issue brief HEALTH INSURANCE COVERAGE ANDMississippi Adults Knowledge, Attitudes, and Behaviors of THE ACA UPDATE PUBLISHED AUGUST 2018 This brief summarizes results from a survey conducted in 2017 of non-elderly Mississippi adults regarding their health insurance coverage, as well as federal and state policies related to health coverage. It serves as a follow-up to similar surveys conducted in 2013 and 2014-15. The Center for Mississippi Health Policy commissioned researchers at the Social Science Research Center (SSRC) at Mississippi State University to survey non- elderly Mississippi adults to assess their knowledge, attitudes, and behaviors related to health insurance, the Affordable Care Act (ACA), and proposals to replace the ACA. More detailed information, including the full report and a chartbook, is available at www.mshealthpolicy.com. Opinions of the Affordable Care Act and Its Components As found in the previous surveys, respondents report little knowledge of the ACA or the Health Insurance Marketplace (formerly known as “Exchanges”). Three Three out of five say they know nothing or only a out of five (60%) say they know nothing or only a little about the ACA, and 64 percent know little or nothing little about the ACA, and 64 percent know little or about the Health Insurance Marketplace. nothing about the Health Insurance Marketplace. The rates of the uninsured reporting little or no knowledge of the ACA or the Health Insurance Marketplace are significantly higher than those with insurance, as shown in Figure 1. FIGURE 1. MISSISSIPPIANS’ KNOWLEDGE OF THE ACA BY HEALTH INSURANCE STATUS (2017) Insured Uninsured Percentage who reported knowing little or nothing about the health reform law known as the Affordable Care Act (ACA)* 58% 70% Percentage who reported knowing little or nothing about the health insurance exchange or marketplace under the ACA* 64% 68% Percentage who believe they have enough information about the health reform law to understand how it affects them 56% 49% Source: Southward, L.H., et al. (2017). Health Insurance Survey: Knowledge, Attitudes, and Behaviors of Mississippi Residents. Social Science Research Center, Mississippi State University. *Note: Statistically significant difference. 1 of 4 Center for Mississippi Health Policy � Issue Brief: Health Insurance Coverage and the ACA­— Knowledge, Attitudes, and Behaviors of Mississippi Adults � AUGUST 2018 In a departure from previous surveys, more Mississippi adults have a positive opinion of the ACA than have a negative one, as shown in Figure 2 (47% support vs. 38% non-support and 15% unsure). FIGURE 2. SUPPORT FOR THE ACA (2013-2017) SUPPORT FOR THE ACA BY INCOME 50% INCOME PER YEAR SUPPORT 40% < $10,000 68% 30% $10,000 to $29,999 71% 20% $30,000 to $59,999 63% 10% $60,000 to $99,999 46% 2013 2015 2017 Supports ACA Does Not Support Doesn’t Know/Not Sure > $100,000 36% Source: Blackburn, J., et. al. (2013). Health Insurance Knowledge, Attitudes, and Behaviors of Mississippi Residents. Survey Research Source: Southward, L.H., et. al. (2017). Unit, School of Public Health, University of Alabama Birmingham. Southward, L.H., et al. (2015). Health Insurance Survey: Knowledge, Note: Statistically significant difference (p<.001) Attitudes, and Behaviors of Mississippi Residents. Social Science Research Center, Mississippi State University. Southward, L.H., et al. (2017). Health Insurance Survey: Knowledge, Attitudes, and Behaviors of Mississippi Residents. Social Science Research Center, Mississippi State University. As in previous surveys, respondents showed support for many of the components of the ACA, with the notable exception of the individual mandate penalty (Figure 3). CHANGE IN PERCEIVED IMPACT OF THE ACA FIGURE 3. MISSISSIPPIANS’ OPINIONS ON HEALTH REFORM (2017) How do you think that you and your family will be PERCENTAGE (2013)/have been (2017) affected by the ACA? STATEMENT AGREEING 2013 2017 People should be able to buy health insurance in any state if the plan offers better value 91.7% All large employers should be required to provide health insurance to their employees 85.4% There should be subsidies to help low-income people buy health insurance 81.6% Unaffected 18% 47% People with pre-existing conditions should not have to pay more for health insurance 77.9% Children should be able to be covered on their parent’s health insurance policy to age 26 73.9% The Medicaid program in Mississippi should be expanded to cover everyone below the Federal Poverty Level 72.1% Most individuals should be required to have health insurance 58.1% Better Off 22% 17% Penalties or fines should be imposed on people who don’t buy health insurance 18.0% Source: Southward, L.H., et al. (2017). Health Insurance Survey: Knowledge, Attitudes, and Behaviors of Mississippi Residents. Social Science Research Center, Mississippi State University. There was a considerable increase in the percentage of those surveyed who said Worse Off 40% 29% they had enough information about the ACA to understand how it affects them or their families: from 37 percent in 2013 to 54 percent in 2017. As illustrated on the left, 40 percent forecasted in 2013 they would be worse off as a result of the ACA, only 29 percent in 2017 said they were worse off due to the ACA. Almost half Don’t Know 22% 6% (47%) said they were unaffected by the ACA, an increase from 2013 when only 18 percent predicted they would be unaffected. Source: Blackburn, J., et al. (2013). Southward, L.H., et al. (2017). Of those surveyed, approximately 16 percent reported not being currently covered by health insurance, a drop from 23 percent in 2013. By far, the most common (45%) obstacle to having health insurance cited was By far, the most common (45%) obstacle cost. When asked about the Health Insurance Marketplace, over to having health insurance cited was cost. half of Mississippi adults think that the Marketplace has led to higher insurance costs, compared to seven percent who see the Marketplace as lowering costs. Over one-third expressed the opinion that the Marketplace has resulted in a smaller choice of health plans, while one-fifth said the result was a larger choice of health plans. 2 of 4 Center for Mississippi Health Policy � Issue Brief: Health Insurance Coverage and the ACA­— Knowledge, Attitudes, and Behaviors of Mississippi Adults � AUGUST 2018 Responses of the Uninsured Uninsured respondents overwhelmingly perceive health insurance as something they need, but were also significantly more likely to state that insurance is not worth the cost as shown in Figure 4. FIGURE 4. PERCEIVED NEED VS. AFFORDABILITY (2017) INCOME AND THE UNINSURED Of those with household incomes less than Uninsured $10,000 per year, over half (56%) reported being Health Insurance Is Insured uninsured, and over one-quarter (27%) of those Not Worth The Cost* with incomes between $10,000 and $29,999 per year reported being uninsured. In contrast, Health Insurance Is only 6 percent of adults with incomes between Something I Need* $60,000 and $99,999 reported being uninsured, and 3 percent of those with incomes of $100,000 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% or more were uninsured. Source: Southward, L.H., et al. (2017). Health Insurance Survey: Knowledge, Attitudes, and Behaviors of Mississippi IV Residents. Social Science Research Center, Mississippi State University. *Note: Statistically significant difference (p<.001) Approximately a third of the uninsured reported that they tried to enroll in insurance coverage through the Health Insurance Marketplace. Of these respondents, most (52%) said they did not enroll because the plans in the Marketplace were unaffordable. One strategy proposed for making health insurance more affordable is to allow A CHRONIC ISSUE insurers to offer plans with high deductibles and co-pays or fewer benefits in order Most (62%) of those surveyed that did not have to lower the premiums. When asked if they would purchase such a plan if the cost insurance had been uninsured for a year or more, and 43 percent had been uninsured for two or was affordable, 77 percent of the uninsured said they would. When asked what more years. amount they would be willing to pay per month for an affordable plan, more than half (55%) listed a price that was $75 or less. Without substantial subsidies, the price of basic health insurance coverage with reasonable cost-sharing far exceeds the amount people are willing to pay. Access to Care and Health Status ACCESS TO CARE AND HEALTH STATUS BY INSURANCE TYPE (2017) There were significant differences in self-reported health status and access Difficulty Fair or Poor Accessing Care Health Status to care based on the type of health insurance coverage and lack of coverage. Those enrolled in a government-based health insurance plan (i.e. Medicare or Government Medicaid) were more likely to rate their health status as poor or fair than those in Insurance* 32% 49% other insurance categories. Almost half (49%) of those in government insurance programs self-reported their health as poor or fair, compared to 29 percent of the uninsured, 23 percent of those with individual policies, and 19 percent of those with Individual employer-based coverage. The fact that eligibility for government-based programs Insurance* 13% 23% encompasses old age and disability may strongly influence these ratings. Employer-based The uninsured were significantly more likely to report difficulty in accessing health Insurance* 11% 19% care services than those with government coverage, private individual policies, or employer-based insurance. More than half (55%) of uninsured respondents reported not having a regular source of health care, compared to 22 percent of those with individual policies, 18 percent of those with employer-based Uninsured* 62% 29% coverage, and 12 percent of those covered by government programs. Source: Southward, L.H., et al. (2017). *Note: Statistically significant difference (p<.001). 3 of 4 Center for Mississippi Health Policy � Issue Brief: Health Insurance Coverage and the ACA­— Knowledge, Attitudes, and Behaviors of Mississippi Adults � AUGUST 2018 Discussion The findings of this follow-up survey provide insight into the attitudes, opinions, and behaviors of Mississippi adults since the initial survey in 2013. There continue to be low levels of knowledge about the Health Insurance Marketplace and the Affordable Care Act, particularly among uninsured adults in Mississippi. Although there was a significant increase in support of the ACA, less than half of adults favor the law overall, and a very high proportion oppose the individual mandate penalty. However, Mississippians strongly support many of the health reform components in the law, including subsidies for low income individuals and Medicaid expansion. The percentage of Mississippi adults who are uninsured has dropped since 2013, but cost is still the greatest barrier to their obtaining health insurance coverage. The uninsured overwhelmingly perceive value in health insurance coverage, although not to the extent of the insured, but are more likely to state that health insurance is not worth the cost. For those with low incomes, unafforable private coverage and lack of access to premium assisted coverage through an employer, the Marketplace, Medicaid, or other source leave some adults with no other alternative than to remain uninsured. Information on all survey responses can be obtained from the full SSRC report and a chartbook on the Center’s website at www.mshealthpolicy.com. Sources Blackburn, J., Ginter, P.M., Morrisey, M.A., & Rucks, A. (2013). Health Insurance Knowledge, Attitudes, and Behaviors of Mississippi Residents. Final Report, December 16, 2013. Survey Research Unit, School of Public Health, University of Alabama at Birmingham. Prepared for the Center for Mississippi Health Policy. http://www.mshealthpolicy.com/2013-health- insurance-survey. Southward, L.H., Walker, B.H., McCown, J.S., Hanna, H., Patev, A., Mc- Millen, R., & McKee, C. (2015). Health Insurance Survey: Knowledge, At- titudes, and Behaviors of Mississippi Residents. Final Report, June 2015. Family and Children Research Unit, Social Science Research Center, Mississippi State University. Prepared for the Center for Mississippi Health Policy. http://www.mshealthpolicy.com/2015-health-insurance-survey. Southward, L.H., Pellegrine, I., Walker, B.H., & Barr, S.G. (2017). Health Insurance Survey: Knowledge, Attitudes, and Behaviors of Mississippi Residents. Final Report, November 2017. Family and Children Research Unit, Social Science Research Center, Mississippi State University. Pre- pared for the Center for Mississippi Health Policy. http://www.mshealth- policy.com/2017-health-insurance-survey. Plaza Building, Suite 700 120 N. Congress Street Jackson, MS 39201 Phone 601.709.2133 Fax 601.709.2134 www.mshealthpolicy.com 4 of 4 Center for Mississippi Health Policy � Issue Brief: Health Insurance Coverage and the ACA­— Knowledge, Attitudes, and Behaviors of Mississippi Adults � AUGUST 2018