There are 7% of uninsured adults, age 18-64, in the U.S., and they are hard to reach, says Linda Blumberg, a senior fellow at The Urban Institute. Yet, the government has high expectations of doing just that. 

“That is the big challenge. Reaching those remaining uninsured who by definition are harder to get,” says Larry Levitt, senior vice president at The Henry J. Kaiser Family Foundation. “The key is reaching the millions who are eligible for subsides and/or Medicaid.”

Part of closing that gap, both Levitt and Blumberg say, will come with the assistance of brokers. “Assisters and brokers are huge here,” Levitt says. But that will get harder, he adds. “Brokers are feeling pinched by lower commissions and the money for navigators may diminish over time,” he explains.

Blumberg believes brokers can play a larger role. The early technology issues on the exchanges turned brokers off from selling in the exchanges, she says. “We need to invest more to make sure that …. IT systems are properly attributing to the broker so they get compensated.”

“The more systems that work for brokers, the more they will be involved and the more they will sell through the marketplace,” she adds.

Levitt says Kaiser data has found brokers are making less for each person they sign up through an exchange, but signing up more people. “They may be working harder, but on average they are maintaining their incomes,” he says.

“Brokers have been an underappreciated force in getting people insured,” he adds. “They have established relationships in communities and they know insurance. There have been a variety of logistical problems that brokers encountered and working through those would help increase signups.”

Who gets the credit?

Overall, the uninsured rate of American adults, age 18-64, was 13% in the first three months of 2015 — down from 2014’s uninsured rate of 16.3%, according to a report by the National Institutes of Health and Centers for Disease Control and Prevention. The largest decreases in the uninsured are in states that operate a state-based marketplace, as compared to those on the federally-facilitated marketplace.

However, it is not clear if the state-run exchanges are making the difference. It is more likely the decreases came through Medicaid expansion. Every state that ran its own exchange also expanded Medicaid, while most states using the federal marketplace did not, says Blumberg.

“It makes it complicated to figure out what the difference is,” Blumberg says. “You have this problem of two different policies at the same time.”

In those states that expanded Medicaid, the percentage of uninsured decreased from 18.4% in 2013 to 10.6% in the first three months of 2015. In the non-expansion states, the percentage of uninsured decreased from 22.7% in 2013 to 16.8% in the first three months of 2015, according to the NIH-CDC report.

In these numbers that are self-reported through the National Health Interview Survey, there is “a complexity of people really not understanding at this point where they are getting insurance coverage from,” Blumberg explains. “That may sound ridiculous, but talk through it.” For example, one can go to the marketplace website and sign up for coverage but actually be eligible for, and then receive coverage through Medicaid. It could also be the case that a consumer went to a broker for coverage and that broker either signed them up through an exchange or for private insurance.

“These differences are not meaningful [to people]. They know they’ve gotten health care coverage,” she says. “Those subtle differences about where and how … [are] lost on a lot of people who get these household surveys.”

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