Survey finds state policies have critical impact on ACA applications, enrollment

A new survey by researchers at Harvard T.H. Chan School of Public Health finds that the variable approaches states have taken to implementing the Affordable Care Act (ACA) have had major effects on whether low-income adults are aware of the law, whether they have applied and obtained coverage, and whether or not they think the law has helped them.

The study, one of the most in-depth analyses of the recent enrollment experiences of adults under the health reform law, focused on three states with markedly different ACA policies: Arkansas, Kentucky, and Texas. They found that insurance application rates, successful enrollment, and positive experiences with the ACA were highest in Kentucky, followed by Arkansas, with Texas performing worst. Latinos were equally likely to apply for coverage as other groups, but much less likely to complete the process and obtain coverage. Surprisingly, more than half of low-income adults in the study said they had heard little or nothing about the law's new coverage options.

The study appears in the June 2015 issue of the journal Health Affairs.

"Although millions of Americans have gained health insurance under the ACA, our findings suggest that there is still a huge need to increase awareness, especially among low-income populations," said lead author Benjamin Sommers, assistant professor of health policy and economics at Harvard Chan School

In 2014, the ACA expanded Medicaid eligibility to 138% of the federal poverty level in participating states. However, a U.S. Supreme Court ruling in 2012 made this expansion optional. More than half of states have expanded, some have decided not to expand, and others are still debating the issue. Kentucky expanded Medicaid and supported outreach efforts; Arkansas expanded coverage to low-income adults using private insurance instead of Medicaid, and placed legislative limitations on outreach; Texas did not expand Medicaid, and passed restrictions making it hard for organizations and individuals to assist people applying for coverage.

Sommers and colleagues surveyed nearly 3,000 low-income adults in November and December 2014. They found that application rates for coverage were higher in Kentucky (44.1%) and Arkansas (42.8%) than Texas (32.8%). Among those who applied, receiving assistance with the application process from a navigator or social worker was most common in Kentucky (46.2%) and least common in Texas (31.9%), and obtaining this assistance was one of the biggest contributing factors related to improved enrollment rates. Adults in Kentucky and Arkansas were much more likely than adults in Texas to report that the ACA had helped them personally, though in all three states, the majority said the law had neither helped nor hurt them.

Across all three states, Latinos enrolled at much lower rates than non-Latino whites (75.2% versus 90.7%). The researchers hypothesize that this might partly be attributed to cultural barriers or concerns about immigration-related issues, even though everyone in the sample was a U.S. citizen.

"The decisions made by state policymakers have a major impact on people's experiences and perceptions of the ACA—not just whether the state expands Medicaid, but also whether people can get help applying for coverage, and whether the state is helping to inform the public about the law," said Sommers. "In Texas and other states that are not expanding Medicaid and that are making it hard for people to get assistance applying for coverage, we will likely see a widening gap in insurance rates compared to those state supporting the ACA's coverage expansion efforts."