October Research Roundup: What We’re Reading

The leaves may be changing, but the importance of health policy research is evergreen. Last month, we read up on the results of a survey on the state of U.S. health insurance coverage, enrollment patterns on- and off-marketplace, and the impact of marketplace enrollment strategies.

Sara R. Collins, Lauren A. Haynes, and Relebohile Masitha, The State of U.S. Health Insurance in 2022, The Commonwealth Fund, September 2022. The Commonwealth Fund published the results of its biennial health insurance survey assessing coverage rates and the adequacy of insurance by interviewing a nationally representative sample of working-age adults (ages 19 to 64) from March 28 and July 4 2022.

What it Finds

More than 40 percent of working-age adults had inadequate health insurance in the last 12 months, either going uninsured (9 percent); facing a gap in coverage (11 percent); or experiencing “underinsurance,” the lack of affordable access to health care while insured (23 percent).
Working-age adults who were uninsured for a year or more were disproportionately young, Latino/Hispanic, low-income, sicker, or living in the South.
Premium affordability was the primary reason provided for not buying or losing marketplace or individual market coverage.
Most working-age adults who were underinsured or lacked continuous coverage in 2022 reported forgoing needed care due to cost, such as not filling a prescription or skipping a follow-up visit or test.
Nearly half of working-age adults could not cover an unexpected $1000 medical bill within 30 days; the share reporting this financial difficulty was higher among low-income adults, Black adults, and Latino/Hispanic adults.

Why it Matters

Though the percentage of Americans without health insurance has decreased since the Affordable Care Act’s (ACA) enactment, many Americans still lack comprehensive coverage. This survey reminds us of the gaps that remain, particularly in the realm of insured patients’ access to affordable care. As the Commonwealth Fund authors note, making the current, more generous marketplace subsidies permanent; banning non-ACA-compliant products like short-term plans; and creating new public insurance options would help expand access to comprehensive and affordable coverage to protect Americans’ health and financial wellbeing.

Jared Ortaliza, Krutika Amin, and Cynthia Cox, As ACA Marketplace Enrollment Reaches Record High, Fewer Are Buying Individual Market Coverage Elsewhere, KFF, October 2022. With the ACA’s now-arrived tenth open enrollment period, KFF evaluates individual enrollment patterns on and off the ACA marketplace.

What it Finds

As of early 2022, an estimated 16.9 million people have individual market coverage—the highest since 2016.

The American Rescue Plan Act’s subsidies both brought people from off-marketplace plans onto the marketplace and generally increased overall individual market enrollment, which sits roughly 20 percent higher than it did in early 2020.

With enhanced subsidies in place, almost three in four individual market enrollees receive subsidies to reduce premiums and/or cost sharing, compared to just 44 percent in 2015.
Enrollment in non-ACA-compliant plans (such as short-term plans and grandfathered plans) is likely at an all-time low. In mid-2021, an estimated 1.3 million people were in non-compliant plans, significantly lower than the 5.7 million in mid-2015.
Unsubsidized premiums may increase more steeply in 2023 compared to previous years due to rising health care costs and utilization, which may cause further decreases in off-marketplace coverage, where consumers are not shielded from the brunt of premium hikes by subsidies.

Why it Matters

The individual market provides a critical source of health insurance to those who are ineligible for coverage through their jobs or a public program. More generous premium subsidies have not only driven people in off-marketplace individual plans to the marketplaces, but have increased overall enrollment on the individual market. This is coupled with a decline in non-ACA-compliant coverage, which can leave consumers at financial risk when they need care. This KFF study suggests that more generous premium subsidies have been key to increasing access to and take up of comprehensive health insurance on the individual market.

Adrianna McIntyre, Evidence-Based Outreach Strategies for Minimizing Coverage Loss During Unwinding, JAMA Health Forum, October 2022. The author reviews what the evidence says about effective outreach strategies to minimize health insurance coverage loss with the ending the COVID-19 public health emergency and resulting disenrollment of individuals who are no longer eligible for Medicaid.

What it Finds

Studies have shown that people leaving Medicaid rarely take up marketplace coverage, and those who do often experience gaps in coverage

In states using the federal marketplace platform, HealthCare.gov, only 3 percent of people transitioning off Medicaid enrolled in the marketplace within a year, and a majority experienced a gap in coverage.
In a study conducted in California, only 5 percent of people referred from county Medicaid to Covered California took up marketplace coverage.

One strategy that has proven effective is personalized outreach to consumers eligible for marketplace plans.

Randomized controlled trials (RCTs) suggest that reminder letters sent through the mail during open enrollment can increase coverage by 7 to 16 percent.
Another RCT indicated that receiving a personalized phone call increased coverage take-up among consumers who had applied but not selected a plan by 23 percent; calls had a greater impact on individuals transitioning from Medicaid (a 54 percent increase) and on individuals who preferred Spanish assistance (a 74 percent increase).

A recent RCT evaluated the relative impact of adding emails, phone calls, and a combination of both to the required eligibility determination notice sent to households qualifying for subsidized marketplace coverage after losing Medicaid. Phone calls connected participants to call center representatives to assist with the enrollment process. The study showed that the combination of phone and email outreach and phone-only outreach outperformed the email-only outreach.

Why it Matters

The “unwinding” of continuous Medicaid coverage at the end of the COVID-19 public health emergency will be the biggest coverage event since the ACA’s implementation. To connect individuals and families losing Medicaid with subsidized marketplace plans, states will need to use effective outreach strategies. This article highlights the success of direct and personalized outreach, and how phone calls may be a more successful method than emails—particularly phone calls that connect consumers to assistance with the enrollment process rather than just reminding them of their opportunity to enroll. State and federal policymakers providing guidance and resources to states can look to these evidence-based approaches as they brace for the huge shift in coverage once the public health emergency expires.