Study Indicates Challenges Ahead in Health Insurance Marketplace Enrollment


In a final report to the Iowa Department of Public Health, a study by the University of Iowa Public Policy Center concludes that many potential users of the new Health Insurance Marketplace (Marketplace), sometimes called Exchanges, face a series of challenges with current levels of insurance, lack of familiarity with the Affordable Care Act (ACA), and unease in using an online system to choose a health insurance plan. The vast majority of those surveyed anticipated needing some or “a lot” of help with the new system.  To read the full report, click here.

In collaboration with the Iowa Department of Public Health, the State of Iowa’s Health Insurance Marketplace Interagency Workgroup, and the University of Iowa College of Public Health, a survey of potential users of the Marketplace was conducted to evaluate their insurance purchasing needs and knowledge about the new Marketplaces in order to help the state design and structure the education and outreach programs for the Marketplace. A sample of individual Iowa consumers of health insurance (focusing on uninsured and self-insured people) was surveyed during the late spring/early summer of 2013. 

Health Insurance Marketplaces were established as part of the ACA to provide a way to purchase regulated private health insurance with subsidies from the government for those with incomes up to 400% of the federal poverty level (FPL).

But consumers most likely to be eligible for subsidies through the Health Insurance Marketplace (those currently uninsured, purchase insurance themselves (not through their business or have public insurance) expressed the following concerns with the new system: their current health insurance coverage is either non-existent or not as good as those with employer-sponsored insurance, thus they were significantly more likely to have had delays in care in the last year and worried much more about the cost of health care for themselves and their families; they are less aware and knowledgeable about the ACA generally and the specific aspects of the changes soon to occur (though supportive of most aspects of the ACA); they were uneasy about using an online system for selecting a health insurance plan and the vast majority thought they would need extensive help with enrollment.

“Many who would be most able to benefit from the subsidized insurance in the Marketplace, will have serious challenges understanding if this is appropriate for them, and how to enroll and select a plan-they will need assistance”, said Peter Damiano, Director of the UI Public Policy Center and lead author on the report.

Consumers listed cost as the most important factor when selecting a health insurance plan, and expressed a need for one-on-one assistance in choosing a plan, or a guided online system with as many options as possible. They were most likely to learn about the Marketplace from either television or their employer, but had most confidence in the information for Marketplace purchase assistance provided by an employer’s human resource department, printed materials, community resources such as public health agencies, or by health care providers.

Thus, there are significant challenges in educating and getting this population enrolled into the Marketplace. Due to the lack of previous insurance coverage, many users of the Marketplace may also be less familiar with using the health care delivery system, another significant challenge after purchase of the insurance. This may be a reason they indicate they would look to health care providers for assistance after purchasing insurance more than prior to purchase.

Primary investigators on the report are Peter Damiano, Suzanne Bentler, and Daniel Shane.

The full report is available here: