Eligible but Unenrolled: From ACA to Medicaid and Beyond, Good Policy Must Reach People

It is a little-known fact that many people who are eligible for low-cost health insurance coverage or financial help to pay for health care services remain unenrolled. They number in the millions, and they include children and adults of all ages. Because of administrative hurdles, lack of awareness, and possibly stigma or fear around enrolling in government programs (for a variety of reasons), assistance available to help low-income children and adults afford health care or buy health insurance are not being accessed to their fullest extent. This must change; we need to raise the public’s attention and action needs to happen on multiple fronts to connect people to these benefits.

Pervasive Challenge

While the reality of millions of eligible people not receiving a crucial benefit does not receive headlines, it’s well documented. Studies have shown low enrollment in the Medicare Savings Program (MSP), a program that helps pay for Medicare premiums or out-of-pocket costs for low-income Medicare beneficiaries. According to a government report, state enrollment rates for MSP among those eligible range from 78 percent in some states to as low as 25 percent in others.

It doesn’t stop there. According to a recent 2021 study, nearly 11 million uninsured individuals eligible for Affordable Care Act (ACA) Health Insurance Marketplace subsidies that would lower their monthly insurance premiums did not sign up for coverage in 2020. And for many, a reduced premium is not even standing in the way: six out of 10 of them qualified for $0 premium plans, including 1.3 million who additionally qualified for financial help to significantly reduce their out-of-pocket costs. Even among adults ages 50-64, who are more likely to experience chronic health conditions and face higher premiums, 1.4 million remain uninsured despite eligibility for financial assistance.

The same phenomenon plays out in programs, such as Medicaid and the Children’s Health Insurance Program, with minimal to no cost-sharing. About 7 million people are eligible for such programs but not enrolled in them, including nearly four million adults living in states with expanded Medicaid and nearly three million children living across the country.

Key Policy Ingredient: Getting the Word Out

Access to affordable health care is critical to people leading healthy, productive, and secure lives. And health insurance provides more than health security. Having comprehensive insurance provides financial security and the accompanying peace of mind by protecting individuals and their families from catastrophic health care costs and the stress that comes with them. Older adults, with their higher rates of chronic health conditions, would benefit substantially from having affordable health coverage that meets their needs.

Ensuring that older adults have access to good health coverage is a priority for AARP, reflected in its strong advocacy efforts in this area. And following any policy progress, AARP follows through with the next key step: ensuring people are both aware of and enroll in programs that lower their health care expenses.

To that end, last year, AARP worked to spread the word about temporary expanded financial assistance to lower premiums for Marketplace plans as well as an extended enrollment period, made available through the pandemic-related American Rescue Plan. We focused on older adults in multicultural communities, creating educational materials to disseminate through multiple channels, as well as sponsored public service announcements and worked with partners to reach communities locally. AARP celebrates the work of other organizations around the country who also reached out to consumers: the combined effort led to over 2.8 million additional adults signing up for ACA coverage during that time and gaining access to affordable care during the public health emergency. That is a testament of the recognition of people’s needs and demonstrates what’s possible when attention and effort is directed to improve enrollment.

At this moment in Congress, the Inflation Reduction Act —a high profile legislation that covers a range of issues—just passed the Senate and House, and includes provisions to extend for another three years the expanded financial assistance, which is scheduled to expire at the end of 2022. That extension is vital to ensure millions of older adults will continue to have access to affordable health care.

To reach the millions who may not be aware of this opportunity to lower their premiums or health care costs, the good news of the extension must translate to enrollment, so that the people for whom the legislation was intended receive its crucial benefits. That will be accomplished through efforts to make it easier to enroll or education and outreach to directly connect with older adults. At AARP, we will again continue these activities, the next step in an important journey—a journey that will have started with turning a proposal into a policy, then continuing on by ensuring that good policy reaches people.

Additionally this year, AARP and the AARP Foundation are working together to raise awareness of, and help enroll individuals in, another important program: the Medicare Savings Program. The MSP program provides financial assistance so low-income Medicare beneficiaries can afford the care they need. And it also helps them in other important ways, such as in freeing up their limited funds for other essential expenses and automatically qualifying them for additional financial assistance to pay for prescription drugs, through the Extra Help program. AARP is leveraging its multi-channel communication muscle to raise awareness, building educational resources to share information and offering grants to help with outreach and enrollment.

Participation Challenges Beyond the ACA and MSP: Opportunity Awaits

In addition to the need to address ACA and MSP participation rates, opportunities are waiting to be tapped to improve Medicaid enrollment rates in states that have expanded the program to low-income adults. Moreover, this journey is not unique to health care. The Supplemental Nutrition Assistance Program (SNAP), the nation’s largest anti-hunger program that provides financial assistance to help buy food, also has millions of low-income older adults who are eligible but not participating. To fully realize the potential of all these programs and their reach, we need to understand who’s not enrolled and why, to appropriately target our outreach efforts. Stay tuned for more as AARP dives deeper into these questions.