title: The Impact Of State Policies On ACA Applications And Enrollment Among Low-Income Adults In Arkansas, Kentucky, And Texas.
abstract: States are taking variable approaches to the Affordable Care Act (ACA) Medicaid expansion, Marketplace design, enrollment outreach, and application assistance. We surveyed nearly 3,000 low-income adults in late 2014 to compare experiences in three states with markedly different policies: Kentucky, which expanded Medicaid, created a successful state Marketplace, and supported outreach efforts; Arkansas, which enacted the private option and a federal-state partnership Marketplace, but with legislative limitations on outreach; and Texas, which did not expand Medicaid and passed restrictions on navigators. We found that application rates, successful enrollment, and positive experiences with the ACA were highest in Kentucky, followed by Arkansas, with Texas performing worst. Limited awareness remains a critical barrier: Fewer than half of adults had heard some or a lot about the coverage expansions. Application assistance from navigators and others was the strongest predictor of enrollment, while Latino applicants were less likely than others to successfully enroll. Twice as many respondents felt that the ACA had helped them as hurt them (although the majority reported no direct impact), and advertising was strongly associated with perceptions of the law. State policy choices appeared to have had major impacts on enrollment experiences among low-income adults and their perceptions of the ACA.
authors.affiliation: Benjamin D. Sommers (bsommers@hsph.harvard.edu) is an assistant professor in the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, and in the Department of Medicine, Brigham and Women's Hospital, in Boston, Massachusetts.
authors.forename: Benjamin D
authors.initials: BD
authors.lastname: Sommers
authors.affiliation: Bethany Maylone is a project manager at the Harvard T.H. Chan School of Public Health.
authors.forename: Bethany
authors.initials: B
authors.lastname: Maylone
authors.affiliation: Kevin H. Nguyen is a master's degree candidate at the Harvard T.H. Chan School of Public Health.
authors.forename: Kevin H
authors.initials: KH
authors.lastname: Nguyen
authors.affiliation: Robert J. Blendon is the Richard L. Menschel Professor of Health Policy and Political Analysis in the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Blendon
authors.affiliation: Arnold M. Epstein is the deputy assistant secretary for planning and evaluation in the Department of Health and Human Services and on leave from the Harvard T.H. Chan School of Public Health, where he is the John H. Foster Professor of Health Policy and Management.
authors.forename: Arnold M
authors.initials: AM
authors.lastname: Epstein
mesh_terms: D000328:Adult; D005260:Female; D006630:Hispanic or Latino / Q000706:statistics & numerical data; D006801:Humans; D019458:Insurance Coverage / Q000331:legislation & jurisprudence* / Q000706:statistics & numerical data; D008297:Male; D008484:Medicaid / Q000331:legislation & jurisprudence; D017057:Medically Uninsured; D008875:Middle Aged; D058991:Patient Protection and Affordable Care Act / Q000331:legislation & jurisprudence; D057766:Policy; D011203:Poverty; D013219:State Government; D011795:Surveys and Questionnaires; D014481:United States
keywords: Consumer Issues; Health Reform; Insurance Coverage < Insurance; Public Opinion; State/Local Issues