Association for Public Policy Analysis & Management

The Affordable Care Act created health insurance Marketplaces where individuals with moderate incomes could purchase subsidized private insurance coverage. Enrollment in the Marketplaces fell short of expectations in 2014, but administrative data and rapid turnaround surveys have shown more robust growth in 2015 and 2016. In this study, we use data from the 2014 and 2015 National Health Interview Survey (NHIS) to examine the characteristics of Marketplace enrollees and consider how the Marketplace population and enrollees’ affordability of care has changed since 2014.

We used the Marketplace recode provided on the NHIS to identify Marketplace enrollees in 2014 and 2015, and examined changes in insurance coverage for nonelderly adults (19-64) since 2013. We described the demographic, socioeconomic and health status characteristics of Marketplace enrollees in each year and explored changes over time in enrollee characteristics and health care affordability. Finally, we compared 2015 Marketplace enrollees in states that expanded Medicaid under the ACA to those in nonexpansion states.

Preliminary findings using NHIS early release data through September 2015 show that the share of nonelderly adults with Marketplace coverage grew from 2.7% in 2014 to 4.8% in 2015. Despite this growth, there were few changes in the demographic, socioeconomic or health status characteristics of Marketplace enrollees between 2014 and 2015. In 2015, however, 75% of Marketplace enrollees had been insured for all of the past 12 months compared to only 54% in 2014. Moreover, 11% of Marketplace enrollees in 2015 reported foregoing medical care due to cost in the past year, down from 15% in 2014, which likely reflects the increased continuity of coverage in 2015. 

Consistent with underlying differences in state populations as well as subsidy eligibility in nonexpansion but not in expansion states for those with incomes from 100-138% of poverty, Marketplace enrollees in nonexpansion states in 2015 were more likely to be black and Hispanic and to have incomes below 138% of poverty than those in expansion states. Marketplace enrollees in nonexpansion states were also more likely to have been uninsured and to live in families that had trouble paying their medical bills in the past year than those in expansion states.

Before fall 2016, we will extend this analysis using the full-year 2015 NHIS. This will allow us to examine more characteristics of Marketplace enrollees, including citizenship and health care service use. We also plan to examine regression-adjusted differences in access and affordability measures over time and between expansion and nonexpansion states.

Marketplace coverage nearly doubled in 2015, with more enrollees covered all year and fewer reporting unmet needs due to cost in the past year. In nonexpansion states, however, where Marketplace enrollees were more likely to be low-income and non-white than in Medicaid expansion states, Marketplace enrollees were more likely to have been uninsured and to have had trouble paying family medical bills in the past year. Thus, while Marketplace coverage is helping to fill the coverage gap in nonexpansion states, continuity of coverage and affordability of care may pose issues for these lower income enrollees.