Awareness and Experience with Affordable Care Act Insurance Exchanges: Perspectives from Low-Income Adults in Two Nonexpansion States

The success of the Affordable Care Act (ACA) and its policy goal of increasing health insurance coverage across the United States, particularly for low income populations, rests in part on community-based outreach activities focused on consumer education and strategies to encourage sign–up. This paper draws on focus group data collected to evaluate and learn from one such community effort, located in a two-state region with significant political opposition to the ACA. Specifically, the research objectives were to better understand low income consumers’ experiences with ACA marketplaces during the initial sign–up period, both barriers and facilitators, and to learn what improvements they recommend for future outreach efforts. Focus group results show very limited knowledge of basic insurance concepts as well as the ACA. Participants reported numerous technological and related access barriers, which further complicated sign–up and caused them to lose confidence and become suspicious of the process. When asked how best to provide information and assistance to individuals such as themselves, participants pointed to several reasons conventional outreach might not be effective and suggested alternative strategies. Although public attention has focused on technical aspects of ACA sign–up, our findings suggest that future obstacles for those who remain uninsured are also likely to be related to perceptions and culturally–based understandings of “Obamacare” and how insurance works. This study underscores the importance of incorporating trusted, community relationships into efforts to expand coverage.