The ACA's Choice Problem

Association of Funding Cuts to the Patient Protection and Affordable Care Act Navigator Program With Privately Sponsored Television Advertising

Importance

Many individuals eligible for coverage in the Patient Protection and Affordable Care Act (ACA) marketplace remain unenrolled because of information barriers. Whether the private sector or the public sector should conduct outreach to address these barriers is a topic of active debate.

Objective

To determine whether cuts to the funding of the ACA navigator program were associated with changes in the volume of private sector advertising.

Design, Setting, and Participants

Using data from the 2015 to 2019 open enrollment periods, this economic evaluation analyzed the changes in advertising associated with 2017 to 2019 cuts to navigator program funding. A difference-in-difference analysis was used to compare outcomes before and after the cuts in counties with higher and lower exposure to the navigator program. Health insurance advertising was measured using data from Kantar/Campaign Media Analysis Group in collaboration with the Wesleyan Media Project, the most comprehensive data available on local broadcast and national cable advertising. The data set included all counties that met the eligibility criteria for the navigator program from 2015 through 2019. Data were analyzed from August 2021 to May 2022.

Exposures

Counties were classified as having higher or lower exposure to the navigator program according to the intensity of program activity in 2016, before the funding cuts. Counties served only by statewide navigator programs were categorized as lower exposure, while those also served by local navigator programs were categorized as higher exposure.

Main Outcomes and Measures

Number of privately sponsored television advertisement airings for the ACA individual health insurance marketplace during the 2015 to 2019 open enrollment periods in each county, adjusted for population.

Results

All counties in 33 states that met the eligibility criteria for the navigator program from 2015 through 2019 were included in the analysis (2435 counties). Cuts to the navigator program were not associated with changes in the number of privately sponsored health insurance advertisements aired. Results were similar under several alternative approaches including an event study specification.

Conclusions and Relevance

In this study of the association between television advertising and navigator funding in the ACA marketplaces, private sector entities did not increase their advertising to compensate for declines in government-sponsored navigator activity. This finding can inform policy debates about the extent to which the private sector adjusts in response to changes in government outreach, and thus improve the design of state waivers and federal funding allocations.

Experiences of Health Insurance among American Indian Elders and Their Health Care Providers

CONTEXT

American Indian elders have a lower life expectancy than other aging populations in the United States because of inequities in health and in access to health care. To reduce such disparities, the 2010 Affordable Care Act included provisions to increase insurance enrollment among American Indians. Although the Indian Health Service remains underfunded, increases in insured rates have had significant impacts among American Indians and their health care providers.

METHODS

From June 2016 to March 2017, we conducted qualitative interviews with 96 American Indian elders (age 55+) and 47 professionals (including health care providers, outreach workers, public-sector administrators, and tribal leaders) in two southwestern states. Interviews focused on elders' experiences with health care and health insurance. We analyzed transcripts iteratively using open and focused coding techniques.

FINDINGS

Although tribal health programs have benefitted from insurance payments, the complexities of selecting, qualifying for, and maintaining health insurance are often profoundly alienating and destabilizing for American Indian elders and communities.

CONCLUSIONS

Findings underscore the inadequacy of health-system reforms based on the expansion of private and individual insurance plans in ameliorating health disparities among American Indian elders. Policy makers must not neglect their responsibility to directly fund health care for American Indians.