Insuring Young Adults in the United States Through the Affordable Care Act

Journal of Adolescent Health 57 (2015) 131e132 www.jahonline.org Editorial Insuring Young Adults in the United States Through the Affordable Care Act The Patient Protection and Affordable Care Act (ACA), passed by U.S. Congress in 2010, represents an unheralded opportunity to meet the unmet health needs of young adults, a population that traditionally has represented a third of all the uninsured (ages 19e25 years), when compared with 16.3% among the general adult population (26e64 years) [1]. A motivating force for young adults’ health insurance enrollment is that they represent an important pool of healthier covered lives; thus, offsetting the health care costs associated with sicker older adults. Because of the ACA’s efforts to make health care insurance available and affordable, the uninsurance rate for young adults declined from 34.1% to 27.7% between the baseline of 2010 through the start of the open enrollment in 2013, representing an additional 2.3 million young adults gaining health insurance coverage [2]. With the implementation of the Medicaid expan- sion in 30 states and insurance exchanges, an additional 3.4 million gained coverage through October 2013. Thus, an esti- mated 5.7 million young adults gained coverage between 2010 and March 4, 2015 [3]. This initial success in decreasing the uninsured was initially due to the well-established enrollment and coverage mecha- nisms already in place [4]. Young adult family members up to age 26 years could easily be added (or extended if they were already part of the existing plan) regardless of their marital status, residency, ﬁnancial dependency, student status, and the availability of other coverage or health status. This extension strategy was effective as increasingly the young adult popula- tion was entering a job market in which employer-based health coverage is often not included as part of the beneﬁts offered for entry-level positions [5]. The success of the initial health in- surance enrollment was likely attributable to a large pool of young adults who previously did not have health insurance and parental motivation to cover young adults with more serious conditions [6]. In spite of this historical increase in health insurance coverage, in this issue of the Journal of Adolescent Health, the research by Wong et al. [7] offers timely and sobering insights shared by young adults themselves about the persistent and signiﬁcant barriers to their successful enrollment. Although the reasons for lack of insurance among young adults have been documented, how ACA policies and state health insurance exchanges are perceived on an individual level has previously received limited attention. Assessing the personal experiences of young adults seeking health insurance through the government portal for health insurance exchange, Wong et al. document low levels of health insurance literacy: only about half understand concepts such as deductibles, and nearly 78% incorrectly deﬁne coinsurance. Yet, these concepts and concerns regarding pre- mium costs were key factors inﬂuencing plan selection. Although this select and small study sample was highly educated, tech-savvy, and motivated to seek health insurance coverage, they had difﬁculty selecting plans that were ﬁnancially manageable and reasonable. Although it is likely that this sample represents the “tip of the iceberg” of the uninsured, they provide valuable insights into the needs of other young adult populations who may be far less health literate. Young adults are likely to require more intense outreach and support if they were never eligible to receive health insurance through their parents’ plan or those who chose to apply independently for other personal reasons or young adults who are now aging out of their parent’s plans. Although the study points of Wong et al. to the challenges encountered initially in using the Healthcare.gov Web site, these ﬁndings reﬂect the problematic experiences of many other populations who face the cumulative effects of technological snafus, low health literacy, and the complexity of selecting among competing health insurance plans [8]. A number of study participants perceived a lack of congruence between the ACA’s “affordability” and its costly impact on their limited monthly incomes. Weighing the pros and cons, many young people were less likely to place value on being insured and more willing to pay the penalty, without exploring their eligibility for subsidies and tax credits. The spotlight of Wong et al. on the importance of health lit- eracy in predicting the likelihood of enrolling in health coverage is consistent with other studies documenting the relationship between low health literacy, lack of insurance, and higher levels of illness [9,10]. Although some recognized the potential “peace of mind” that insurance coverage would provide, others did not feel at risk for major problems, a surprising result as more than a third reported having a medical condition. The most attractive advantage associated with health insur- ance was access to preventive and primary care, particularly See Related Article p. 137 1054-139X/O 2015 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2015.05.008