Association for Public Policy Analysis & Management

Objectives: This study has three objectives. First, we present an approach for identifying likely Marketplace enrollees in the Urban Institute’s Health Reform Monitoring Survey (HRMS). Second, we highlight differences between Marketplace enrollees, other insured adults, and uninsured adults across various characteristics. We also examine how Marketplace enrollees choose their health plans and compare plan satisfaction levels across insurance types. Third, we examine the association between self-reported health insurance literacy and take-up of Marketplace coverage.

Design: We use March 2015, September 2015, and March 2016 data from the HRMS, a nationally representative, Internet-based survey of nonelderly adults. The sample includes approximately 7,500 US adults ages 18 to 64 in each quarter.

Respondents answer Likert scale questions about their level of confidence in understanding 7 basic insurance terms and performing 8 activities associated with using their health plans. To better understand how health insurance literacy could influence Marketplace enrollment, we compare literacy of adults in the Marketplace target population—i.e., those enrolled in or potentially eligible for Marketplace coverage—with that of adults with employer-sponsored insurance (ESI) and other adults. 

Findings: Key findings from 2015 show that:

• Adults likely to have enrolled in the Marketplace were predominantly non-Hispanic whites.

• 48.6 percent of uninsured adults, but only 37.5 percent of Marketplace enrollees, were ages 18–34.

• Marketplace enrollees were more aware of the availability of Marketplace subsidies than adults who remained uninsured. One-third of uninsured adults with family incomes below 400 percent of poverty reported that they had heard “nothing at all” about the availability of subsidies, compared to 13.8 percent of Marketplace enrollees in the same income group.

• Marketplace enrollees were significantly less likely to use only a website to search for a plan, compared to people who looked for information but remained uninsured (33 percent versus 57 percent).

• Relative to adults with ESI, the Marketplace target population is less confident in understanding each insurance term. 

• Marketplace enrollees are less likely to be satisfied with various aspects of their health plan than adults with ESI or public coverage.

Findings will be updated with March 2016 data prior to presentation.

Conclusions and Policy Implications: The extent to which the ACA will lead to further Marketplace enrollment depends on how successful targeted outreach efforts are at reaching people who remain uninsured. Many of these people are ineligible for Marketplace coverage because of their immigration status. Nonetheless, our results suggest that further outreach and public education may need to be geared toward young adults and those with moderate incomes who can potentially benefit from subsidized Marketplace coverage

Many adults in the Marketplace target population report a limited understanding of insurance and satisfaction with their plans. Uninsured adults with low health insurance literacy may be discouraged from purchasing coverage in the Marketplace, and those who do enroll may have difficulty comparing plans, posing challenges to enrollment and retention. Study findings have implications for efforts to standardize Marketplace plan options, develop educational tools, and engage navigators in explaining differences in plan design.