of Insurance Marketplaces Figure 3 Reasons Adults 50–64 Didn’t Plan to Look for Health Insurance Information in the Marketplace, by Health Insurance Status Satisfied with existing 12.6%* health insurance 84.4% 24.9% Does not want health insurance 3.7% 24.8% Cost is too high 0.7% 13.8% Website has not been working 5.4% Does not know how 8.1% to find information 2.2% 0 20% 40% 60% 80% 100% Uninsured Nongroup insurance Source: Authors’ calculations using the HRMS-AARP, December 2013. Note: Statistics are limited to respondents who heard about the health insurance Marketplace and did not look for information on insurance plans in the Marketplace. Respondents reported only one main reason that they did not look for information on Marketplace plans. Those who did not report a main reason are not included in the statistics above and represent 2.0 percent of those with nongroup insurance and 7.3 percent of the uninsured. * The anomaly of the uninsured being satisfied with their current insurance reflects that some people were counted as uninsured because they reported having insurance but wrote in responses that suggest that they get care from a clinic (likely charity care), which is not insurance. satisfied with their existing health to 64 who used or planned to use the insurance. Marketplace did so through the website. ■■ Smaller shares of the uninsured Website use varied significantly by in- and those with nongroup coverage come, education, and ethnicity (figure 4). reported that website issues Other channels are available besides the influenced their decision not to use website that people can use to obtain in- the Marketplace. formation about the Marketplace. Those What Information Channels Did channels, which include the Marketplace 50- to 64-Year-Olds Use to Get call center and other professionals Information? trained to answer questions, give people information about coverage options and The federal and state Marketplaces guide people through the process of ap- built websites so people could shop and plying for coverage and subsidies (ap- apply for health care coverage, could pendix table 3). Other sources of help access subsidies, and could enroll in are family, friends, and insurance agents Marketplace plans. Failure of the federal or brokers. The survey showed use of re- and some state Marketplace websites sources to obtain information: to provide a simple and efficient expe- rience—at least in the first months of ■■ Fewer than half of adults ages 50 to implementation—has been well docu- 64 with the lowest family incomes mented. Despite these obstacles, the vast reported using the Marketplace majority (71 percent) of adults ages 50 website, and they were more than 4 Monitoring the Impact of Health Reform on Americans 50–64: Use of Insurance Marketplaces Figure 4 Adults Ages 50–64 Who Used Marketplace Website to Find Health Insurance Information ≤ 138% FPL 48.7% Income 139% to < 400% FPL 72.3% ≥ 400% 85.6% Less than high school 28.7% Education High school graduate 70.4% College graduate 85.2% Hispanic 46.2% Ethnicity Black or other 65.3% White, non-Hispanic 78.5% 0 20% 40% 60% 80% 100% Source: Authors’ calculations using the HRMS-AARP, December 2013. Note: Statistics are limited to respondents who were aware of the health insurance Marketplace and who either looked or planned to look for information on insurance plans in the Marketplace. Respondents were able to report more than one method. Those who did not report any method are included in the statistics above but are not reported. The range of nonresponse rates was 0.8–4.8 percent across income categories, 0.9–5.6 percent across education categories, and 2.1–3.8 percent across race or ethnicity categories. twice as likely to report turning to for help compared with white non- the call center and family and friends Hispanics. for assistance than were the highest ■■ Blacks and other nonwhite, non- income group. Hispanic adults also relied on the ■■ Those who had not completed high website less than did white non- school used call centers, family and Hispanics. They were more likely to friends, and brokers and agents for seek help from family and friends and other in-person assistance, such information and help with enrollment as navigators, compared with white nearly as much as they used the non-Hispanics. Marketplace website. Only about 3 in 10 of this group reported using The delayed launch of the Spanish lan- the Marketplace website, which was guage version of the federal Marketplace well below half the rate of those with website may be a factor in lower a high school diploma or more. Marketplace website use and in higher use of alternate sources of assistance ■■ Hispanic adults ages 50 to 64 among Hispanic adults. Similarly, reported using the Marketplace greater use of call centers and alternative website considerably less than did sources of assistance among other racial white non-Hispanics. Hispanics were and ethnic groups could, in part, be at- more likely to turn to family and tributable to a need for information in friends and professional assistance another language. 5 Monitoring the Impact of Health Reform on Americans 50–64: Use of Insurance Marketplaces Ways to Improve the Use of the ■■ Maintaining a well-functioning, Marketplaces and Alternative well-designed website where people Sources of Information can easily find the information they need and can get answers to their Widespread awareness of the new health questions. insurance Marketplaces among the un- ■■ Educating the public about insured and those with nongroup health the various ways they can get insurance—the groups that are most information and personal assistance, likely to benefit from the 2014 health and letting the public know that help reforms—indicates that public education with coverage costs is available. and outreach efforts leading up to and ■■ Having an adequate supply of well- during the 2013–14 open enrollment pe- trained professionals to provide riod were generally effective. personal assistance through call centers and in person. Nevertheless, the survey results sug- ■■ Targeting outreach to those with gest that there is room for improvement. educational or language barriers, and State and federal policy makers need to providing them with information and renew their focus on the following: assistance that meets their needs. This work is based on the Health Reform Monitoring Survey’s oversample of individuals ages 50 to 64, which is referred to as the HRMS-AARP and was from December 2013 and March 2014. The Health Reform Monitoring Survey 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 population 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 about the HRMS 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 Reform on Americans 50–64: Use of Insurance Marketplaces 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 Reform on Americans 50–64: Use of Insurance Marketplaces 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 Reform on Americans 50–64: Use of Insurance Marketplaces Table 2 Reasons Adults Ages 50–64 Looked, or Planned to Look, for Information about Health Insurance in the Marketplace, December 2013 Compare Know more current about health Other (did Know if health insurance not report eligible for insurance plans with any reason   Purchase subsidies options for Marketplace already   insurance or Medicaid retirement plans listed) At or below 27.4% 48.8%** 11.6%** 17.6%** 19.8% 138% FPL 139% to less Family than 400% 31.5%** 42.4%** 12.6%** 39.2%** 18.9%* income FPL 400% FPL or 19.2% 17.4% 22.3% 49.7% 24.7% greater (R) Uninsured 45.6%** 51.8%** 8.1%** 7.9%** 16.1%** Nongroup 42.1%** 39.6%** 9.2%** 60.5%** 8.3%** Medicaid Health or medical 23.3%* 55.2%** 20.3% 20.4%** 18.3% insurance assistance status Medicare 15.2% 37.8%** 4.1%** 34.7%** 29.5% Employer- sponsored 11.1% 21.2% 23.5% 49.4% 28.0% insurance (R) Source: Authors’ calculations using the HRMS-AARP, December 2013. Note: 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 Reform on Americans 50–64: Use of Insurance Marketplaces Table 3 Methods Used by Adults 50–64 to Look for Information on Health Insurance Plans in the Marketplace Assistance from INSIGHT on the Issues navigators, ap- plication Assistance assisters, from an certified applica- Assistance insurance Call tion counselors, from family agent or Website center or CHWs or friends broker Other At or below 48.7%** 36.0%** 17.5%** 21.2%** 16.6% 7.1%** 138% FPL 139% to less Income than 400% 72.3%** 23.8%* 11.9% 17.7%* 21.6% 3.2% FPL 400% FPL or 85.6% 16.7% 10.9% 12.8% 23.2% 1.7% greater (R) Less than high 28.7%** 27.0% 20.1% 25.3%** 26.5% 7.6%* school High school Education graduate or 70.4%** 26.2%* 12.1% 17.1% 20.0% 4.0%** some college College 85.2% 19.9% 12.2% 13.8% 21.0% 1.6% graduate (R) Hispanic 46.2%** 31.4% 21.2%* 22.0%* 25.2% 4.2% Black or other race or 65.3%** 28.2% 15.3%* 22.7%** 17.9% 4.1% Ethnicity ethnicity, non- Hispanic White, non- 78.5% 21.5% 10.3% 14.0% 20.9% 3.3% Hispanic (R) Source: Authors’ calculations using the HRMS-AARP, December 2013. Note: CHW = community health worker. Estimate is statistically different from the reference group marked with “R” using a two-tailed test. Significance level: * = 5 percent, ** = 1 percent. Statistics are limited to respondents who were aware of the health insurance Marketplace and who either looked or planned to look for information on insurance plans in the Marketplace. Respondents were able to report more than one method. Those who did not report any method are included in the statistics above but are not reported. The range of nonresponse rates was 0.8–4.8 percent across income categories, 0.9–5.6 percent across education categories, and 2.1–3.8 percent across race/ethnicity categories. Insight on the Issues 97, December 2015 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 © 2015, AARP. Reprinting with permission only. 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