Friday, August 15, 2014

"What's a subsidy?" -- It's hard to reach the uninsured

Back in May, I noted a remarkable finding in a McKinsey survey of those who bought or sought health insurance in the individual market during the ACA's first open season:  Most of those who failed to obtain coverage were eligible for subsidies but did not know they were eligible. Two thirds of subsidy-eligible respondents who visited but did not enroll were not aware of their eligibility -- and so had no idea how much health insurance would actually cost them.

Those findings are corroborated in a survey conducted at about the same time (April 10-28), commissioned by EnrollAmerica and conducted by PerryUndem Research/Communication. I just happened on this because HuffPost's Jeffrey Young cited the results in a story about the challenges of meeting signup targets in ACA year 2. Ignorance among the uninsured remains perhaps the greatest barrier (excepting the refusal of about half the states to accept the law's Medicaid expansion).

The EnrollAmerica survey drew responses from 671 new enrollees and 853 people who remained uninsured. 60% of those who remained uninsured said they wanted insurance. Only 21% of those who did not try to enroll knew that financial help was available to low-to-moderate income buyers -- and only 38% of those tried but failed to enroll were aware of this basic fact.

Perhaps even more remarkably, only 56% of those who did enroll in coverage knew that the law gives financial help to low- and moderate-income buyers. At the same time, 75% of enrollees, including 69% of those who enrolled online, said that the signup process was easy. Perhaps in this one regard it was a bit too easy, i.e., it was not hammered home that your friendly federal government was subsidizing your purchase.

"What's a subsidy?"

I am reminded of a comment by Ning Liang, co-founder of online broker HealthSherpa, which has a home page designed to let you know within 30 seconds how much you're likely to pay per month for health insurance.  "I never use the word 'subsidy' any more," Liang told me -- and he has spoken to thousands of prospective buyers. "Half the time, when I'd say to a customer, 'let's check your subsidy,' they'd say 'what's a subsidy?' Now I say, 'let's check your savings.'" Or "discount," I might suggest.

That's fine for HealthSherpa, a private for-profit company. But it's bad policy for the federal government. Submerged state benefits should at least be visible to the beneficiaries! And more importantly, to prospective beneficiaries. Not only do many have no idea what health insurance will cost them -- many did poke around or their state exchange and came away knowing only the retail, unsubsidized price of insurance.  More on this in an article forthcoming elsewhere.

Ignorance of the subsidies is all the more striking in light of far more widespread knowledge of the individual mandate -- that is, of the  fine the ACA imposes on those who remain uninsured (if they do not qualify for an exemption). 84% of the newly enrolled knew about the mandate, as did 69% of the still-unenrolled. Everyone knows about the stick; few know about the carrots. No wonder the law is unpopular.

Other important areas of ignorance:
  • Only 42% of the still-uninsured know that under the ACA, health plans cannot deny people coverage based on pre-existing conditions.  That compounds the perception of unaffordability, as many of the uninsured  have long been shut out of the individual market because of pre-existing conditions.

  • Only 21% of the uninsured, and 41% of the newly enrolled, know that the health law requires plans to offer free preventive care. That gap recalls a top-line complaint highlighted in a University of Pennsylvania study of 33 well-educated young adults who shopped on Nowhere in the signup process, respondents noted, was it brought to their attention (though the info is present in info sections on the site)  that every plan provides specified Essential Health Benefits, including an array of free preventive screenings and services. Among the study's recommendations:
  • Emphasize mandatory inclusion of preventive primary care services in all marketplace plans at no additional cost. Young adults identified preventive services (for example, well-woman visits and contraception) as top coverage priorities but were unaware of their universal inclusion and instead assumed that available plans would charge for these services. Emphasizing free preventive coverage within each plan’s details may motivate more young adults to purchase marketplace plans.
One inescapable conclusion of the EnrollAmerica survey and several others is that effective in-person help is essential to reaching many of the uninsured. There are many ways that and the state exchanges could get more essential information to more visitors more quickly, however. These include 1) making people begin with the shop-only feature, which asks a handful of questions and then delivers price quotes incorporating the user's likely subsidy and 2) providing various bits of essential information in context, via mouseover or pop-up box (a key recommendation of the UPenn study). 

1 comment:

  1. Social Security has real offices with paid staff. If you visit one of those offices, you will wait in line behind persons who are not internet savvy and do not own a computer.
    Of course this costs more and takes longer to become universal.
    But that is how true social insurance works.