Tuesday, April 08, 2014

This subsidized health insurance was brought to you by...?

Urging caution in response to current ACA signup stats and polling results, Jonathan Bernstein reiterates his  favorite question with regard to the political fallout:
How many of those in the exchanges, in expanded Medicaid, and newly eligible for their parents’ insurance plans are aware that they are covered by Obamacare? I’ve consistently guessed that a large number of people wouldn't make the connection, but we still have no data.
I have always found the possibility that some people would sign up for coverage made available through the ACA without knowing that the ACA (or "Obamacare") was responsible fascinating and challenging. Sometimes Bernstein emphasizes that over time -- say, five years from now -- a lot of people who buy Qualified Health Plans or sign up for Medicaid on Healthcare.gov or the state exchanges won't know that their options originated with the new law. That seems easier to credit than that a significant percentage, if not a majority, of this year's signups would not know that "Obamacare" was the source of their coverage.

Regarding awareness among this year's signups, a few thoughts:

1. It takes a village:  Drew Altman, President of the Kaiser Family Foundation, points out that in California, which spent more on ACA outreach than all the federal exchange states combined, relatively few of the uninsured signed up on their own:

But the pictures showed something else as well. Those people weren’t online, they were lining up at community centers and local government agencies. When they finally decided to enroll they wanted to go somewhere and talk to a real person. And they felt they needed help navigating the enrollment process...For the long term, harder to reach uninsured, enrolling will never be as simple as shopping on Travelocity or Amazon.com. Reaching them will take hands on community based outreach.

Now, not everyone who received in-person signup help would know that they were accessing "Obamacare" -- particularly not in red states, where the word is anathema. In Kentucky, a red state with a Democratic governor and an active, highly successful ACA outreach effort, navigators were often careful not to mention "Obamacare" or the Affordable Care Act, according to news reports (sorry, can't find recent link).  The same was probably the case for outreach workers in red states generally, at least when targeting white people.

But as Altman points out, outreach was generally far more robust in blue states, which accessed federal grant money, than in red. (Some states with Republican governors and/or legislatures, such as North Carolina and Pennsylvania, have a "purple" culture and therefore fielded relatively robust private outreach efforts.)

For those reaching out to minorities, particularly to African Americans, "Obamacare" would have a positive valence. I made calls for GetCoveredAmerica to people in Newark and environs, and I always mentioned "Obamacare" in the second breath. Most people I spoke to knew what I was talking about, though a few Hispanics with limited English had a pretty vague idea (one woman, who put her daughter on to translate, asked me through her, "what is health insurance"?).

2. Over 80% of private health plan signups qualified for subsidies. It would be pretty hard to get through the online signup process without knowing that "the government" was paying a portion of your premium -- though I suppose in some cases people might not particularly register which government, i.e. that the availability was the result of a new national program.  It also may well be true that people who qualified for Medicaid might not be aware that the ACA had made them eligible (and in fact, according to Charles Gaba's tracking, about two-sevenths of those enrolled in Medicaid via the ACA were previously eligible).

My home state, New Jersey, has accepted the Medicaid expansion, and outreach and enrollment continue year-round, unaffected by the March 31 open enrollment deadline (as Medicaid enrollment does in all states, with or without the ACA expansion). But the Republican appointees at the top of the state Dept. of Human Services are surely not associating continued efforts with the ACA, though workers on the ground, including at private nonprofits, may be.

3. Healthcare.gov and the state exchanges got a lot of media attention. One paradoxical side effect of the disastrous launch and two months of dysfunction for the federal site, and even more extended dysfunction for many state online exchanges, is that people who tried and failed in the fall and later were able to enroll online (or on paper for that matter) doubtless know that the website in question is an artifact of Obamacare.

It's probably true that it's hard to overestimate the extent to which many millions of Americans tune out political news and may have only vague ideas of what's in the ACA or of the provenance of newly available services. It's also true that you can search far and wide not only on state exchanges but on Healthcare.gov itself without coming across any reference to the ACA. Still, I suspect that this year most signups through the websites, with or without in-person assistance, knew that they were accessing "Obamacare."  I also think it probable that that won't be true three or five years from now.

4. People know about the individual mandate -- i.e., the tax penalty imposed by the ACA on those who do not obtain health insurance.* Otherwise, 3 million people -- about 40% of total signups -- wouldn't have enrolled on the exchanges in March -- and millions more in Medicaid. Further, the newly published RAND survey of changes in health insurance enrollment since 2013 finds that enrollment in employer-sponsored insurance has increased more than 8 million this year and speculates that "some of these newly insured individuals may have taken up an employer plan as a result of the incentive created by the individual mandate" (p. 3). 

* Point #4 added on 4/9.

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