Health Reform Monitoring Survey -- Texas

March 2016

Shao-Chee Sim, PhD, Elena Marks, JD, MPH, Vivian Ho, PhD, and Philomene Balihe, MPH

InSeptember2015,justbeforethethirdopenenrollment period of the Affordable Care Act’s(ACA)HealthInsuranceMarketplacewasabout toopen,wesurveyedinsuredTexansages18to64toassess their confidence level in understanding thebasic terminology about health insurance plansand in how they use their health insurance plans.Our data show that, as compared to Texans withemployer-sponsored insurance (ESI) and thosewithpublichealthinsurance,Texanswithindividualplansweremorelikelytolackconfidenceinunderstandinghealthinsuranceterminology.Texanswith individual plans also expressed more difficulty in understanding how to use their healthinsuranceplans.

ABOUT THE SURVEY

TheHealthReformMonitoringSurvey(HRMS)isaquarterlysurveyofadultsages18-64thatbeganin2013.ItisdesignedtoprovidetimelyinformationonimplementationissuesundertheACAandtodocumentchangesinhealthinsurancecoverageandrelatedhealthoutcomes.HRMSprovidesquarterlydataonhealthinsurancecoverage,access,useofhealthcare,healthcareaffordability,andself-reportedhealthstatus.TheHRMSwasdevelopedbytheUrbanInstitute,conductedbyGfK,andjointlyfundedbytheRobertWoodJohnsonFoundation,theFordFoundation,andtheUrbanInstitute. Rice University’s Baker Institute and The Episcopal Health Foundation are partneringtofundandreportonkeyfactorsaboutTexansobtainedfromanexpanded,representativesampleofTexasresidents(HRMS-Texas).TheanalysesandconclusionsbasedonHRMS-Texasare thoseof the authors and do not represent the view of the Urban Institute, the Robert Wood JohnsonFoundationortheFordFoundation.InformationaboutthesampledemographicsofthecohortisavailableinIssueBrief#1.ThisIssueBriefisasummaryofdataextractedfromtheHRMSSurveys

Issue Brief #20: Insured Texans lack clear

understanding of their health insurance plans

2 HEALTHREFORMMONITORINGSURVEY--TEXAS2 HEALTHREFORMMONITORINGSURVEY--TEXAS

AT A GLANCE

The percentage of adult Texans with individually purchased health insurance plans increased by 78% from 2013 to 2015.

Texans who purchased individual plans were more likely than those with public or employer-sponsored plans to lack confidence in understanding health insurance terms and in understanding how to use their health insurance plans.

Improving health insurance literacy is critical to the long term success of the coverage provisions of the ACA.

inTexasadministeredbetweenSeptember2013andSeptember2015.WewillcontinuetoreportonsurveydatathroughadditionalIssueBriefsandfuturesurveys.

TEXANS WITH INDIVIDUAL HEALTH PLANS WERE MOST LIKELY TO LACK CONFIDENCE IN UNDERSTANDING HEALTH PLAN TERMINOLOGY One of the main goals of the Affordable Care Act (ACA) was to enable more Americans toobtainhealthinsurancecoverage.SincetheopeningoftheHealthInsuranceMarketplaceandtheexpansionofMedicaidinmanystatesinJanuary2014,millionsofAmericanshaveobtainedhealthinsurance.AswereportedinIssueBrief#16,from2013to2015,therateofuninsuredadultsages18-64droppedby41%acrossthecountryandby21.4%inTexas.AsshowninFigure1below,thesignificantdropinthepercentageofuninsuredTexansisprimarilyattributabletoa78%increaseinthepercentofTexanscoveredbyindividuallypurchasedplans,includingthenearlyonemillionwhohadpurchasedMarketplaceplansbytheendof2015.

HEALTHREFORMMONITORINGSURVEY--TEXAS 3

Figure 1: Insurance Status of Adult Texans, 2013 and 2015

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As we reported in Issue Brief #19, approximately 25% of insured Texans stated that they lackedconfidence in their understanding of basic health plan terminology. When we stratified the dataaccordingtothetypeorsourceofinsurance,welearnedthatthosewhohadpurchasedindividualplansweremuchlessconfidentabouttheirunderstandingofthetermsofthoseplans,ascomparedtothosewithpublicinsurance(primarilyMedicaidandMedicare)oremployer-sponsoredinsurance(includingmilitaryandpublicsectoremployees).Specifically,about4in10Texanswithindividualplansexpressedlackofconfidenceinunderstanding“co-insurance”and“maximumoutofpocketexpenses.”

*Lack of confidence represents responses of “not too confident” or “not at all confident” for each term.

Chart 1: Lack of Confidence* in Understanding Health Insurance Terms

among Insured Texans ages 18-64 by Coverage Type, September 2015

HEALTHREFORMMONITORINGSURVEY--TEXAS 5

As shown in Chart 2 below, Texans with individual plans also expressed more difficulty inunderstanding how to use their health plans. While most with individual plans were confident oftheirabilitytofindproviders,morethanone-thirdoftherespondentswerenotconfidentthattheycouldfigureoutwhatservices(36%)ordrugs(40%)werecoveredbytheirplans.Nearlyhalf(46%)didnotunderstandwhatcountsaspreventiveservices,manyofwhichareprovidedatnoadditionalcost.Largepercentagesofrespondents reported that they lackedconfidence inunderstanding theactualcostofcoveredservices(42%),whichcostscounttowardthedeductible(38%),andhowmuchitwouldcosttogooutofnetwork(51%).

*Lack of confidence represents responses of “not too confident” or “not at all confident” for each term.

Chart 2: Lack of Confidence* in Using Health Insurance among

Insured Texans, by Coverage Type, September 2015

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Theunfortunateironyisthatthosewithindividualplansaretheleastlikelytounderstandplanterminologyandhowtouse theirplansbut, theyare in fact theveryoneswhoare ingreatestneedof understanding. People with public or employer-sponsored plans have comparatively few choicesto make regarding which plan they have. Public plans like Medicaid and Medicare generally havestandardizedplanswithlimitedopportunitiesforbeneficiariestomakedecisionsabouttheircoverage.Most employer-sponsored insurance programs offer participants only one or two plan options. Inadditiontohavingabroadersetofoptionsfromwhichtochoose,thosepurchasinganinsuranceplanintheindividualmarket,unlessheavilysubsidizedthroughtheMarketplace,bearallofthecostsoftheirplans,whilethosecoveredbypublicandemployerplansgenerallypayacomparativelysmallshareofthecosts.Therefore,theirneedtounderstandwhattheyarebuyingiscritical.

CONCLUSIONS

The long-term success of the ACA depends on people buying, using, and experiencingsatisfactionwithhealthinsurance.Thelackofunderstandingaboutthebasicfinancialandcoverageprovisions of health plans expressed by so many insured can lead to surprise, frustration, anddisillusionment,whichcanundermineeffortstoincreasecoverage.Ournationalconversationabouthealthinsurance—itscostsandbenefits—haslargelytakenplaceamongindustry,government,andpolicyexpertsuntilrelativelyrecently.Thisresearchhighlightstheimportanceofhealthinsuranceliteracyfromthehealthcareconsumerperspective.ItwillbeimportantforallAmericanstogainabasicunderstandingofthiscomplexsysteminorderforthemtoparticipatefullyandmakethebestdecisionsabouthealth insuranceandhealthcarechoices for themselves and their families.Thosewhohaveworkeddiligently toexpandenrollment inhealthcoveragemusthelp thenewly insuredunderstandtheirplans.

LOOKING AHEAD

Later thisSpring,wewill reportondata collected in theMarch2016HRMS survey. Thosebriefswillincludeinformationaboutthe2016statusandrecentexperiencesofTexansinaccessingandusinghealthcareandhealthinsurance.

HEALTH REFORM MONITORING SURVEY -- TEXAS 7

ABOUT THE AUTHORS

Shao-Chee Sim, PhD, is the Vice President for Applied Research at The EpiscopalHealthFoundation.

Elena Marks, JD, MPH,isthePresidentandChiefExecutiveOfficerofTheEpiscopalHealthFoundationandanonresidentHealthPolicyFellowatRiceUniversity’sBakerInstituteforPublicPolicy.

Vivian Ho, PhD, is the James A. Baker III Institute Chair in Health Economics, aprofessor intheDepartmentofEconomicsatRiceUniversity,andaprofessor intheDepartmentofMedicineatBaylorCollegeofMedicine.

Philomene Balihe, MPH,isadataanalystattheEpiscopalHealthFoundation.

The authors gratefully acknowledge the assistance of Meei Hsiang Ku-Goto and thefinancial support of the Episcopal Health Foundation and members of the BakerInstitute’s Health Policy Forum. The core HRMS is supported by the Robert WoodJohnsonFoundation,theFordFoundation,andtheUrbanInstitute.WeappreciatetheUrbanInstitute’swillingnesstocollaborateonexpandingtheHRMSsampletosupportestimatesforTexas.

METHODOLOGY

Each quarter’s HRMS sample of nonelderlyadults is drawn from active KnowledgePanel®memberstoberepresentativeoftheUSpopulation.In the first quarter of 2013, the HRMS providedananalysissampleofabout3,000nonelderly(age18–64) adults. After that, the HRMS sample wasexpanded to provide analysis samples of roughly7,500 nonelderly adults, with oversamples addedto better track low-income adults and adults inselectedstategroupsbasedon(1)thepotentialforgainsininsurancecoverageinthestateundertheACA(asestimatedbytheUrbanInstitute’smicrosimulationmodel)and(2)statesofspecificinteresttotheHRMSfunders. Althoughfreshsamplesaredrawneachquarter,thesameindividualsmaybeselectedfordifferentroundsofthesurvey.Becauseeachpanelmemberhasauniqueidentifier,itispossibletocontrolfortheoverlapinsamplesacrossquarters.ForsurveysbasedonInternetpanels,theoverallresponserateincorporatesthesurveycompletionrateaswellastheratesofpanelrecruitmentandpanelparticipationovertime. The American Association for Public Opinion Research (AAPOR) cumulativeresponserate for theHRMSis theproductof thepanelhouseholdrecruitmentrate,thepanelhouseholdprofilerate,and theHRMScompletionrate—roughly5percenteachquarter. While low, this response rate does not necessarily imply inaccurate estimates; asurvey with a low response rate can still be representative of the sample population,althoughtheriskofnonresponsebiasis,ofcourse,higher. All tabulations from the HRMS are based on weighted estimates. The HRMSweights reflect the probability of sample selection from the KnowledgePanel® andpost-stratificationtothecharacteristicsofnonelderlyadultsandchildrenintheUnitedStatesbasedonbenchmarksfromtheCurrentPopulationSurveyandthePewHispanicCenter Survey. Because the KnowledgePanel® collects in-depth information onpanelmembers,thepost-stratificationweightscanbebasedonarichsetofmeasures,includinggender,age,race/ethnicity,education,householdincome,homeownership,Internetaccess,primarylanguage(English/Spanish),residenceinametropolitanarea,andregion.Giventhemanypotentialsourcesofbiasinsurveydataingeneral,andindatafromInternet-basedsurveysinparticular,thesurveyweightsfortheHRMSlikelyreduce,butdonoteliminate,potentialbiases. ThedesigneffectfortheTexasdatainSeptember2015is2.243andtheMOEis+/-3.7.ThesurveyfieldedfromSeptember1-25.

Health Reform Monitoring Survey -- Texas

HEALTH REFORM MONITORING SURVEY -- TEXAS 9

Foundedin1993,theJAMESA.BAKERIIIINSTITUTEFORPUBLICPOLICYhasestablisheditselfas one of the premier nonpartisan public policy think tanks in the country. The institute ranks 11thamonguniversity-affiliatedthinktanksworldwide,20thamongU.S.thinktanksandfifthamongenergyresource think tanks, according to a2013 studyby theUniversityofPennsylvania’sThinkTanks andCivilSocietiesProgram.AsanintegralpartofRiceUniversity,oneofthenation’smostdistinguishedinstitutionsofhighereducation,theBakerInstitutehasastrongtrackrecordofachievementbasedontheworkofitsendowedfellows,Ricefacultyscholarsandstaff.LocatedinHouston,Texas,thenation’sfourth-largestcityandtheenergycapitaloftheUnitedStates,aswellasadynamicinternationalbusinessandculturalcenter,theBakerInstitutebringsauniqueperspectivetosomeofthemostimportantpublicpolicychallengesofourtime.

Contact information can be found at: http://bakerinstitute.org

THE EPISCOPAL HEALTH FOUNDATION isanewlyestablishedentitywith$1billioninassetsdedicated to improving thehealthandwell-beingof thepeople andcommunities in theEpiscopalDioceseofTexas.TheFoundationembracestheWorldHealthOrganization’sbroad,holisticdefinitionofhealth:a stateofcompletephysical,mentalandsocialwell-beingandnotmerely theabsenceofdisease. The Foundation’s work includes research, grant-making and other initiatives aimed attransformationalchange.

Contact information can be found at: http://www.episcopalhealth.org

SuggestedCitation:

Sim,S.,Marks,E.,Ho,V.,andBalihe,P.

JamesA.BakerIIIInstituteforPublicPolicy,RiceUniversity,

TheEpiscopalHealthFoundation,

Health Reform Monitoring Survey – Texas,

Issue Brief #20: Insured Texans lack clear understanding of their health insurance plans.

©2016JamesABakerIIIInstituteforPublicPolicy,EpiscopalHealthFoundation