The Obama administration recently made news by announcing that the number of people expected to obtain insurance under the exchanges will fall far short of previous projections. Specifically, they are now expecting about 10 million people to enroll in private exchange plans in 2016, compared to the 13 million that were previously thought might enroll not long ago.
Why so many fewer? Many have speculated as to the reasons behind this difference, but it doesn't make sense to guess when we can just ask. The Commonwealth Fund did just that in their most recent Affordable Care Act Tracking Survey. Specifically, they analyzed responses from people who visited the exchanges, but did not decide to enroll in any insurance plans. About 25% of working-age adults had visited the marketplaces to shop for health insurance by Spring of 2015. About half of them eventually purchased health insurance, enrolling in a private plan about twice as often as Medicaid.
The good news is that, contrary to many people's fears, young people were not under-represented in enrollees. More than a third of people signing up for insurance were 19-34 years old. Many of them qualified for Medicaid, but more than 30% of those who bought private plans were in the age group, as well.
The most important factor noted in the selection of a plan was the cost of the premium (41%). Next most common was the amount of the deductible and copayments (25%). This means that, in some way, the cost of health insurance was the most important factor in choosing a plan for two-thirds of people enrolling in the marketplace.
About 22% of people noted that their biggest concern was the size of their network, and whether their provider of choice was covered in a plan they were considering. That said, of those who had the option of choosing a cheaper plan with a narrower network, more than half decided to go that route.
When considering those who did not choose to enroll, more than half (57%) reported that they could not find a plan that they could afford.More than a third (38%) reported that they found the process difficult or confusing. And 43% found that they were not eligible to enroll in Medicaid or financial assistance. Many of the latter were likely in states that did not participate in the Medicaid expansion, meaning that they were too poor to qualify for subsidies, and could not afford private coverage without them.
The cost of insurance is still the main driver of uninsurance. This could be fixed with more generous subsidies, but such a change is unlikely to occur anytime soon. Increasing uptake of the Medicaid expansion would also make a difference, but that, too, is politically fraught, especially in an election year.
There are other options, however. People who received personal assistance in shopping for plans were much more likely to obtain them. Almost 80% of those who had help eventually signed up for coverage, versus 56% of those who didn't. This may be because, without help, it's very hard to make decisions. About half people who didn't obtain coverage reported that it was difficult to compare premium costs. More than that had difficulty understanding differences in benefits covered, potential out-of-pocket costs, and who might be in and out of networks.
This could also be a problem with information dissemination. More than half of the people who didn't enroll because of the cost of insurance were eligible for subsidies. It's not clear whether the subsidies were just inadequate, or whether they understood they were eligible at all. If the latter is the case, then - again - providing assistance might improve the chance that people might sign up for insurance plans. Doing so makes sense, given how bad people are at choosing health plans in general.
That's the crucial thing to consider here. It is becoming abundantly clear that the Affordable Care Act has significantly reduced the numbers of the uninsured in the United States. It's also becoming clear that there is still much work to be done to reduce those numbers further. There are many steps we can take to make sure that more people sign up for insurance. Whether we choose to do so is up to those implementing the policy,