Why Many Americans Have Gained Insurance Under the Affordable Care Act While Others Have Not?


According to the most recent Commonwealth Fund Affordable Care Act Tracking Survey, March–May 2015, an estimated 25 million adults remain uninsured. To achieve the Affordable Care Act’s goal of near-universal coverage, policymakers must understand why some people are enrolling in the law’s marketplace plans or in Medicaid coverage and why others are not. This analysis of the survey finds that affordability—whether real or perceived—is playing a significant role in adults’ choice of marketplace plans and the decision whether to enroll at all. People who have gained coverage report significantly more positive experiences shopping for health plans than do those who did not enroll. Getting personal assistance—from telephone hotlines, navigators, and insurance brokers, among other sources—appears to make a critical difference in whether people gain health insurance.

The third open enrollment period for the Affordable Care Act’s health insurance marketplaces begins on November 1, 2015, for coverage beginning January 2016. This will give the estimated 25 million working-age adults who still lack health insurance and are eligible for coverage the opportunity to sign up.1 In addition, people who currently have insurance—either through the marketplaces or the individual market—will need to reenroll during this period if they want their coverage to continue through next year. Some people, however, may choose not to enroll in coverage. To help policymakers increase the number of people with health insurance, it’s important to understand why some people have enrolled while others have not. Earlier research, based on results from the Commonwealth Fund Affordable Care Act Tracking Survey, March–May 2015, identified possible reasons why people remain uninsured, including the fact that 20 states have yet to expand eligibility for Medicaid and a general lack of knowledge among many uninsured adults about the marketplaces and the availability of financial assistance.

In this latest analysis of the survey, we gain more insight by looking at the experiences of adults who took the first steps toward gaining coverage by visiting the marketplaces but who did not ultimately enroll. The survey findings can be viewed here.