摘要：Objectives. We determined whether and how Minnesotans who were uninsured in 2013 gained health insurance coverage in 2014, 1 year after the Affordable Care Act (ACA) expanded Medicaid coverage and enrollment. Methods. Insurance status and enrollment experiences came from the Minnesota Health Insurance Transitions Study (MH-HITS), a follow-up telephone survey of children and adults in Minnesota who had no health insurance in the fall of 2013. Results. ACA had a tempered success in Minnesota. Outreach and enrollment efforts were effective; one half of those previously uninsured gained coverage, although many reported difficulty signing up (nearly 62%). Of the previously uninsured who gained coverage, 44% obtained their coverage through MNsure, Minnesota’s insurance marketplace. Most of those who remained uninsured heard of MNsure and went to the Web site. Many still struggled with the enrollment process or reported being deterred by the cost of coverage. Conclusions. Targeting outreach, simplifying the enrollment process, focusing on affordability, and continuing funding for in-person assistance will be important in the future. The Affordable Care Act (ACA; Pub L No. 111–148) significantly increased the availability of health insurance coverage for millions of Americans through expansion of the Medicaid program and the offer of insurance options and subsidies through health insurance marketplaces. 1 The ACA also devoted significant resources to outreach and enrollment to ensure that increases in availability and access led to gains in coverage. There is clear evidence that the ACA has led to significant health insurance coverage gains. Between September 2013 (before the initial ACA open enrollment) and December 2014, more than 10.75 million additional individuals enrolled in Medicaid and the Children’s Health Insurance Program across the United States, representing an 18.6% increase in the average monthly enrollment. 2 Enrollment gains in qualified health plans offered through marketplaces were also significant. As of January 2015, 9.5 million people were enrolled in health plans purchased through marketplaces. 3 Data from several national cross-sectional surveys confirmed these enrollment gains and indicated significant reductions in the number of uninsured. 4–6 We followed uninsured Minnesotans over time to examine the impact of the ACA. History has shown that availability of health insurance options does not necessarily translate into enrollment. Specifically, participation in Medicaid among eligible adults is incomplete and varies across the states, ranging from less than 44% in Oklahoma to 88% in the District of Columbia, with a national average of 62%. 7 Key barriers to Medicaid enrollment include a lack of knowledge among potentially eligible individuals about the program (e.g., eligibility and renewal requirements, and how to sign up) and inadequate enrollment support for individuals (e.g., language and literacy barriers). 8 For this reason, the architects of the ACA included a variety of provisions intended to encourage participation in health insurance coverage, including outreach and enrollment support, as well as an individual mandate to obtain coverage. The development of health insurance marketplaces was central to outreach and enrollment efforts; these marketplaces were intended to be a one-stop shop for individuals looking to find coverage and an organizer for outreach efforts. States could opt to implement a state-based marketplace or rely fully or partially on the federally facilitated marketplace. Marketplaces were tasked with implementing a single, streamlined eligibility process; consumer assistance activities, including Web site development, call center, and assister programs; and supporting multiple pathways for gaining coverage (e.g., online, mail, telephone, and in person). Significant federal resources were available to both support Marketplace development and fund enrollment efforts by those marketplaces. 9–11 As a state-based marketplace, MNsure has been responsible for outreach and enrollment efforts, and benefited from the available federal funding. As of fall 2014, Minnesota received a total of $155 million in federal grants for state-based Marketplace planning and implementation, 9 including nearly $6 million to support public outreach, navigators, and other in-person assister programs. 12,13 Specifically, MNsure developed a Consumer Assistance Program to support “no-wrong-door” application assistance through the training and funding of certified application counselors, navigators, and outreach and enrollment grantees who were charged with engaging communities, educating individuals about their coverage options, and supporting them through the enrollment process. Specific activities conducted by consumer assistance providers included regular weekly navigator enrollment and assistance hours at community centers and places of worship, referrals with small business groups and health care providers, locally focused print and social media campaigns, and town hall forums. 14 Our purpose was to determine whether and how individuals most likely to be eligible for new ACA health insurance coverage options gained insurance in 2014, the first year of expanded Medicaid and nongroup enrollment under MNsure. Specifically, we followed a group of children and adults who were uninsured in the fall of 2013 and asked a year later about their insurance coverage, main reasons for lack of coverage, awareness of MNsure, coverage-related information-seeking, use of MNsure enrollment resources, overall enrollment experiences, access to care, and perceived financial protection related to health care. We add to the limited data that examine the enrollment experiences of the uninsured during the first full year of ACA implementation. 15,16
