The summer months are fleeting, but health policy research is here to stay. This month, the CHIR team read studies about the role of Affordable Care Act (ACA) in increasing access to health insurance coverage, the impact of consumer assistance programs on rates of enrollment, and challenges Americans have faced affording coverage during the COVID-19 pandemic.

Pollitz, K, et al. Consumer Assistance in Health Insurance: Evidence of Impact and Unmet Need. Kaiser Family Foundation, August 7, 2020. To assess the importance of in-person consumer assistance programs, researchers at The Kaiser Family Foundation (KFF) conducted a national survey of consumers aged 18-64 who were most likely to use these services, including uninsured individuals, marketplace enrollees, and Medicaid beneficiaries.

What it Finds

• Eighteen percent of consumers who looked for or renewed health insurance coverage for 2020 received help from someone other than a family member or friend, including Navigators and certified enrollment assistance programs (40 percent), brokers (36 percent), health plan representatives (29 percent), and other entities.
• Among those who enrolled in coverage with assistance, 40 percent said they believe it is unlikely they would have found coverage without help.
• Consumers sought help at roughly the same rate across age groups, income levels, and between metropolitan and non-metropolitan areas, and those applying for coverage for the first time were just as likely to receive or seek assistance as those who renewed their coverage. Hispanic consumers were more likely than white consumers to receive assistance, which the authors indicate may be due to immigration concerns or language barriers.
• Consumers receiving assistance cited a variety of reasons for seeking help with applying for or renewing coverage, including confusion over coverage options (62 percent of those seeking), finding the application process too complex to complete alone (52 percent), issues navigating the marketplace website (18 percent), or  needing help in another language (15 percent).
• Of marketplace enrollees who were assisted by brokers or health insurance agents, 22 percent reported that they were shown alternatives to a marketplace plan, such as short-term plans, while 25 percent reported they were shown other non-ACA-compliant products such as hospital indemnity policies to supplement marketplace coverage.
• Among consumers seeking coverage in the past year, 12 percent were unable to find assistance, citing issues such as finding assistance close to home (32 percent), trouble getting an appointment (30 percent), lack of assistance available in Spanish (10 percent).

Why it Matters

These findings illustrate that consumer assistance programs can be an important source of help to those who are uninsured and those seeking coverage. The ACA’s Navigator Program has proved to be a particularly critical resource for consumers undergoing coverage or eligibility changes during the COVID-19 pandemic. Despite the significant and demonstrated need for these entities, the Trump Administration has cut funding for the ACA’s Navigator program in federal marketplace states by 84 percent since 2017. This study exposes the results of that, as many consumers have missed opportunities to access coverage due to a lack of assistance available in their geographic area or spoken language. Given the ongoing pandemic and continuing job and income insecurity, policymakers should find ways to help people who lost or are at risk of losing coverage, and consumer assistance programs have a proven track record.

Collins at al. U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability. The Commonwealth Fund, August 19, 2020. Researchers at the Commonwealth Fund examined health insurance for U.S. adults aged 19-64 in the latest Biennial Health Insurance survey, which evaluates the extent and quality of coverage for this population. The survey uses three measures to assess coverage adequacy: if people have insurance, whether the insured experienced a gap in coverage in the past year, and whether high out-of-pocket costs cause people to be underinsured.

What it Finds

• In the first half of 2020, 43.4 percent of nonelderly adults were inadequately insured, made up of 12.5 percent of nonelderly adults who were uninsured, 9.5 percent who were insured but had a gap in their coverage during the past year, and 21.3 percent were underinsured.
• Researchers found high rates of uninsurance among people of color, small business workers, people with low incomes, and young adults.
• Half of adults who were underinsured or spent any time uninsured over the last year said they struggled to pay medical bills, or reported that they were paying off medical debt. A quarter of adults who did not report uninsurance or underinsurance also experienced problems paying medical bills. Participants in this group also experienced long-term financial difficulties.
  • Black people were more likely to have problems paying medical bills than white people (45 percent compared to 35 percent). The same was true for those with household incomes below 133 percent of the Federal Poverty (FPL) compared to people with incomes at or above 400 percent FPL (42 percent compared to 27 percent).
• Deductibles have grown significantly; the proportion of adults covered by private health plans with deductibles of $1,000 or more has increased from 22 percent in 2010 to 46 percent in 2020.
• Adults who do not have coverage, have high deductibles, or who are underinsured were more likely to avoid or delay getting medicine or treatment, such as skipping a recommended treatment, compared to those who were covered for the entire year.

Why it Matters

The COVID-19 pandemic has exacerbated gaps in insurance coverage. High premiums and cost sharing in private health plans along with a growing number of uninsured people will leave households facing exorbitant health care costs during a time of significant income insecurity. Consequently, more people will be exposed to medical debt, and they will also experience difficulties accessing essential medical care needed to test and treat for COVID-19 and reduce the spread of the virus. This is especially true for vulnerable and minority populations. It is essential for federal and state-level actors to get in front of these developments to preserve and expand access to life-saving care.

Agarwal, S. and Sommers, B. Insurance Coverage after Job Loss — The Importance of the ACA during the Covid-Associated Recession. New England Journal of Medicine, August 19, 2020. In this study, researchers affiliated with Harvard University and Brigham and Women’s Hospital sought to demonstrate how the ACA has increased health coverage options for those experiencing job loss using national data from the Medical Expenditure Panel Survey to compare the trajectories of non-elderly adults who lost their jobs before 2014 with the trajectories of those who lost their jobs between 2014 and 2016.

What it Finds

• From 2011-2013 (pre-ACA), among survey participants, job loss was associated with an average health coverage loss of 4.6 percentage points, with the share of insured participants decreasing from 66.3 percent to 61.7 percent after losing a job. This was due to a 12.8 percentage point decrease in employer-based insurance following job loss that was only partially offset by increased rates of Medicaid and non-group private health insurance enrollment.
• After the ACA took effect in 2014, survey participants reported a higher level of coverage before job loss occurred (76.2 percent, compared to 66.3 percent prior to 2014), reflecting additional coverage options made available through Medicaid and marketplace plans under the ACA. In addition, job losses were no longer linked to an increase in the uninsured rate, with more participants reporting coverage after a job loss (77.6 percent, up from 76.2 percent before job loss) than in the pre-ACA period, with Medicaid and marketplace coverage almost fully offsetting loss of employer-based coverage.
• There was a 6.0 percentage point decrease in net coverage reduction among participants following a job loss in the post-ACA period compared to the pre-ACA period.

Why it Matters

These findings indicate that the ACA has played an essential safety net role during the COVID-19 pandemic and resulting recession. Minorities, especially Black and Hispanic people, have disproportionately suffered job losses and increased rates of morbidity and mortality amid the pandemic. The ACA has helped to reduce racial disparities in health insurance coverage in recent years, but the law could be overturned in a case pending before the Supreme Court.  In the current climate of widespread job loss that is exacerbating existing coverage inequity, the progress made under the ACA’s reforms in protecting and expanding access to coverage is at stake, and while seeking to strike down the law, the Trump administration has yet to produce a replacement plan.