Chokshi DA. Young Adults and the Affordable Care Act—Invincible or Convincible? JAMA Forum Archive. Published online October 11, 2013. doi:10.1001/jamahealthforum.2013.0046
As the marketplace for the Affordable Care Act (ACA) opened for business last week, software glitches and the volume of consumer interest prevented some people from accessing the sites, perhaps an encouraging sign of demand. But the success of the ACA hinges not just on the overall number of people who ultimately purchase insurance but also on whether a substantial number of those who sign up are young adults—those aged 18 to 35 years, about 19 million of whom are currently uninsured.
Dave A. Chokshi, MD, MSc
These young adults play an important role in the ACA’s success because they are needed to help balance the insurance risk pool. If the healthier, so-called “young invincibles” don’t enroll in the insurance exchanges, a disproportionate number of older and sicker people purchasing insurance could raise premiums significantly. But will young Americans be convinced by outreach campaigns cajoling them to enroll?
There is some evidence that young adults will respond favorably to expanded health insurance options. As a result of the ACA requirement that dependents younger than 26 years be permitted to stay in or join a parent’s health plan, more than 3 million young people gained health insurance. The proportion of young adults who were uninsured decreased from 48% to 41% between 2010 and 2012, reversing a decade-long trend for the 19-to-25-year age group. This ACA provision resulted in a significant increase in the proportion of young adults who had private coverage for nondiscretionary visits to the emergency department.
Advocacy groups like the pointedly named Young Invincibles argue that young people want and need health coverage, but many cannot afford it. A recent Kaiser Family Foundation poll found that about 75% of young adults believe health insurance is important for them and more than two-thirds agreed that “insurance is worth the money it costs.” Some 67% of 19- to 29-year-olds responding to a Commonwealth Fund survey enrolled in an employer-sponsored plan when it was offered. Among those who chose not to join, only 5% stated they did not need coverage; 55% said they had another insurance source and 22% said the coverage was unaffordable.
A host of challenges to attaining the young adult enrollment goal remain. Some young people may not have access to affordable health plans despite the ACA’s expansion of Medicaid and subsidies for those earning 100% to 400% of the federal poverty level. About 22 states are likely not to expand Medicaid—including Texas and Florida—meaning that young adults in those states earning less than 100% of the federal poverty level may be excluded from subsidized coverage options. And there is no guarantee that those who are eligible for subsidized coverage will be aware of their eligibility.
Creative techniques are being deployed to try to reach the target population. The Department of Health and Human Services and Young Invincibles partnered to sponsor a video contest with prizes of up to $5000 for the best content encouraging young Americans to take advantage of the benefits of health insurance. In addition, microtargeting methods refined in modern political campaigns can draw on a sophisticated demographic breakdown of subpopulations of young adults to customize outreach messages.
However, some messages may remain difficult to distill into succinct points. For instance, in addition to enrolling in regular plans, people up to age 30 years will have the option of using the marketplaces to buy less costly, high-deductible policies that protect primarily against catastrophic health events. Outreach campaigns will have to strike a balance between promoting catastrophic coverage plans and promoting more traditional plans, where healthier young adults can offset a sicker risk pool.
Beyond immediate outreach considerations, the demographic characteristics of uninsured young people should be of interest to clinicians and public health practitioners because they point to opportunities for improving their health.
Mortality differences among individuals younger than 50 years account for two-thirds of the lower life expectancy at birth between US males compared with their counterparts in 16 other high-income countries; among US females, the figure is two-fifths. The 4 major causes of death responsible for the differences were unintentional injuries, including drug overdose; noncommunicable diseases; perinatal conditions, such as pregnancy complications and birth trauma; and homicide.
In a similar vein, a preliminary analysis showed young adults who gained insurance through a parent’s health plan via the ACA were more likely to incur claims related to mental health, substance abuse, and pregnancy compared with an analogous cohort that was previously insured. Finally, although many in the young adult population don’t suffer from chronic diseases, it is a critical period for the development of risky health behaviors such as tobacco use, alcohol use, poor diet, and a sedentary lifestyle.
Effective use of technology is likely to be a linchpin of efforts to attract healthy young adults to health care systems and insurers. For example, the start-up primary care network One Medical Group offers a mobile app and the ability for patients to schedule appointments online and to engage in rapid and secure e-mail communications with their physicians. For routine medical issues—such as immunizations or simple, acute problems like urinary tract infections—young adults may favor retail clinics or electronic or video consultation.
Health plans will have to accommodate these preferences in the design of their benefits. Risk-based contracting, in which payment is contingent on how a provider accomplishes certain health care goals, could drive competition for younger patients, thereby improving care delivery for them. For instance, accountable care organizations might seek a financial return from enrolling patients when they are healthier and investing in cost-effective preventive and wellness interventions for them.
Policy makers, while currently focused on outreach for enrollment, would be wise to simultaneously plan for how the health system will absorb the young adult population—and indeed market those changes as a reason to enroll. As a start, the Patient-Centered Outcomes Research Institute created by the ACA could take on patient engagement for young adults as a priority funding area. There may also be an opportunity to link various White House policy initiatives on prominent health issues for young adults—such as the Office of National Drug Control Policy’s focus on prescription drug abuse, the Office of Science and Technology Policy’s espousal of Blue Button (a program that allows patients to download their own health information), and President Obama’s inclusion of mental health treatment as a pillar of his gun violence proposals—to the importance of health insurance coverage.
Young adults will make their preferences known soon enough. Ultimately, physicians, policy makers, and other patients will have to contend with the ramifications of their choices, however they decide.
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Dave A. Chokshi, MD, MSc Dave A. Chokshi, MD, MSc, is Chief Population Health Officer at New York City Health + Hospitals, clinical associate professor at NYU School of Medicine, and primary care physician at Bellevue Hospital. Previously, Dr Chokshi served as a White House...