A deeper dive into who is, isn't buying insurance from the exchanges

The third open enrollment period for the health insurance marketplaces under the Affordable Care Act begins Nov. 1 for coverage effective in January, giving the 25 million adults who still lack healthcare coverage the opportunity to sign up.

However, some people may choose not to enroll in a health plan. The Commonwealth Fund's Affordable Care Act Tracking Survey, administered from March to May 2015, identified possible explanations for why people remain uninsured.

The Commonwealth survey was conducted among a random, nationally representative sample of 4,881 adults, ages 19 to 64, living in the United States. 

Here are seven important findings from the survey.

1. One-quarter of all U.S. working-age adults had visited a marketplace to shop for health insurance by May 2015. Even higher rates were reported among young adults and people with low and moderate incomes. Nearly half (47 percent) of adults who visited the marketplaces and shopped for health insurance over the past two years ultimately enrolled in plans, with 30 percent selecting a private health plan and 15 percent enrolled in Medicaid. Two percent either did not know their coverage type or refused to respond.

2. Young adults comprise more than 38 percent of the combined enrollment in marketplace and Medicaid plans among working-age adults, despite concerns young adults would not sign up for coverage.

3. Premiums and out-of-pocket costs had the biggest influence on decisions regarding choice of marketplace plans. Of the 66 percent of adults who had enrolled in private plans through the marketplace for the first time or switched health plans in the most recent open enrollment period, 41 percent said the amount of the premium and 25 percent said the amount of the deductible and copayments were the most important factors in their decision. Twenty-two percent said having their preferred physician, health clinic or hospital included in the plan's network was most important.

4. Adults who visited the marketplace but did not enroll in a health plan largely indicated cost concerns a main reason. More than half (57 percent) of adults who did not enroll in a plan after visiting the marketplaces said they could not find a plan they could afford.

5. Many adults (43 percent) said they did not enroll because they were not eligible for subsidized coverage or Medicaid. An estimated 26 percent fell into the "Medicaid coverage gap," meaning they lived in states that had not expanded Medicaid eligibility at the time of the survey and had incomes under 100 percent of poverty and thereby not eligible for marketplace subsidies.

6. The complexity of the process was too challenging for some consumers. Other adults who did not enroll indicated they felt overwhelmed by the process. Nearly four in 10 adults who did not enroll in a health plan said they found the process of enrolling difficult or confusing.

7. Receiving assistance during the process helped people obtain coverage on the marketplaces. After controlling for demographic differences, the Commonwealth Fund found 78 percent of adults who said they had received assistance enrolled in a marketplace plan or Medicaid. In comparison, only 56 percent of those who did not receive personal assistance ultimately enrolled.

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