Reducing Uninsurance by Addressing Administrative Burdens in the Health Insurance Marketplaces

PROJECT SUMMARY/ABSTRACT Over 27 million Americans remain uninsured in 2022, and millions more have lost Medicaid coverage with the end of the Public Health Emergency in 2023. Over 40% of uninsured persons were eligible for large subsidies to obtain coverage through the Health Insurance Marketplaces created by the Affordable Care Act. Health in-

surance is critical to providing access to care and improving health outcomes. While the American Rescue Plan Act greatly reduced affordability barriers to Marketplace coverage, other key barriers to coverage remain un- addressed. Administrative burdens—the compliance, learning, and psychological costs people face when inter-

acting with government services—have a large effect on health insurance coverage take-up. Despite the Market- places’ critical role in providing health insurance coverage to Americans during the COVID-19 pandemic, lim- ited research exists on the effects of administrative burdens on Marketplace enrollment. This proposal’s objec-

tive is to assess how different types of administrative burdens impact Marketplace enrollment. The applicants will use state-of-the-art research methods from economics, public administration, and anthropology to address three specific aims: (1) determine if eliminating premium payment-related compliance costs affects reenroll-

ment in Marketplace coverage; (2) determine whether reducing the burden of information costs through adver- tising affects Marketplace coverage take-up; and (3) create a person-centered understanding of how compli- ance, information, and psychological costs erect barriers to Marketplace coverage. Aims 1 and 2 will use Mar-

ketplace enrollment data and causal inference approaches; Aim 3 will use semi-structured interviews in three diverse states, Arizona, Connecticut, and North Carolina, to study administrative burdens. This mixed methods research addresses a critical need for evidence on cost-effective policies that can reduce the number of unin-

sured, who disproportionately consist of AHRQ priority populations, including racial and ethnic minorities and rural and low-income populations. In so doing, this proposal is directly responsive to AHRQ’s interest in re- search on health insurance coverage, access and affordability, and its special emphasis notice on health services

research to advance health equity. It also is responsive to the President’s executive order on reducing adminis- trative burdens. Results will provide state and federal policymakers with easily implementable approaches to reducing the uninsured rate by making the process of Marketplace enrollment less burdensome. This proposal

is particularly timely with the end of the Public Health Emergency, which will require millions of former Medi- caid enrollees to successfully navigate Marketplace administrative burdens to remain insured. The applicants will directly disseminate findings to Marketplace policymakers and administrators to facilitate translation of

the proposed research into policies that reduce the number of uninsured.