Forty Percent of Uninsured People Still Don’t Know the Health Insurance Marketplace Exists. Cuts to Outreach Will Make Sure It Stays That Way.

Last week the Department of Health and Human Services (HHS) announced a 72% cut to funding to support enrolling eligible individuals into coverage under the ACA. This includes a 90% cut to the advertising budget for the 2018 marketplace enrollment period—from $100 million to $10 million—and a 41% cut to funding for navigators, the in-person assistors who, in addition to actually helping people sign up for insurance through the marketplace, also help them explore and understand their coverage options and any financial assistance for which they might be eligible.

These are not the first actions by the Trump administration to sabotage enrollment through healthcare.gov, the federal marketplace. As soon as Trump was inaugurated, his administration began to quietly undermine the ACA, by immediately stopping all advertising and outreach related to the health insurance marketplace in the final days of the 2017 enrollment period. As far back as April, the administration began chipping away at the upcoming 2018 enrollment period, when the Center for Medicare and Medicaid Services (CMS) issued a rule shortening the marketplace enrollment period from three months to 45 days. Enrollment for 2018 will start on November 1 and end on December 15, instead of running through January 31 as it has in the past. Then in July, in a prelude to the slashing of the navigator budget, CMS said it would not renew enrollment assistance contracts in 18 cities—contracts that enabled community groups to help people enroll in coverage at libraries, local businesses, and other easily accessible locations.

A lot of uninsured people still don’t know about the marketplace and what it offers.

The majority of individuals across the country who shop for health insurance through a marketplace will do so through healthcare.gov. Only 11 states plus Washington, DC, operate their own fully independent marketplaces. The remaining 39 states rely on the federal marketplace (this includes five that operate state marketplaces that are hosted on the federal platform). (Source: Health Affairs) That means most people looking to buy insurance through a marketplace this year will have less information, less help, and less time to enroll than they would have in previous years.

Nearly all uninsured adults (94%) have incomes that could make them eligible for either Medicaid or subsidies. It’s reasonable to conclude, then, that if more of the uninsured had access to information about the marketplace, more of them would enroll in coverage.

HHS officials explained the funding cuts by saying that people already know how the sign-up process works. That’s simply not accurate when it comes to the 24 million people who are still uninsured, and HHS officials admit they haven’t done a study on public awareness of the marketplace. According to a report by the Commonwealth Fund, the proportion of uninsured people who are aware of the marketplace has hovered around 60% since 2014. That means 40% of uninsured people don’t even know there is a marketplace, let alone how to use it to sign up for insurance. Even those who know about the marketplace aren’t always fully aware of what it offers—about half of uninsured people don’t know that they might be able to get financial assistance through the marketplace to buy insurance if they don’t qualify for Medicaid.

Latinos have been among the hardest to reach so far. Despite gains in coverage, they represent a greater proportion of the uninsured today than they did in 2013.

The dramatic cuts to outreach and enrollment will have a serious negative impact on Latinos, whose awareness of the marketplace is significantly lower than for other groups. In 2016, 55% of uninsured Latinos were unaware of the marketplace. This contributes to their growing prevalence among the uninsured. Latinos have gone from being 29% of the uninsured in 2013 to 40% in 2016 (meanwhile, they make up only about 20% of the adult population). This is despite the fact that, since the rollout of the ACA, there has been a narrowing in the disparities between Latinos and whites in access to healthcare, as well as a significant overall increase in the percentage of Latinos who have health insurance.

Outreach is absolutely necessary right now to make sure all eligible individuals can enroll.

Nearly all uninsured adults (94%) have incomes that could make them eligible for either Medicaid or subsidies. It’s reasonable to conclude, then, that if more of the uninsured had access to information about the marketplace, more of them would enroll in coverage. But without a meaningful investment in outreach, enrollment numbers will drop. Timothy Jost, a consumer advocate at the National Association of Insurance Commissioners, told Vox, “The surest way to kill the exchanges is to keep them a secret.” In fact, enrollment for 2017 dropped off suddenly in the latter part of January, right around the same time that the Trump administration cut advertising by $5 million.

Rather than cutting the outreach budget, we should be encouraging navigator programs to pursue new and innovative ways to reach the remaining uninsured. . . The fact that these Americans are still without coverage tells us that we need to do more, not less.

The degree of uncertainty that has surrounded the ACA makes it even more important to spread the message that the marketplace is open for business and to explain clearly what plans and subsidies are available. That’s why California, which operates its own state exchange, plans to spend over $111 million on advertising for its own 2018 enrollment period, which runs the complete 90 days from November 1, 2017 to January 31, 2018. In the past, California has used radio, television and internet advertising, as well as email reminders, to publicize its marketplace.

In contrast, with only $10 million to spend, HHS will focus its advertising dollars on “digital media, email and text messages,” methods that were chosen because they “have proven the most effective in reaching existing and new enrollees.” But clearly what has been successful in reaching other groups in the past has not been successful in reaching the people who are still uninsured. Further, referencing what has worked to reach existing enrollees is completely meaningless when it comes to communicating successfully with the uninsured.

While CMS indicated that outreach will be “targeted based on specific demographic and geographic data,” they offered no further details, so it’s unclear whether this will include tailoring the message to address those issues that might be preventing people from signing up. Many of those who are still uninsured are low-income and have less past experience with health insurance. Some might not be fluent in English. And some people who are themselves in the United States legally might be fearful of accessing a government system because they have family members who are undocumented. Messaging for this group has to take these and other factors into account if it’s going to be successful. Rather than cutting the outreach budget, we should be encouraging navigator programs to pursue new and innovative ways to reach the remaining uninsured. We should be creating advertising that addresses people’s concerns and questions about the ACA, speaks to them in their language, and reaches them in the forums and venues they trust most. The fact that these Americans are still without coverage tells us that we need to do more, not less.

What we need now is a grassroots effort to (1) pressure Congress to restore funding for outreach and enrollment assistance, and (2) get as much information as possible out to as many people who need it.

Two great resources for learning what you can do to help are Families USA, who will be hosting an outreach and enrollment webinar on September 14, at 2:00 pm EST (go here for info), and the Indivisible ACA Signup Project.

Plus, start a conversation right here!

Do you buy your insurance through the federal exchange? Are you a navigator? What is needed in your state to get the word out? What can those of us who live in states that operate their own exchanges do to help you?

Tell us in the comments below, or on Facebook or Twitter.

See you again soon on the #stairwaytohealthcare. Keep climbing!

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