With 20 million more Americans with healthcare coverage just six years after its passage, it is undeniable that the Patient Protection and Affordable Care Act (ACA) has had a profound impact on the uninsured rate in the U.S. and here in Northeast Ohio. Due to the combination of Medicaid extension and the Federally-facilitated Marketplace, Ohio now touts one of its lowest uninsured rates on record – with only 8.7 percent of its residents remaining uninsured. While many of the previously uninsured now qualify for Medicaid coverage, thousands more are still eligible for health coverage through Ohio’s Federally-facilitated Marketplace, a key component of the ACA.

Marketplace Plans and Available Subsidies
Consumers at all income levels can use the Marketplace to find coverage, however, those with incomes between 100 – 400 percent of the Federal Poverty Level (FPL) are eligible for a Premium Tax Credit, which lowers monthly premium payments, or a Cost-Sharing Subsidy, which lowers out-of-pocket costs. Typically, the higher the income, the less the offset will be to the consumer. To understand more about how subsidies work, watch this video:

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Expected contributions for Marketplace plans vary by family size and income. For example, a family of three with a gross monthly income of around $3,400 – just over 200 percent of the FPL – would be expected to contribute between $217 and $278 per month for healthcare coverage.

Marketplace plan selection in Ohio has been on the uptick in recent years. During the 2016 open enrollment period, consumers in the Buckeye State had 17 issuers with an average of 81 Qualified Health Plans (QHPs) to choose from – up 11 percent from 2015. And, with 80 percent of Ohio consumers qualifying for an average tax credit of $240 per month, 249,715 Ohioans decided to purchase their healthcare plan through the exchange during the last open enrollment period.[3]

Northeast Ohio Marketplace Plan Selection Figures:

             

Yet, despite increased plan selection, recent evidence suggests that enrollment is still low among the working poor, with 11.5 percent (3.2 million) of the remaining uninsured between the ages of 18 – 64 earning less than 200 percent of the FPL, according to a study from the Kaiser Family Foundation and Urban Institute. Similarly, 12.2 percent of the remaining uninsured earn between 201 – 400 percent of the FPL, but select plans on the Marketplace at a lower rate when compared to lower-income persons. It’s important to note that both groups are eligible for subsidies or cost-sharing programs through the Marketplace.

Where do Marketplace-eligible Residents Live?
Historically, Northeast Ohio has a higher concentration of total Medicaid recipients in comparison to the rest of the state, largely due to the size of the population. Medicaid extension has certainly reinforced this trend, adding an additional 100,000 persons to the Medicaid program as of May, 2016. However, focusing solely on Marketplace plan selections, it is clear that certain pockets of Marketplace-eligible consumers remain uninsured across the Northeast Ohio region.

Marketplace take-up rates – the percentage of eligible consumers who selected a plan – were generally higher in Cleveland’s suburbs and contiguous semirural communities. Zip codes located in downtown Cleveland tended to have similar take-up rates when compared to residents living in Cleveland’s suburbs on the whole, presumably because downtown residents have income levels comparable to their suburban counterparts. However, inner-ring suburbs, those closer to the city’s core with older housing stock, had much lower Marketplace take-up rates, ranging from 11 percent to 32 percent despite higher income when compared to their Cleveland counterparts. This may be due to a number of factors including the fact that their income is higher and thus they are likely to receive a smaller subsidy for the purchase of a plan, as well as the rising costs of plans.

Reaching the Remaining Uninsured in Northeast Ohio
One of the most crucial components to ensuring the long-term success of the ACA, at least with regard to health care coverage, is outreach and education. While the three previous periods of open enrollment have been led by groups like the Department of Health and Human Services (HHS) and Enroll America, with assistance from community-based assisters, it is clear that additional coordination and strategic outreach is needed to drive the uninsured rate even lower.

The Robert Wood Johnson Foundation and the Urban Institute have identified several outreach strategies to connect to hard-to-reach populations. One recommendation is to target outreach through non-health-related public benefit programs. As the study points out, “just over half of the low-income uninsured eligible for tax credits live in families in which at least one person is reported to receive a public benefit not related to health.” The report recommends identifying families enrolled in the Supplemental Nutrition Assistance Program (SNAP) or those receiving the Earned Income Tax Credit (EITC) as potential targets for Marketplace outreach efforts. In order to enact these changes, states would have to perform outreach to SNAP enrollees, and the U.S. Treasury would need to identify families receiving the EITC in order to provide educational opportunities about the Marketplace accordingly.

In late-June, the Centers for Medicare and Medicaid Services (CMS) outlined its plans to work more closely with the Internal Revenue Service (IRS) to identify consumers who paid a fee for not having a health insurance plan in 2014, which was 7.9 million filers. Of those paying a penalty or claiming an exemption in 2014, 45 percent were under the age of 35 – the age range often identified by healthcare officials and insurance companies as crucial for participation in the Marketplace. The partnership between these two governmental agencies would be a giant step in the right direction and could save many low-income Americans money during the tax season, since the penalty for not having health insurance will be $695 per uninsured adult in 2016, or 2.5 percent of taxable household income, whichever is higher.

In addition to policy changes needed to further bolster outreach and enrollment, it’s imperative for providers and community-based assisters to work more collaboratively around outreach and enrollment strategies in preparing for the fourth round of open enrollment. Ideally, coordination and planning would use the data provided by HHS, along with any new data that are released, to more pointedly target their Marketplace outreach efforts. This is especially true as the areas with the greatest density of eligible participants also have the potential for the highest Marketplace subsidization. Lastly, additional educational opportunities are needed for consumers to fully understand the health insurance plan and corresponding subsidies available to them through the Marketplace.