About one month before public insurance exchanges open, less than one-third of the healthiest, lowest-cost population acutally knows about them.
Only 27 percent of the 1,885 19-to-29-year-olds surveyed by the Commonwealth Fund in March knew that they'll be able to buy subsidized insurance through an online exchange starting in October.
That may be somewhat problematic for health insurance exchanges, considering that these young people are needed for functioning risk pools, the Commonwealth Fund's Sara Collins and colleagues said in a report on the survey -- especially when almost half the states are likely to decline expanding Medicaid eligibility. That effectively leaves several million young people earning below100 percent of the federal poverty level uninsured.
"How things turn out will likely depend on outreach efforts and states' decisions on expanding Medicaid," Collins, a health economist, and her colleagues wrote. "Meanwhile, most uninsured young adults living below poverty will not have access to subsidized public or private insurance in states opting out of the Medicaid expansion."
Awareness of health insurance exchanges in the survey was lowest among young people who were uninsured during some part of the previous year (19 percent) and those eligible for subsidized coverage or Medicaid (18 percent). Whether young people knew about the exchanges also varied by education levels: Just over 30 percent of college graduate were aware of exchanges, compared to 20 percent of young adults with a high school diploma or less.
The individual mandate and more robust, more expensive insurance plans are coming as America's young adults face an increasingly competitive economy and stagnating earnings. Many 20-somethings are carrying student loan debt and working hourly-wage jobs -- and something like 36 percent of 18-to-31-year-olds are living with their parents.
Collins and her colleagues found some of those trends appearing in survey results -- costs are likely to be the prime concern for many young people.
"The stereotype of 'young invincibles' assumes that young adults go without health insurance because they believe they do not need it," Collins and colleagues wrote. "But there is considerable evidence suggesting that affordability is the key reason young adults are not enrolled in a health plan."
Among 19-to-29-year-olds surveyed who opted out of their employer's insurance, only 5 percent said they did not need coverage. About 19 percent said they had coverage through a spouse or partner, 22 percent said the coverage was too expensive, and 36 percent said they already had insurance through their parents.
Massachusetts also offers an example of possible success for the ACA in insuring young people. In 2007, after a state individual mandate and subsidies for low-income residents were enacted, the uninsured rate for 19-to-26-year-olds fell from 21 percent to 8 percent.
Still, whether or not subsidized insurance will be affordable for young people and draw them in, there is the inconsistency of Medicaid policy across the states that may sow more public confusion.
The "biggest risk" to enrolling young adults, Collins and colleagues wrote, "is the lack of opportunity to enroll in Medicaid in states that choose not to expand their Medicaid programs."