AAPOR - The ACA’s First Years: Focusing In On Non …...– For more on re-contact efforts, see presentation by Eran Ben-Porath earlier today • Non-group sample: – Adults ages

The ACA’s First Years: Focusing In On Non-GroupPurchasers and the Uninsured In CaliforniaAAPOR 2015 Annual Conference

Mollyann Brodie, Liz Hamel, and Bianca DiJulio

May 15, 2015

Public Opinion and Survey ResearchKaiser Family Foundation

• ACA made major changes to availability of insurance coverage• Large government surveys take a long time to produce estimates,

but people want to know how the ACA is working NOW:– How many people got coverage?– How and where did they get it?– What were enrollment experiences like?– Is coverage affordable and how is it working?

• Challenges:– State variation– Small size of groups potentially impacted– Insurance market churn– Respondent recall problems in reporting insurance changes

Assessing ACA Impact

• California uninsured longitudinal panel survey• Surveys of non-group health insurance enrollees

• Plan:– Briefly describe methods, advantages and disadvantages of each– Highlight a few key findings– Discuss common themes in findings from both surveys and

implications for future ACA research efforts

Two KFF Projects Looking at Different Groups

• Longitudinal panel of 2,000 CA residents who were uninsured summer 2013– Baseline: July-August 2013 (prior to open enrollment)– Wave 2: April-June 2014 (after 1st open enrollment)– Wave 3: Feb-May 2015 (after 2nd open enrollment)– Wave 4 planned for late 2015/Early 2016

• Advantages:– One state– Panel design eliminates respondent recall problems– Can track who among the uninsured gets & keeps insurance– Can also look at those who remain uninsured, find out whether they tried to get

coverage & why they didn’t get it• Disadvantages:

– Cannot estimate overall change in number of uninsured, since we don’t know howmany lost coverage at the same time

– Limited in ability to talk about groups who got coverage from any individual source(i.e. Covered CA)

California uninsured longitudinal panel survey

• Series of surveys with people who purchase their own health insurance, inside oroutside the ACA’s Marketplaces

– Wave 1: April-May 2014 (after 1st open enrollment)– Wave 2: Feb-April 2015 (after 2nd open enrollment)– Wave 3 planned for late 2015/Early 2016

• Advantages:– One coverage type allows us to explore subgroups within non-group market– Ability to compare those in new, ACA-compliant plans with those remaining in older

plans that may not comply with ACA rules (“non-compliant” plans)• Disadvantages:

– National, cannot account for state-to-state variation– Previous insurance status subject to respondent recall– Only looks at those covered at time of survey, can’t measure experiences of those

who tried to get coverage and failed, or those who lost non-group coverage at somepoint during year

Surveys of non-group health insurance enrollees

• Both surveys conducted by RDD landline and cell phone in Englishand Spanish, fielded by SSRS

• Weighted to adjust for sample design and differential non-response• CA sample:

– California residents ages 19-64 who were uninsured for at least 2 months atthe time of the baseline survey

– N=2001 for baseline survey; 1,219 for Wave 2 survey– Shorter web survey offered to non-respondents in Waves 2 & 3– For more on re-contact efforts, see presentation by Eran Ben-Porath earlier

today

• Non-group sample:– Adults ages 18-64 who purchase their own non-group health insurance– N=742 for Wave 1 survey

Methods in brief

CALIFORNIA PANEL WAVE 2 SELECTED FINDINGS

SOURCE: Wave 2 of the Kaiser Family Foundation California Longitudinal Panel Survey (April 1- June 15, 2014)

Sources Of Coverage Among California’s Previously Uninsured

Medi-Cal25%

Covered California9%

Othernon-group

5%

Employer-Sponsored

12%

Other/Unknown

6%

RemainingUndocumented

Uninsured13%

Remaining EligibleUninsured

29%Newly

Insured58%

RemainingUninsured

42%

NewlyInsured

61%

RemainingUninsured

39%

Eligible Hispanic

NewlyInsured

61%

RemainingUninsured

39%

White, Non-Hispanic

NewlyInsured

52%Elig.Uninsured

25%

Undoc.Uninsured

22%

Total Hispanic

In California, Previously Uninsured Whites and EligibleHispanics Report Gains In Coverage At Similar Rates

NOTE: “Eligible” refers to those who would be eligible for participation in the ACA coverage expansions based on their self-reported status as acitizen, permanent resident, or lawfully present immigrant.SOURCE: Wave 2 of the Kaiser Family Foundation California Longitudinal Panel Survey (April 1- June 15, 2014)

Total HispanicsRemaining Uninsured

48%

Are you, yourself, now covered by any form of health insurance or health plan including a private health insurance plan, aplan through an employer, or a plan through Medi-Cal, or do you not have health insurance at this time?

NOTE: Don’t know responses not shown.SOURCE: Wave 2 of the Kaiser Family Foundation California Longitudinal Panel Survey (April 1- June 15, 2014)

Outreach Made a Difference

69%

52%

31%

48%

Among those who werepersonally contacted about

signing up for healthinsurance

Among those who were notpersonally contacted

Newly Insured Remaining Uninsured

NOTE: Don’t know/ Refused answers not shown.SOURCE: Wave 2 of the Kaiser Family Foundation California Longitudinal Panel Survey (April 1- June 15, 2014)

Most Say Process Of Signing Up For Coverage Was Easy, ButMore Challenging For Covered CA Enrollees

AMONG CA NEWLY INSURED: How easy or difficult was the process of signing up for (Medi-Cal/health insurance)?

44%

46%

22%

55%

32%

28%

38%

32%

16%

20%

25%

8%

8%

6%

14%

5%

Total California NewlyInsured

Medi-Cal

Covered California

Employer-SponsoredInsurance

Very easy Somewhat easy Somewhat difficult Very difficult

Coverage Type

1Among remaining uninsured who tried to get coverage through Medi-Cal or a plan purchased themselves directly from an insurer or throughCovered California 2Among remaining uninsured who tried to get coverage through a plan they purchased themselves directly from an insureror through Covered California 3 Among remaining uninsured who tried to get coverage .SOURCE: Wave 2 of the Kaiser Family Foundation California Longitudinal Panel Survey (April 1- June 15, 2014)

Majority Of The Remaining Uninsured Who Tried To Enroll HadA Difficult Time Exploring Their OptionsAMONG CALIFORNIA REMAINING UNINSURED WHO TRIED TO GET COVERAGE: How easy or difficult was it for you to…

40%

34%

31%

28%

18%

36%

37%

38%

39%

40%

…Find a health insurance policy to meet your needs?

…Compare the services that would be covered by theplans?

...Compare the amount you would have to pay to usehealth services?

...Compare the monthly amount you would have to pay forcoverage?

…Find the information you needed about getting healthinsurance?

Very difficult Somewhat difficult

1

2

2

2

3

2 yrs+45%

1-<2 yrs12%

2 months-<1 yr6%

NeverInsured

37%

Length Of Uninsurance And Income/Eligibility AmongRemaining Uninsured

NOTE: For those who report being U.S. citizens or permanent residents, “Medi-Cal target group” refers to those with incomes 138% FPL or lessand “exchange subsidy target group” refers to those with incomes greater than 138% and up to 400% FPL.SOURCE: Wave 2 of the Kaiser Family Foundation California Longitudinal Panel Survey (April 1- June 15, 2014)

Medi-Caltarget

(<138% FPL)39%

Exchangesubsidy target

(138-400%FPL)24%

> 400% FPL4%

Unknown4%

Undocu-mented

30%

Length Of Time Uninsured Income/Eligibility

AMONG CALIFORNIA REMAINING UNINSURED: What isthe main reason you have not gotten health insurancethis year?

34%

15%

9%

9%

Can't afford it/ too expensive

Don't qualify for coverage/ financialhelp

Haven't tried/ too busy

Lack of information/ Don't knowhow to get it


The Remaining Uninsured In Their Own Words“I still cannot afford health

insurance.”“It’s a total rip-off, it’s extremely

expensive.”“I don’t have enough income.”

“Can’t apply for it because of mylegal status.”

“My husband’s income is toohigh.”

“Don’t think I qualify.“

“Working so much I haven’t hadtime.”

“I’m limited with my time and theapplications are too long. I don’t

have time.”

“I find it too difficult to understandand there’s no support from

anybody to help me.”“’Confused about the system.”

NOTE: Haven’t paid yet (Vol.) and Don’t know/ Refused answers not shown.SOURCE: Wave 2 of the Kaiser Family Foundation California Longitudinal Panel Survey (April 1- June 15, 2014)

About Half Of Covered California Enrollees Say Paying ForCoverage Is Difficult

16%

11%

19%

30%

23%

32%

25%

33%

32%

25%

33%

16%

Total


Covered California

Very difficult Somewhat difficult Not too difficult Not at all difficult

Coverage Type

AMONG CALIFORNIA NEWLY INSURED, NOT THROUGH MEDI-CAL: How difficult is it for you to afford to pay the cost ofhealth insurance each month?

NOTE: Don’t know/ Refused answers not shown.SOURCE: Where Are California’s Uninsured Now? Wave 2 of the Kaiser Family Foundation California Longitudinal Panel Survey (April 1- June 15,2014)

So Far Most Newly Insured Report Positive Experiences WithTheir PlanAMONG CALIFORNIA NEWLY INSURED: Overall, would you say your experiences with your current health insurance planhave been very positive, somewhat positive, somewhat negative, or very negative?

38%

41%

31%

36%

37%

37%

28%

43%

7%

6%

12%

9%

3%

3%

2%

2%

14%

13%

27%

11%

Total California NewlyInsured

Medi-Cal

Covered California


Very positive Somewhat positive Somewhat negative Very negative Haven't used plan yet (vol.)

Coverage Type

NON-GROUP SURVEY WAVE 1 SELECTED FINDINGS

Non-Group Market Following 1st Open Enrollment Period

SOURCE: Kaiser Family Foundation Survey of Non-Group Insurance Enrollees (conducted April 3 – May 11, 2014)

Marketplaceplans48%

ACA-compliant

planspurchased

outsideMarketplace

19%

Non-compliant

plans31%

Other/Unknown

4%

Employer14%

Public9%

Othernon-

group16%

Among all non-group enrollees, percentwho are in:

Among those in Marketplace plans, percentwhose previous insurance status was:

Uninsured57%

Most Marketplace Enrollees Say Comparing Plans Was Easy

58%

59%

64%

64%

69%

34%

33%

30%

29%

26%

Compare providernetworks

Set up an account withthe marketplace

Compare copays anddeductibles

Figure out if yourincome qualifies you for

financial assistance

Compare monthlypremiums

Very or somewhat easy Very or somewhat difficult

AMONG NON-GROUP ENROLLEES WITH MARKETPLACE PLANS:Thinking about when you signed up for your current health plan, how easy or difficult was it for you to…

NOTE: Don’t know/Refused and Not Applicable answers not shown.SOURCE: Kaiser Family Foundation Survey of Non-Group Health Insurance Enrollees (conducted April 3 – May 11, 2014)

Internet Most Widely Used For Shopping And Enrollment, ButMany Spent Time On Phone And In Person

65%

49%

27%

47%

41%

43%

On the Internet

On the phone

In-person withsomeone helping

Marketplace plan enrollees

Enrollees in ACA-compliant, non-Marketplace plans

Percent who say they completed any part of the shopping and enrollment process…

SOURCE: Kaiser Family Foundation Survey of Non-Group Health Insurance Enrollees (conducted April 3 – May 11, 2014)

Very easy24%

Somewhateasy30%

Don'tKnow/

Refused3%

Somewhatdifficult

29%

Verydifficult

14%

Most Say Plan Is A Good Value, But Many Find It Difficult ToAfford PremiumsAMONG NON-GROUP ENROLLEES WITH ACA-COMPLIANT PLANS:

How easy or difficult is it for you to afford to paythe cost of your health insurance each month?


Excellent21%

Good34%

Don'tKnow/

Refused6%

Only fair21%

Poor18%

Would you say your health insurance is anexcellent value, good value, only a fair value or a

poor value for what you pay for it?

• Enrollment process went fairly smoothly for most of those whoenrolled, but the remaining uninsured who tried to sign upencountered more difficulties

• Internet is not the only mode of enrollment; outreach and in-person help were important for many who enrolled

• Most people feel good about their (new) coverage• Affordability of insurance remains a concern, both for those who

got coverage and those who did not

Common Themes

• Post-second enrollment period waves of each of these surveys arecurrently being analyzed

• At least one more wave for each is planned• Continue tracking each group to find out:

– Who retains insurance vs. “churning” in and out of coverage?– How do people evaluate their coverage, and what problems (if

any) do they run into when using their plans?– For the previously uninsured, does expanded access to health

insurance make a dent in people’s worries about the future?

Future Research

Thank you!

Full survey reports at www.kff.orgQuestions? [email protected]

Extra slides


Enrollment Process Went Smoothly For Most, But SomeExperienced Bumps in the Road

54%

30%

42%

29%

25%

33%

23%

24%

12%

13%

14%

23%

7%

13%

15%

19%

1%

11%

4%

6%

...Medi-Cal

…financial assistance

Newly Insuredthrough Medi-Cal

Newly Insuredthrough Covered

California

Very easy Somewhat easy Somewhat difficult Very difficult Don't know/ Refused

How easy or difficult was it for you to get confirmation from [the county/ Covered California] that your coverage hasstarted?

How easy or difficult was it for you to figure out if your income qualifies you for…

(Among California NewlyInsured Through Medi-Cal)

(Among California NewlyInsured Through Covered

California)


Enrollment Method Varies By Coverage Type

AMONG CALIFORNIA NEWLY INSURED, NOT THROUGH EMPLOYER: Did you (purchase/sign up for) your plan on thephone, in-person, on the internet, or some other way?

19%

14%

29%

38%

52%

15%

23%

15%

52%

6%

11%

12%

8%

2%

Total

Medi-Cal

Covered California

By phone In-person On the internet By mail (Vol.) Other

Coverage Type

NOTE: Don’t know/Refused not shown.SOURCE: Wave 2 of the Kaiser Family Foundation California Longitudinal Panel Survey (April 1- June 15, 2014)

Did someone help you enroll in health insurance or did you completethe enrollment process on your own?

Covered California Medi-Cal

Someone helped me 61% 60%Family member or friend 25% 9%Covered CA representative 26% 8%Health insurance broker or agent 8% 4%Community or county health worker 2% 31%Someone else * 6%

Completed it alone 39% 40%

How easy or difficult was it for you to find someone to help you enrollor answer your questions?Very easy 28% 42%Somewhat easy 23 29Somewhat difficult 16 12Very difficult 21 13Did not attempt (vol.) 11 2

Many Newly Insured Had Assistance Enrolling, But From VariedSources

A Few Basic Demographics Of California RemainingUninsured

NOTE: For those who report being U.S. citizens or permanent residents, “Medi-Cal target group” refers to those with incomes 138% FPL or lessand “exchange subsidy target group” refers to those with incomes greater than 138% and up to 400% FPL.SOURCE: Wave 2 of the Kaiser Family Foundation California Longitudinal Panel Survey (April 1- June 15, 2014)

Elig.Hispanic

32%

Undoc.Hispanic

29%Black

5%

Other8%

White24%

Medi-Caltarget group

39%

Exchangesubs. target

group24%

> 400% FPL4%

Dk/Ref4%

Undoc.Uninsured

30%

Length Of TimeUninsured

Race/ Ethnicity

19-2517%

26-3425%

35-4933%

50-6424%AgeIncome/Eligibility

2 yrs+45%

1-<2 yrs12%

2 months-<1 yr6%

NeverInsured

37%Total

Hispanics62%


Many Remaining Uninsured Hispanics Worry Signing Up ForHealth Insurance Will Draw Attention To Immigration StatusAMONG CALIFORNIA REMAINING UNINSURED: How worried, if at all, are you that if you sign up for health insurance youwill draw attention to your or a family member’s immigration status?

40%

53%

57%

24%

14%

16%

15%

13%

9%

10%

10%

6%

37%

20%

17%

57%

Total Hispanic

Hispanics whocompleted the survey

in Spanish

UndocumentedHispanics

Eligible Hispanics

Very worried Somewhat worried Not too worried Not at all worried

Enrollees In Compliant Plans Report Being Somewhat LessHealthy Than Those In Non-Compliant Plans

22%

28%

29%

37%

31%

28%

13%

6%

4%ACA-compliant plans

Non-compliant plans

Excellent Very good Good Only fair Poor

NOTE: Don’t know/Refused answers not shown.SOURCE: Kaiser Family Foundation Survey of Non-Group Health Insurance Enrollees (conducted April 3 – May 11, 2014)

AMONG NON-GROUP ENROLLEES: In general, would you say your health is…

<1%

Similar Shares Of Plan Switchers Report Increase and DecreaseIn Premiums

Higher39%

About theSame15%

Lower46%

AMONG THOSE WHO SWITCHED FROM NON-COMPLIANT TO COMPLIANT NON-GROUP PLANS:

Is the monthly premium amount you pay (after tax credit) for your CURRENT plan higher or lower than whatyou paid for your previous plan, or is it about the same?


Internet Most Widely Used For Shopping And Enrollment, ButMany Spent Time On Phone And In Person

32%

54%

50%

57%

72%

56%

13%

9%

13%

13%

12%

13%

21%

12%

22%

17%

10%

16%

13%

10%

7%

6%

2%

9%

18%

16%

7%

5%

3%

5%

Exchange Plans

Non-Exchange, ACA-compliant

Exchange Plans


Exchange Plans


No time Less than 1 hour 1-3 hours 3-5 hours 5+ hours

On the Internet

In-Person with Someone Helping

AMONG THOSE WITH ACA-COMPLIANT NON-GROUP PLANS: Reported time spent on the process of shopping andsigning up for health insurance…

On the Phone

NOTE: Don’t know/Refused answers not shown.SOURCE: Kaiser Family Foundation Survey of Non-Group Health Insurance Enrollees (conducted April 3 – May 11, 2014)

Documents

AAPOR - The ACA’s First Years: Focusing In On Non …...– For more on re-contact efforts, see presentation by Eran Ben-Porath earlier today • Non-group sample: – Adults ages