How Does Gaining Coverage Affect People's Lives? Access, Utilization, and Financial Security among Newly Insured Adults

In 2014, millions of people gained health insurance as the major coverage provisions of the Affordable Care Act (ACA) were implemented. While much attention has been paid to enrollment in new coverage options and changes in the number of uninsured over the past year, less is known about how this coverage has affected people’s lives. This report, based on the 2014 Kaiser Survey of Low-Income Americans and the ACA, aims to understand the impact that gaining coverage has had on the lives of the “newly insured” adult population. The survey of 10,502 non-elderly adults was fielded between September 2 and December 15, 2014, with the majority of interviews (70%) conducted prior to November 15, 2014 (the start of the second open enrollment period). Additional detail on the survey methods is available in the methods appendix available online.

Based on the survey findings, approximately 11 million nonelderly adults were newly insured in 2014, meaning they reported that they obtained health coverage in 2014 and were uninsured before that coverage started. While many of these people gained coverage in the first quarter of 2014—which coincided with the “open enrollment period” for Marketplace coverage—most gained it after March 2014. Medicaid enrollment is available throughout the year, and some people were eligible to enroll in Marketplace coverage outside of open enrollment. In addition, people can gain non-ACA coverage at any time.

The vast majority (95%) of adults who gained coverage in 2014 have family income below 400% of poverty, the income range for financial assistance under the ACA, with more than half (53%) in low-income families (at or below 138% of poverty) and more than one in four (42%) in middle-income families (139 to 400% of poverty). While this income profile is not significantly different than that for the remaining uninsured population, the newly insured population is significantly more likely than the previously insured to be low- or middle-income and significantly less likely to be higher income (greater than 400% of poverty). Because of these differences in income, we restrict the analysis in this brief to the population below 400% of poverty.

Who gained coverage in 2014?

Most newly insured adults are in working families, many with a part-time worker. Despite concerns about adverse selection into coverage, about half of newly insured adults are under age 35 (similar to those who remained uninsured), and newly insured adults are actually less likely to report fair or poor health than those who remained uninsured. Notably, newly insured adults were more likely to be female than their counterparts who remained without coverage, and they were also more likely to have insurance coverage for all their children (if they had any) than those who remained uninsured. In addition, half of newly insured adults are people of color, and more than half do not have dependent children—groups that have historically faced disparities in coverage rates or exclusions from coverage in the past.

How do newly insured adults access care?

A primary goal of expanding health insurance coverage is to help people access the medical services that they need. The survey findings reinforce other findings that insurance facilitates access to health care, indicating that adults who gained coverage in 2014 are more likely to be linked to regular care, less likely to postpone care when they need it, and more likely to use preventive services than those who remained uninsured. While some newly insured adults changed where they regularly go for care and most see private doctor’s offices for their regular care, many continue to seek services from community clinics and health centers, which have historically served under-served populations such as the uninsured and may be the most available source of care in their area. Still, survey findings show that newly insured adults face some access barriers compared to adults who were insured before 2014. This finding may indicate that newly insured adults are not as settled into regular care as their previously insured counterparts; it may also reflect difficulty finding a provider, problems navigating the health system and health insurance networks, misunderstanding about how to use coverage and when to seek care, or concerns about out-of-pocket costs.

How does coverage affect financial security?

Health care costs can be a major burden for low- and middle-income families. While many newly insured adults report difficulty affording their monthly premium, they also report lower rates of problems with medical bills and lower rates of worry about future medical bills than their uninsured counterparts. However, newly insured adults still face financial insecurity: they are more likely than those who had coverage before 2014 to worry about future medical bills, and they face general financial insecurity at rates similar to the uninsured. These patterns may indicate that while coverage can ameliorate some of the financial challenges that low- and moderate-income adults face, many will continue to face financial challenges in other areas of their lives.

How do the newly insured view their coverage?

People’s views of their plan may affect not only their use of their coverage but also the likelihood that they re-enroll in coverage or change plans. Survey results reveal that newly insured adults were very sensitive to cost in choosing their plan, placing a priority on cost over benefits and provider networks. A minority of both newly insured and previously insured adults reported problems in using their plan. However, newly insured adults were more likely than previously insured to say they do not understand the details of their plan and were more likely to give their plan a low rating. These findings indicate that additional education may be needed to help people understand their coverage.

Policy Implications

As more and more evidence mounts to document coverage gains during the first year of the ACA, there is interest in understanding how these gains in coverage have affected the lives of the newly insured. Findings from the 2014 Kaiser Survey of Low-Income Americans and the ACA show, not surprisingly, that adults who gained coverage had better access to health care and better financial security from medical costs than those who remained without coverage. In addition, survey findings reveal few differences in outcomes among the newly insured population by type of coverage, and the differences that do exist largely reflect Medicaid’s role in targeting the lowest income and most vulnerable.

Still, comparison between newly insured adults and those who have had coverage since before 2014 shows some areas for ongoing attention as policymakers strive to translate coverage to care. Ongoing monitoring of newly insured adults’ access and utilization is important to assess whether this population continues to face challenges or whether these differences subside over time.