To Enroll or Not to Enroll? Why Many Americans Have Gained Insurance Under the Affordable Care Act While Others Have Not

By Sara R. Collins, Munira Gunja, Michelle M. Doty, Sophie Beutel

The Commonwealth Fund, September 25, 2015

Exhibit 2.  Just under half of the adults who have visited the marketplace enrolled in a marketplace plan or Medicaid

52% – Did not select a private plan or enroll in Medicaid
30% – Selected a private health plan
15% – Enrolled in Medicaid
2% – Don’t know/refused

Exhibit 6.  Among market-place visitors who didn’t enroll, more than half said they couldn’t find an affordable plan

Can you tell me why you did not obtain a private health insurance plan or Medicaid coverage when you visited the marketplace? Was it because…?

Percent of adults ages 19-64 who visited the marketplace but did not select coverage

57% – Could not find a plan you could afford
51% – Obtained health insurance through another source
43% – Not eligible to enroll in Medicaid or for financial assistance
38% – Found the process of enrolling in a plan difficult or confusing
32% – Could not find a plan with the type of coverage you need
15% – Decided you did not need health insurance
14% – Did not know where to get help to sign up
23% – Some other reason

Affordability was a key reason people did not enroll in plans. More than half (57%) of adults who visited the marketplaces but did not enroll said they could not find a plan they could afford. Excluding the adults who also said they gained coverage elsewhere, the majority of those who did not enroll because they couldn’t find affordable plans had lower incomes. More than half (54%) had incomes in the range that made them eligible for subsidies (i.e., from 100 percent to 400 percent of the federal poverty level, or $11,670 to $46,680 in annual income for an individual). Thirty percent had incomes under 100 percent of poverty. An estimated 26 percent (and thus nearly all of those with incomes under 100 percent of poverty) were likely in the so-called Medicaid coverage gap. That is, they were living in states that had not expanded eligibility for Medicaid at the time of the survey and had incomes under 100 percent of poverty and thereby not eligible for marketplace subsidies. About 11 percent had incomes that exceeded the threshold that made them eligible for subsidies (i.e., 400 percent of poverty).

Many adults (43%) said they did not enroll because they were not eligible for subsidized coverage or Medicaid. Again, excluding those who gained coverage elsewhere, most people who gave this reason had lower incomes: 50 percent had incomes that made them eligible for subsidies, and 33 percent had incomes under 100 percent of poverty. An estimated 27 percent — most of those with incomes under 100 percent of poverty — were likely in the Medicaid coverage gap. About 14 percent had incomes above the threshold that made them eligible for subsidies.

Other adults who did not enroll were overwhelmed by the process. About four of 10 adults (38%) who did not sign up for coverage said they found the process of enrolling difficult or confusing.

http://www.commonwealthfund.org/publications/issue-briefs/2015/sep/to-en…

Is the Affordable Care Act a misnomer? Although half of the individuals who visited the insurance exchanges and did not enroll obtained coverage outside of the exchanges, the other half did not enroll because they found the plans unaffordable.

Making health care affordable for everyone was the primary goal of reform. It didn’t happen. But it would if we were to enact a single payer national health program.