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Introduction

This survey reports on the views and experiences of people purchasing health insurance coverage in the non-group market. Over the past few years, the Affordable Care Act (ACA) has had a significant impact on this group, as new rules took effect that standardized coverage, guaranteed coverage for those with pre-existing conditions, and established income-based federal financial assistance to those buying insurance through new health insurance Exchanges or Marketplaces. Starting on January 1st, 2014, all coverage newly purchased either through a Marketplace or directly from an insurance company had to follow new rules under the ACA (i.e. “ACA-compliant”).

The survey, conducted February 18 – April 5, 2015, after the close of the second open enrollment period, includes individuals who purchased ACA-compliant coverage inside or outside of a Marketplace, as well as those who are currently enrolled in “non-ACA compliant” plans. Non-ACA compliant plans are those purchased before the law was enacted in March 2010 and were grandfathered in under the ACA, as well as those purchased before October 2013 and allowed to continue under a federal transition policy at the discretion of states.1  This survey is the second in a series that seeks to shed light on the experiences and opinions of those purchasing their own health insurance. In addition to stand-alone findings, this report draws trends and comparisons using data from the first survey in the series, conducted at the end of the first open enrollment period, April 3-May 11, 2014.

Related: This Data Note looks at predictors of positive and negative attitudes toward the ACA among non-group enrollees.

Key Findings

Section 1: Basic Demographics Of The Non-Group Market

Looking at the non-group market as a whole, about six in ten enrollees (59 percent) report being in Marketplace plans (including plans purchased directly from a Marketplace and Marketplace plans purchased from an insurance company or an insurance agent2), an increase from 48 percent last year following the first open enrollment period.  In addition, many insurance companies continue to sell non-group insurance policies outside the Marketplaces. Seven percent of all non-group enrollees report having these ACA-compliant, non-Marketplace plans. Another 17 percent purchased ACA-compliant plans from either an insurance company or a broker but say they are unsure whether their plan is a Marketplace plan or not. Sixteen percent of enrollees remain in pre-2014, non-ACA-compliant plans, down from 31 percent in 2014.

Figure 1

Figure 1

An important change made by the ACA prohibited insurers from denying coverage or charging higher premiums to people with non-group coverage because of their health. One concern raised about this change was whether the number of healthy people enrolling because of the new premium tax credits and the law’s individual mandate would be sufficient to offset the higher claims from less healthy people enrolling because insurers could no longer exclude them. At the end of the second open enrollment period, the self-reported health status of people in ACA-compliant plans (which insurers rate as a single risk pool) looks much like it did in 2014, with the vast majority (85 percent) saying their health is excellent, very good, or good. However, as in 2014, those with ACA-compliant plans are somewhat more likely than those with non-ACA compliant plans to report their health as “only fair” or “poor” (15 percent versus 6 percent).

Figure 2: Self-Reported Health Status Of Enrollees In ACA-Compliant And Non-ACA Compliant Plans
    ACA-compliant plans Non-ACA compliant plans
In general, would you say your health is excellent, very good, good, fair, or poor? 2014 2015 2014 2015
Excellent    22% 24% 28% 33%
Very good    29 33 37 34
Good         31 28 28 27
Fair         13 11 6 5
Poor         4 4 <1 1

Most people in the non-group market do not have access to employer coverage. Over half are either not employed (29 percent) or self-employed (28 percent), and another 16 percent are employed part-time and likely do not have an offer of coverage.3 Of the one in four (26 percent) who work full-time for someone else, about four in ten, or just 10 percent of all non-group enrollees, say their employer or union offers a health plan to at least some of its employees. Among those whose employers offer a health plan, the largest share says that the main reason they don’t participate in their employer’s plan is because it is less expensive to buy their own coverage than to pay their portion of the cost for the plan at work.

Figure 3

Figure 3

Section 2: Shopping, renewing, and switching coverage

This year’s open enrollment period saw a number of new buyers in the market — more than a third (36 percent) of those with ACA-compliant plans did not have non-group coverage in 2014. The largest share of this group was uninsured immediately prior to purchasing their current plan (72 percent of those new to the non-group market, or 26 percent of all those with ACA-compliant coverage). Among those who had non-group coverage in 2014, most chose to renew their existing plan rather than make a switch. About half (48 percent) of those currently in ACA-compliant plans say they renewed a health plan they had in 2014; only 15 percent say they switched between non-group plans.

Figure 4: Previous Insurance Status Of Enrollees In ACA-Compliant Plans
Did not have non-group coverage in 2014 36%
       Previously uninsured4      26
       Previously covered by an employer/COBRA      7
       Previously Medicaid or other public coverage      2
       Previously through a family member/other source      1
Renewed ACA-compliant 2014 plan 48
Switched non-group plans 2014 to 2015 15
Undetermined 1

Although relatively few switched plans, many of those who did cite cost-related reasons for making a change, including finding a lower monthly premium than what they would have paid to renew their previous plan (6 percent of all those with ACA-compliant plans), and wanting a plan with a lower annual deductible (3 percent of total). Seven percent of those with ACA-compliant coverage say they switched plans because their previous plan was cancelled. Only one percent say they switched because they were unhappy with their plan’s choice of providers, they wanted to be eligible for government financial help, or their family’s health needs changed.

A large majority of those who renewed an ACA-compliant plan this year say it was very or somewhat easy to renew, including three-quarters of those with Marketplace plans (77 percent). About half (52 percent) say they were automatically re-enrolled, while 46 percent say they took action to renew their plan.

Figure 5: Reported Ease Of Renewal Among Those Who Renewed ACA-Compliant Plans
Total ACA-compliant Marketplace
How easy or difficult was it for you to renew your health plan? Very easy 56% 52%
Somewhat easy 23 25
Somewhat difficult 12 14
Very difficult 6 6

About seven in ten (69 percent) of those who renewed an ACA-compliant plan say they did not shop around before renewing. The most common reason for not shopping was that they were satisfied with their current plan (35 percent). About one in ten each say they were too busy or didn’t have time to shop (10 percent), they didn’t want to deal with the hassle of shopping (9 percent), or they didn’t think they could find a more affordable option (8 percent).

Figure 6

Figure 6

Most (59 percent) of those who did shop for a plan this year (including those who purchased a new plan and those who shopped around but decided to renew a previous plan) say they had about the right number of plans to choose from. This is true of those who bought their coverage both inside and outside the ACA Marketplaces. Still, nearly three in ten (28 percent) feel they had too few plans to choose from, while one in ten say they had too many.

Figure 7

Figure 7

Among those who enrolled in a new plan this year (both those purchased within and outside of the Marketplace) most say that when they signed up for their current plan, it was easy to compare premiums and cost-sharing and to figure out if their income qualifies them for coverage. However, nearly four in ten say it was difficult to set up an account with the marketplace (38 percent) and to compare the providers covered under each plan (37 percent). Reported experiences in the second open enrollment period are very similar to last year, despite the problematic launch of healthcare.gov and state-based Marketplace websites that was widely covered by the media during the first open enrollment.

Figure 8

Figure 8

Last year, with the launch of the new Marketplaces and the accompanying technical issues, personal help with the enrollment process was an important factor in getting people signed up for coverage. Personal help was also important this year, particularly for those new to the market or switching plans. Overall, about six in ten of those either new to the non-group market (60 percent) or those who switched plans this year (57 percent) report getting help with enrollment, while most of those who renewed an ACA-compliant 2014 plan say they completed the process on their own (63 percent).

Figure 9: Reported Help With Enrollment/Renewal Among Those With ACA-Compliant Plans
Did someone help you (enroll in health insurance/renew your health plan for 2015) or did you complete the (enrollment/renewal) process on your own? Switched non-group plans 2014 to 2015 New to non-group market Renewed ACA-compliant plan
Someone helped you (enroll/renew) 57% 60% 28%
Completed the (enrollment/renewal) process on your own 43 39 63
Auto-renewed (Vol.) N/A N/A 8

In weighing their plan options, those purchasing ACA-compliant plans report considering a number of factors, with costs rising to the top. Nearly four in ten (38 percent) cite the monthly premium costs as an extremely important factor in their plan choice, followed by the deductibles and copays (32 percent). Roughly a quarter say that the plan’s choice of doctors and hospitals was an extremely important factor (25 percent) along with the range of benefits covered (23 percent). Fewer say that recommendations from friends and family were a top factor (6 percent).

Figure 10

Figure 10

Section 3: Plan ratings and satisfaction

A large majority of those in ACA-compliant plans, including three quarters (74 percent) of those with Marketplace coverage, rate their overall health insurance coverage as excellent or good. More than half also say their plan is an excellent or good value for what they pay for it, while about four in ten say the value is only fair or poor. Among those with Marketplace coverage, plan ratings are similar to 2014, though the share saying their plan is an “excellent” value decreased somewhat from 23 percent to 15 percent. Although not a large decrease, further changes in how Marketplace enrollees are assessing their plans’ value should be watched closely in the coming years.

Figure 11

Figure 11

Enrollees in ACA-compliant plans (including those purchased from a Marketplace) give similar ratings to their overall coverage and value for the money compared to those in pre-ACA, non-compliant plans. As was true in 2014, those with non-group coverage give their plans lower ratings overall compared to those with employer-sponsored insurance interviewed as part of a separate survey.

Figure 12: Ratings of Coverage Among Those With ACA-Compliant, Non-ACA Compliant, and Employer Plans
    Total ACA-compliant plans Marketplace plans Non-ACA compliant plans Employer-sponsored coverage5
How would you rate your overall health insurance coverage? Excellent 18% 18% 21% 37%
Good 56 56 62 54
Not so good 13 14 12 7
Poor 7 7 4 1
Would you say your health insurance is an excellent value, good value, only a fair value or a poor value for what you pay for it? Excellent value 13 15 10 N/A
Good value 42 44 39 N/A
Only a fair value 26 24 20 N/A
Poor value 16 14 30 N/A

Similar to findings from the 2014 survey, most people with ACA-compliant plans say they are satisfied with various elements of their plans, including their choice of providers, copays, premiums, and deductibles. Among those with Marketplace coverage, at least seven in ten say they are “very” or “somewhat” satisfied with their plan’s choice of primary care providers (75 percent) and hospitals (75 percent), as well as their copays for doctor’s visits (73 percent) and prescriptions (70 percent). About two-thirds (64 percent) say they are satisfied with their choice of specialists, while 16 percent are dissatisfied and about one in five (19 percent) say they don’t know, likely because they have not tried to use a specialist under their plan. While majorities of Marketplace enrollees say they are satisfied with their premiums and deductibles, substantial shares express dissatisfaction, including 32 percent who say they are dissatisfied with their premium and 36 percent who are dissatisfied with their deductible.

Figure 13

Figure 13

Compared to those with older, non-ACA compliant non-group coverage, enrollees in ACA-compliant plans (including those purchased through a Marketplace) are somewhat less likely to say they are satisfied with their plan’s choice of primary care doctors and hospitals, but somewhat more likely to express satisfaction with their monthly premiums and annual deductibles. This is likely because many of them are receiving premium tax credits and cost-sharing subsidies that are not available to those in non-ACA compliant plans. As was true with the 2014 survey findings, satisfaction rates are generally lower among non-group plan enrollees compared to those with employer-sponsored insurance interviewed as part of a separate survey.

Figure 14: Plan Satisfaction Among Those With ACA-Compliant, Non-ACA Compliant, And Employer Plans
Percent who say they are satisfied/dissatisfied with each of the following:  Total ACA-compliant plans Marketplace plans Non-ACA compliant plans Employer-sponsored coverage6
Choice of primary care doctors Very or somewhat satisfied 77% 75% 91% 92%
Very or somewhat dissatisfied 18 20 8 6
Don’t know/Refused 5 5 <1 1
Choice of hospitals Very or somewhat satisfied 75 75 88 92
Very or somewhat dissatisfied 15 14 9 6
Don’t know/Refused 10 11 4 2
Choice of specialists Very or somewhat satisfied 64 64 64 86
Very or somewhat dissatisfied 16 16 11 7
Don’t know/Refused 19 19 25 7
Doctor visit copay Very or somewhat satisfied 72 73 77 81
Very or somewhat dissatisfied 23 21 22 18
Don’t know/Refused 5 6 2 1
Prescription copay Very or somewhat satisfied 68 70 65 81
Very or somewhat dissatisfied 23 21 31 17
Don’t know/Refused 9 8 3 2
Monthly premium Very or somewhat satisfied 61 65 45 73
Very or somewhat dissatisfied 35 32 53 26
Don’t know/Refused 4 4 5 1
Annual deductible Very or somewhat satisfied 59 60 49 72
Very or somewhat dissatisfied 37 36 49 25
Don’t know/Refused 3 3 2 3

Section 4: Financial protection

Despite relatively high plan ratings and satisfaction levels, many non-group enrollees report feeling vulnerable to high medical bills and say they have encountered problems with health care costs. Over half (57 percent) of those with ACA-compliant plans say they feel well-protected by their plan, but nearly four in ten (38 percent) feel vulnerable to high medical bills (similar to 2014). Those with new plans purchased under the ACA are not the only ones feeling financially precarious; a similar share (34 percent) of those with pre-2014, non-ACA compliant plans says they feel vulnerable to high medical bills. Among those with employer-sponsored coverage interviewed as part of a separate survey, a somewhat smaller share, but still nearly three in ten (28 percent), reports feeling financially vulnerable.

Figure 15

Figure 15

Many also worry about future health care costs. Nearly six in ten (56 percent) of those with ACA-compliant plans say they are at least somewhat worried they won’t be able to afford the health care services they need. But again, worry is not confined to those with newer non-group plans; a similar share (57 percent) of those with older, non-ACA-compliant plans report the same worry. And equal shares of those with ACA-compliant and non-compliant plans (46 percent of each group) say it is difficult for them to afford to pay the cost of their health insurance each month.

Figure 16: Financial Worries Among Those In ACA-Compliant And Non-ACA Compliant Plans
ACA-compliant plans Non-ACA compliant plans
How worried are you, if at all, that you won’t be able to afford the health care services you need? Very worried 20% 15%
Somewhat worried 36 42
Not too worried 29 26
Not at all worried 15 16
How easy or difficult is it for you to afford to pay the cost of your health insurance each month? Very easy 21 21
Somewhat easy 31 32
Somewhat difficult 31 35
Very difficult 15 11

As other surveys have found, having health insurance is not a panacea against problems with medical bills, even for those who are continuously insured. Among enrollees in ACA-compliant plans who’ve had their plan for at least a year, 16 percent say that they’ve had problems paying medical bills in the past 12 months. Some also say they or a family member covered by their plan didn’t fill a prescription (18 percent) or didn’t get needed health care (11 percent) because of cost concerns in the past 12 months7. Enrollees in non-ACA compliant plans, who by definition have had their plan for an even longer period of time, are less likely than those with compliant plans to report problems paying medical bills or delaying care due to cost.

Figure 17

Figure 17

Section 5: Opinions and Experiences of Those In High-Deductible Plans

One group that may be particularly vulnerable to high out-of-pocket health care costs are those with high deductible health plans. In the non-group market as a whole (including those in ACA-compliant and non-ACA compliant plans), four in ten enrollees (40 percent) have a plan with a high deductible (defined for purposes of this analysis as $1,500 or more for an individual or $3,000 or more for a family-level deductible). Another four in ten (43 percent) have plans with lower deductibles, while 17 percent are unsure of their deductible amount.

Comparing those with high-deductible versus lower deductible health plans, those with high deductibles are more likely to be in non-ACA compliant plans (22 percent versus 12 percent), and have higher incomes on average. Consequently, they are less likely to report getting government financial assistance to pay their premium (36 percent versus 56 percent).

Figure 18: Income And Tax Credit Status Of Those In High- Versus Lower-Deductible Non-Group Plans
  High-deductible plans Lower-deductible plans
Self-reported income as a percentage of Federal Poverty Level (FPL) <138% FPL 14% 40%
138-250% FPL 23 24
250-400% FPL 23 14
400%+ FPL 32 14
Undetermined 7 7
Premium tax credit status Likely receiving tax credit8 36 56
Not likely receiving tax credit 61 43
Undetermined 3 1

Those in high deductible plans generally report being less happy with their plans than those with lower deductibles. They are more than twice as likely to rate their health plan as “not so good” or “poor” (29 percent versus 12 percent) and to say the value for what they pay is “only fair” or “poor” (60 percent versus 31 percent).

Figure 19

Figure 19

Those with higher deductibles are also less likely than those with lower deductibles to report being satisfied with their deductible and other cost-sharing arrangements of their plan, including their office visit and prescription copays.

Figure 20

Figure 20

In addition, those with higher deductibles are significantly more likely than those with lower deductibles to say they feel vulnerable to high medical bills (55 percent versus 22 percent). These differences between those with high and lower deductibles hold true regardless of income level or whether or not they are receiving federal financial assistance.

However, there is no significant difference between these two groups in reports of cost-related problems, including problems paying medical bills or skipping needed medical care or prescriptions in the past twelve months because of the cost. This may be due to the fact that while higher deductibles leave this group potentially more vulnerable to out-of-pocket costs, their relatively higher incomes make it somewhat easier for them to absorb these costs.

Many non-group enrollees in both high-deductible and lower-deductible plans say they lack the financial resources to cover a large unexpected medical bill without going into debt. When asked hypothetically about an unexpected medical bill for which the portion not covered by insurance is $500, four in ten non-group enrollees overall (44 percent) say they would be able to pay it off without going into debt, but a third (34 percent) say they would have to go into credit card debt or borrow money to pay it and 13 percent say they would not be able to pay the bill at all. For a hypothetical medical bill on which they owe $1,500, just about a quarter could pay it off without going into debt, while four in ten would have to borrow money and nearly a quarter wouldn’t be able to pay the bill at all. In general, those in high-deductible plans are somewhat more likely than those in lower-deductible plans to say they could weather these expenses without going into debt, perhaps because of their relatively higher incomes. Still, among those in high-deductible plans, 43 percent say they would have to borrow money or go into credit card debt to cover a $1500 medical bill, and 15 percent say they wouldn’t be able to pay such a bill at all.

Figure 21: Responses To A Hypothetical Medical Bill Of $500/$1500 Among Those In Non-Group Plans

Suppose you had an unexpected medical bill and the amount not covered by your insurance was $500/$1500. Based on your current financial situation, would you…
Total non-group High-deductible health plans Lower-deductible health plans
$500 $1500 $500 $1500 $500 $1500
Would pay bill without borrowing (NET) 44% 26% 55% 31% 36% 24%
      Pay right away by cash or check     30       16     38    19     25    17
      Put on credit card and pay off at next statement     14       10     17    12     11    7
Would pay bill by borrowing (NET) 34 41 28 43 37 38
      Put on a credit card and pay off over time     26       32     21    35     30    30
      Borrow from bank, payday lender, friends, or family      8        9       7     8      7     8
Would arrange payment plan with provider (Vol.) 6 6 7 9 4 3
Would not able to pay at all 13 23 8 15 19 32

Section 6: Non-Group Enrollees’ Opinions of the ACA

Overall, about half of non-group health insurance enrollees (51 percent) report having a favorable view of the Affordable Care Act, while just over four in ten (43 percent) say they have an unfavorable view. Favorability hasn’t changed much over the past year and is roughly similar to adults nationwide in the same age range (45 percent favorable, 42 percent unfavorable).9

However, there are differences in opinion within the non-group market. Those in ACA-compliant plans are more likely to say they have a favorable view of the law compared to those with non-ACA compliant plans (53 percent versus 39 percent). As is true among the general public, partisanship remains by far the biggest driver of opinion of the ACA among non-group purchasers, with a large majority of Republicans (74 percent) expressing an unfavorable view of the law, while an equally large share of Democrats (75 percent) say they are favorable, and independents are in the middle (51 percent favorable, 40 percent favorable).

Figure 22

Figure 22

When asked about the impact the law has had on them and their families, four in ten non-group enrollees say they’ve benefited from the ACA, up slightly from 34 percent who said this in 2014. A somewhat smaller share – 33 percent – say they’ve been negatively affected (similar to the 29 percent who said this last year). Those who say they’ve benefited are about evenly divided in saying the main reason was because the law allowed someone in their family to get or keep health coverage, lowered their health care or insurance costs, or made it easier to get needed health care.

Figure 23

Figure 23

Among the 33 percent of non-group enrollees who say they’ve been negatively impacted by the law, most say the law increased their health care or insurance costs, while smaller shares say it made it more difficult to get needed health care or that it caused someone in their family to lose their insurance.

Figure 24

Figure 24

Here again there are important divisions within the non-group market in who feels they’ve benefited or been negatively affected by the ACA. Those most likely to feel their families have benefited include those who are likely receiving government tax credits to help with the cost of insurance (57 percent), those with Marketplace plans (53 percent), and those in plans with lower deductibles (48 percent). On the other side, those with non-compliant pre-ACA plans stand out as a group that is particularly likely to feel negatively affected– four in ten (41 percent) say they have been negatively affected while only 8 percent say they’ve benefited. Non-group purchasers in high deductible plans also tilt negative; 45 percent say they’ve been negatively impacted and three in ten say they have benefited. Partisanship provides a stark comparison here as well. More than half of Republicans say they’ve been negatively affected, while nearly two-thirds of Democrats say the law has been a benefit to their family. Independents sit squarely in the middle: 34 percent feel they’ve benefited from the law and 33 percent say they’ve felt a negative impact.

Figure 25

Figure 25

Survey of Non-Group Health Insurance Enrollees, Wave 2: Methodology

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Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.