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Pulling It Together: Uninsured But Not Yet Informed

If there is one thing there is general agreement on when it comes to the Affordable Care Act (ACA) it’s that it will help the uninsured.  The estimates are that 32 million people will gain coverage under the law through an expansion of Medicaid and tax credits, which will help low- and moderate-income people purchase coverage through the new insurance exchanges.

Therefore, it was a real surprise in our latest tracking poll to learn that most of the uninsured don’t know how much the law will benefit them.  About half of the uninsured (47%) don’t think they will be affected much at all by the ACA, either positively or negatively.  Fourteen percent think it will affect them negatively (their main reason is that they are worried about being forced to buy insurance they cannot afford).  We know from survey after survey that the uninsured want insurance coverage.  And we know that the main reason they don’t have it is that they cannot afford it.  Experts who have advocated for expanded coverage for decades probably envision the uninsured sitting around the kitchen table anxiously awaiting the implementation of coverage expansions under the ACA.  But surprisingly, only three in ten of the uninsured say the ACA will help them get health care.  As I have discussed in a previous column, it is possible that some of the uninsured will be faced with choices in the exchanges they don’t like (for example, plans with very high deductibles), and a small number may resent being required to buy health insurance, but the vast majority of the eligible uninsured will benefit from the coverage expansions under the law.

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What’s going on here?  For starters, most people who are uninsured are very busy supporting their families and getting through the day, and they simply do not know much about the ACA, at least not yet.  Nearly half (48% of the uninsured) do not know about the tax credits low- and moderate-income people will get under the ACA (including 41% who not only did not know, but incorrectly said, that the law does not provide tax credits).  And 53 percent did not know about the Medicaid expansion, which covers low-income adults regardless of whether they have children (including 37% who said that the law does not expand Medicaid).

Some may see this as a communications failure.  Certainly it is always possible to get the word out more effectively, but I don’t think that is the issue here.  People who are busy in their everyday lives (and who are being bombarded by a highly spun, confusing political debate about the ACA), will only understand what a complex law like this does when it is tangible for them – when they either get the benefits themselves, see family members and friends benefiting, or see news reports about how the law is working after it is implemented.  When there is real insurance coverage available for people who don’t have it, they will be more aware of it, and they will be able to render a judgment about whether coverage is affordable for them.  These benefits will technically be available in 2014, but outreach and enrollment takes time.  It will be 2015 or 2016 before there is a real test of awareness and affordability.

Experts see the entire law and form a judgment either for it or against it, or come out in the middle.  People will more likely see only pieces.  They may see a Medicaid expansion that touches them (and is likely to carry the name of their state’s Medicaid program), or they may be touched by an insurance reform that they may not even know came from the ACA.  The ACA is not at all like Medicare, which is a single program, with a name, serving a defined population with similar benefits who know they are in it and can form a public judgment about it as a whole.  To predict how the public is likely to react to a real law, we have only one bit of empirical evidence to go on so far.  In my home state of Massachusetts, where they put a similar program in place, our polls and others show that once the people of the Commonwealth experienced the program, they liked it.