In preparation for Health Policy Halloween, CHIR read up on the latest health policy research. In October, we read studies on consumer experiences enrolling in the Affordable Care Act (ACA) Marketplace, health care affordability issues among the insured and uninsured, and the impact of Medicaid expansion on coverage in heavily redlined areas.

Kaye Pestaina, Cynthia Cox, and Rayna Wallace, Signing Up for Marketplace Coverage Remains a Challenge for Many Consumers, KFF, October 30, 2023. Authors analyzed results from KFF’s 2023 Survey of Consumer Experience with Health Insurance, a nationally representative survey of 3,065 adults that included 880 Marketplace enrollees (both HealthCare.gov and state-based Marketplace (SBM) enrollees).

What it Finds

• Over one-third (35 percent) of individuals with Marketplace coverage reported difficulty finding a plan that met their needs, roughly twice the share of individuals with Medicaid (19 percent) or employer-sponsored coverage (17 percent) who reported similar difficulties.
  • When evaluating their plan options, 41 percent of Marketplace enrollees found it somewhat or very difficult to compare provider networks across plans, compared to 32 percent of individuals with employer-sponsored coverage and 27 percent of Medicaid enrollees.
  • Marketplace enrollees also found it challenging to compare financial obligations across plan options: 31 percent struggled to compare copayments and deductibles, and 25 percent had trouble comparing monthly premiums. Moreover, 32 percent reported difficulty determining whether they were eligible for Marketplace financial assistance.
• After selecting a plan, one in four (25 percent) Marketplace enrollees reported difficulty completing the Marketplace application or enrollment process, compared to 12 percent of people with employer-sponsored coverage and 20 percent of people with Medicaid.

Why it Matters

More people than ever rely on the ACA Marketplaces for health insurance. When shopping for coverage, individuals and families often have to make complex comparisons of provider networks, benefits, deductibles, premiums, and cost-sharing amounts, and a significant increase in the number of plan options contributes to suboptimal plan selections. The administrative burden of the enrollment process itself may also deter consumers from signing up for coverage. Marketplaces have pursued a number of policy interventions to improve the shopping and enrollment experience, such as standardizing plan design, simplifying the sign-up process, and investing in enrollment assistance. Still, this KFF survey and analysis identifies ongoing pain points for consumers. As stakeholders consider ways to improve the Marketplaces as a source of coverage, these findings can help guide efforts to help consumers access plans that meet their health and financial needs. 

Sara R. Collins, Shreya Roy, and Relebohile Masitha, Paying for It: How Health Care Costs and Medical Debt Are Making Americans Sicker and Poorer: Findings from the Commonwealth Fund 2023 Health Care Affordability Survey, Commonwealth Fund, October 26, 2023. This analysis of the Commonwealth Fund’s inaugural survey on health care affordability examines challenges affording health care, medical debt, and health outcomes among a nationally representative sample of 6,121 working-age U.S. adults (ages 19–64) with and without health insurance.

What it Finds

• Overall, about half (51 percent) of respondents reported that their family had difficulty affording health care costs. 
  • The majority of uninsured respondents (76 percent) were unable to afford care, while respondents with employer-sponsored insurance (ESI) reported the least difficulty affording care (43 percent). Respondents with individual market coverage (either on- or off-Marketplace) fell in the middle, with 57 percent reporting affordability challenges.
  • Difficulty affording care varied significantly by income level for ESI enrollees; 56 percent of respondents with ESI and household income under 200 percent of the federal poverty level (FPL) reported difficulty affording care, compared to 30 percent of ESI enrollees with incomes at or above 400 percent of the FPL. (Similar data was not included for other coverage groups.)
• More than one-third (38 percent) of respondents said that these affordability barriers caused them to delay or skip needed health care or prescriptions.
  • A majority (64 percent) of the uninsured reported putting off care due to cost.
  • Having insurance did not protect respondents from putting off care due to high costs: 29 percent of ESI enrollees, 37 percent of the individual market enrollees, and 39 percent of Medicaid enrollees reported delaying or forgoing care in the past 12 months.
  • Over half (57 percent) of adults who put off care reported experiencing a worsening health problem as a result. Worsening health problems were more prevalent among individual market enrollees (61 percent) and Medicaid enrollees (60 percent) who reported deferring or delaying care due to affordability issues.
• Almost one-third (32 percent) of respondents said that they were currently paying off medical or dental debt, including those with insurance. 
  • A majority (85 percent) of respondents who reported medical or dental debt were carrying $500 or more of debt; 22 percent of this group had incurred $5,000 or more. Moreover, 36 percent of respondents reporting medical debt indicated that someone in their family had delayed or avoided care due to their debt, and a whopping 78 percent reported anxiety or worry due to the debt.
• Health care costs are substantially cutting into families’ household budgets and other living expenses: 57 percent of respondents reported spending 10 percent or more of their monthly household budget on health care, and 38 percent reported that health care costs have impeded their ability to pay household bills including electric and heating expenses.

Why it Matters

The Commonwealth Fund’s new survey shows the continued disparities in affordability and access between the insured and uninsured and adds to the growing body of evidence that even insured patients are not immune to the consequences of rising provider prices. Respondents with private insurance reported affordability challenges, delayed and foregone care, worsening health outcomes, and struggles with medical debt. The study authors propose a number of promising policy reforms to improve affordability, such as regulating aggressive medical debt collection and using public option plans to help slow cost increases in the commercial market. Although reforms like the ACA, No Surprises Act, and Inflation Reduction Act have made great strides in protecting consumers from the high cost of health care, broader cost containment measures are needed to combat the growing health care affordability crisis.

Joseph Semprini, Abdinasir K. Ali, and Gabriel A. Benavidez, Medicaid Expansion Lowered Uninsurance Rates Among Nonelderly Adults in the Most Heavily Redlined Areas, Health Affairs, October 2023. Researchers analyzed uninsurance rates before and after the ACA’s Medicaid expansion by race and exposure to historical “redlining,” a now-outlawed form of structural racism where neighborhoods were appraised based on their racial composition; neighborhoods consisting of upper-class White residents were deemed “desirable,” and neighborhoods primarily consisting of racial and ethnic minorities were seen as “hazardous,” contributing to wealth and home ownership disparities that persist today. Using American Community Survey (ACS) data coupled with corresponding redlining data derived from the Mapping Inequality project, researchers grouped census tracts into four categories, ranging from the least exposure to redlining (category 1) to the most exposure to redlining (category 4), and compared uninsurance rates before (2009–2013) and after (2015–2019) Medicaid expansion in those census tracts. 

What it Finds

• Before Medicaid expansion, uninsurance rates across all racial and ethnic groups were highest in the census tracts with the most redlining activity (30 percent in expansion states and 26.1 percent in non-expansion states), and lowest in those with the least exposure to redlining (11 percent in expansion states and 12.7 percent in non-expansion states).
• After Medicaid expansion, aggregate uninsurance rates in expansion states decreased the most significantly in redline category 4 areas—a decrease of 6.2 percentage points relative to non-expansion states.
• Within each redline category, Medicaid expansion’s impact on uninsurance rates did not significantly differ by race and ethnicity. However, researchers did find significant differences across redline categories, both at the aggregate level and for the non-Hispanic Black population. 
• For adults with incomes below 100 percent FPL, Medicaid expansion had the largest impact on lowering uninsurance rates in redline category 3 and 4 areas. 
• Researchers found no statistically significant impact of expansion on average uninsurance rates areas in the aggregated census tracts with redline categories 1–3.

Why it Matters  

This study demonstrates how structural racism—even policies that are no longer in effect—influences access to health coverage. The impacts of redlining are still being felt decades after the Fair Housing Act outlawed the practice; before Medicaid expansion, uninsurance rates were highest in census tracts suffering the greatest amount of redlining. Medicaid expansion reduced uninsurance rates in communities where redlining occurred, demonstrating the importance of proactive policy interventions to narrow the disparities stemming from systemic segregation. By choosing not to expand Medicaid, ten states have left low-income residents living in historically redlined areas without sufficient access to coverage. Future policymaking should confront the continuing impact of structural racism on health and coverage disparities, and stakeholders working towards health equity, whether through Medicaid expansion or other policy interventions, can benefit from the contextual framework employed by this study.