Young adults and US healthcare reform: views and marketing strategy

Abstract

The Patient Protection and Affordable Care Act (PPACA) was created to provide affordable health care to all Americans. Though this legislation became law in 2010, there remains much interest, uncertainty and controversy among Americans in regards to the bill’s provisions. Younger Americans are likely to face higher insurance premiums once the PPACA is fully implemented in 2014, but they may also benefit from a provision which allows young people to remain on their parents insurance to age 26. Yet, no research to date has explored the perceptions of college students regarding their views of the PPACA. This exploratory study will examine college students’ awareness of the PPACA and perceptions regarding the main provisions of the PPACA, and investigate how college students search for healthcare information.

Keywords

Health care debate marketing communication young adults health care reform health care system

Introduction

In March 2010 the US Congress passed, and President Obama signed into law, the Patient Protection and Affordable Care Act (PPACA). According to Healthcare.gov, the PPACA ‘puts in place comprehensive health insurance reforms’ with the goal of increasing access to affordable health care for individuals, families, seniors, and businesses by ‘[holding] insurance companies more accountable, [lowering] health care costs, [guaranteeing] more health care choices, and [enhancing] the quality of health care for all Americans’.¹ Starting in 2010 and continuing through 2014, the PPACA will be implemented; attempting to give individuals with or without insurance, small business owners with a desire to provide health coverage to employees, and Medicare recipients more control over decisions regarding health coverage.¹

While the PPACA is in only the initial phases of implementation and its overall success remains to be seen, there is already an effort, particularly by the Republican Party (‘Grand Old Party’, or GOP) and the tea-party movement, calling for a repeal of the act, which some feel is unconstitutional.^2,3 In contrast, President Obama believes that ‘reform is not a luxury, but a necessity’, and although several objections have been raised concerning the legality of the PPACA, even the bill’s opponents feel there is a need for reforming the overall healthcare system in the USA.⁴ The disparity here arises in how the government should go about making the necessary revisions, and specifically which entity, the state or federal government, has the authority to formulate the terms for the healthcare system reorganization.⁵ Furthermore, the PPACA has been challenged as a reform of the insurance industry in America rather than a comprehensive overhaul of current healthcare system standards.^6,7

Though there is much interest and controversy among Americans in regards to the bill’s provisions, no research to date has explored the perceptions of college students regarding their views of the PPACA. College students may be impacted by the PPACA in a positive manner by being eligible to remain on their parents’ health insurance to age 26; however, younger Americans are likely to face higher insurance premiums once the PPACA is fully implemented. This exploratory study will examine college students’ awareness of the PPACA, perceptions regarding the main provisions of the PPACA, and investigate how college students search for healthcare information.

Overview of the affordable care act

Transition from the former system

Prior to the passing of the Affordable Care Act in 2010, the federal and state governments shared responsibility for regulation of health insurance. The majority of large firms, as well as self-insured firms, were regulated by the federal government, namely through three federal laws: (i) the Employment Retirement and Security Act (ERISA); (ii) the Health Insurance Portability and Adjustment Act (HIPAA); and (iii) the Consolidated Omnibus Budget Reconciliation Act.⁸ Individually, state governments, unlike the federal government, had the ability to mandate ‘guarantee-issue rules’ whereby they could require ‘insurance firms to offer insurance [policies] to individual applicants in the individual market’.⁸ Three methods were used by state governments for regulating insurance rates: (i) rate band, or using health status information such as age or gender to set rates; (ii) modified community rating, whereby no current health status information may be used in determining rates; or (iii) pure community rating, which provides for one standard premium for all occupants of the state.⁸ The Affordable Care Act, in effect, changed the ways in which federal and state governments oversee insurance regulations, specifically transferring the majority of the decision-making and regulatory power to the federal government.

Call for reform

According to the World Health Organization’s World Health Statistics Report, the per capita health expenditures in the USA have continued to increase annually. Specifically, from 2000 to 2007, total healthcare-related expenditures increased from $4703 to over $7300 per capita with government health expenditures accounting for approximately 43% and 45%, respectively.^9,10 Additionally, these expenses, as a percentage of national GDP, increased from 13.4% to 15.7%, and the trend is believed to continue upwards if effectual measures are not endorsed to control such spending.⁹ Moreover, while the USA is regarded as having the ‘most expensive health care system in the world’,⁹ nearly double the average of other developed countries, the value to Americans is believed to be disproportionate to the costs.¹¹ Yet the USA ranks poorly (29th among industrialized countries) for infant mortality rates¹⁰ and has low disability-adjusted life expectancy, or the number of ‘healthy years’ expected on average for adults in a given population.⁹

Furthermore, according to the Democratic Policy Committee (DPC), in 2009, 14,000 Americans were losing their health insurance policies daily and insurance for families purchased through employers increased by $5908 on average per policy from 2000 to 2008. The DPC projected that without immediate legislative intervention family healthcare costs would ‘skyrocket’ by $11,611 per family bringing the total annual costs to $24,291 per policy. It is estimated that premiums for employer-sponsored insurance policies have increased at a rate of approximately three times faster than that of wages over the past 9 years.¹⁰

High unemployment rates are also perceived to affect the costs of insurance as a one percent decline in employment is expected to result in approximately 1.1 million uninsured Americans. Correspondingly, this would also increase enrollment in the Medicaid and Children’s Health Insurance programs by one million.¹⁰

Finally, a ‘hidden health tax’ is believed to be imposed on Americans who can afford health insurance in order to cover the costs of uninsured individuals in desperate need of medical care without the financial means to pay for it. For these reasons and more, members of the US government were called as representatives of their constituents to reform healthcare spending and the overall healthcare system.

Main provisions of the PPACA

The overarching goals of the PPACA, as explained by Healthcare.gov are threefold:¹

to establish a modernized and competitive health insurance market;

to ensure accountability by insurance companies; and

to stabilize the US budget and economy.

The result of these goals in action is a 2400+ page document that addresses 10 specific topics, as well as the amendments, which were made throughout the legislative process.¹ This study will attempt to address some of the more publicized and comprehensive components of the PPACA. The 10 all-embracing topics include: Title I. Quality, Affordable Health Care for All Americans; Title II. The Role of Public Programs; Title III. Improving the Quality and Efficiency of Health Care; Title IV. Prevention of Chronic Disease and Improving Public Health; Title V. Health Care Workforce; Title VI. Transparency and Program Integrity; Title VII. Improving Access to Innovative Medical Therapies; Title VIII. Community Living Assistance Services and Supports Act (CLASS Act); Title IX. Revenue Provisions; Title X. Reauthorization of the Indian Health Care Improvement Act. Each of these ‘Titles’ encompasses one of the subcomponents of the overall attempt to reform health care through the PPACA.

From the aforementioned components come several of the most well-known provisions because of their broad reach and appeal. This study looks at five of the most prevalent healthcare reforms. According to the Medical Device Daily, ‘by 2019, the House bill is projected to cover 96% of all Americans and the Senate bill, about 94%’.⁶

First, the Pre-Existing Condition Insurance Plan will guarantee coverage for people who have been denied health insurance by private insurance companies because of a pre-existing condition. This allows for primary, specialty, and hospital care, as well as prescription drug benefits, without charging a higher premium for previous conditions and without regard to income status for eligibility.¹²

Additionally, tax credits of up to 35% will be offered to employers with fewer than 25 employees to provide health insurance coverage. One of the main concerns with this portion of the bill is that some people speculate if a mandate were to be enforced requiring small business owners to purchase insurance for employees, it would lead to unemployment. One of the reasons is that typically uninsured workers are paid within $3 of the minimum wage and employers cannot afford to absorb the additional costs for providing these employees with insurance. Even if the PPACA provides tax credits, for many small businesses the overall costs are still too expensive for the company to bear. Additionally, a large portion of the target market for the government healthcare plan, such as minorities, inexperienced workers, unmarried, and single parents also make up a significant portion of those likely to lose their jobs should the healthcare mandates under this provision be successful.¹³

Further, the act is expected to increase the life of the Medicare Trust fund to at least 2019. This particular provision is aimed at reducing the costs of Medicare spending without reducing patient care. The overall goal is to streamline the payments systems and make the overall process of receiving and using Medicare more efficient so as to reduce the costs without causing an overall reduction in the quality of care.¹⁴

Additionally, parents and guardians will generally be able to insure children in their care who are under age 26 as long as their policy allows for dependent coverage. This has been a major concern in the past as nearly one-third of adults aged 19–29 go without health insurance, which is the highest proportion of any age group.¹⁵ Additionally, this age group is much more likely to forgo medical services due to costs than any other age group. Unfortunately, this specific provision has not reduced the rate of uninsured individuals within this age group thus far.¹⁵

Finally, subsidies are available through sliding scale tax credits to buy insurance if a family is making less than $88,000 per year (per family of four).¹ The plans will ensure free preventative care services for families and cap out-of-pocket expenditures for items such as deductibles and co-pays.¹⁶

Marketing strategies implemented

Tools used to market the PPACA

Prior to signing the PPACA into law, President Obama was already marketing the new government website, Healthcare.gov, which explores and reports on healthcare reform initiatives. Members of the GOP were not pleased about his publicizing the use of this website before the act was officially sanctioned and went so far as to call his exclusive interview with ABC in 2009 an ‘infomercial’, to which ABC responded negatively.¹⁷

Overall, the website is one of the most useful and interactive tools for finding information about the PPACA, seeing a timeline of when the provisions will be enacted, and for finding a copy of the bill in its entirety. Moreover, the website has links to Facebook, YouTube, and Twitter pages representing the PPACA. Additionally, both the Democratic and the Republican Policy Committees’ websites display information tracking the progress of the act; however, the majority of the information is heavily weighted toward each party’s own political opinions.

Representatives from the US Department of Health and Human Services said that although the literature provided in government offices was updated to reflect the changes in the bill, no new marketing materials were actually produced for the purpose of marketing the bill. Therefore, the aforementioned initiatives have been essentially the only marketing tools used to publicize the ACA aside from local news media and lobbyists, which are not directly affiliated with the government.

Effectiveness of the PPACA

Over a year after the bill was signed into law, Americans are still confused and skeptical about the PPACA. In a public opinion survey by the Kaiser Family Foundation, 52% of the population says that they are not sufficiently informed about the act to make a decision as to whether it will benefit them. Of those with annual household incomes of less than $40,000, only 38% of people believe they know how the bill will personally affect them. Additionally, 6 in 10 uninsured people – another primary target market for the PPACA – do not know how this bill will affect them.¹⁸

Furthermore, both supporters and critics are having a hard time swaying the public either way as to the eventual success of the bill. Opposition is nearly completely drawn along party lines with 82% of Republicans opposing the bill and 71% of Democrats supporting it. Additionally, with the exception of the personal mandate requiring all individuals without insurance to pay a fine, which a high percentage of people would like to see repealed, there is no majority support on the individual provisions or on the bill as a whole, even along party lines. For example, Republicans are split as to whether the act should be repealed altogether, undergo extensive amendments, or be appealed and replaced with a version found suitable by Republicans.¹⁸

The PPACA has sparked interest and controversy among Americans in regards to the bill’s provisions. This study explores the perceptions of college students regarding their views of the PPACA. This population is of particular interest because it is expected that premiums will rise for young adults with the advent of health exchanges.¹⁴ Thus, this is a group that is likely to be adversely impacted economically by the new law compared with the amount they currently pay for insurance premiums. In addition, this study seeks to explore college students’ views regarding the marketing of the PPACA, as the need to market the new law has been identified as a key to its success in that Americans must feel a shared stake for it to succeed.¹⁹

Methodology

A total of 126 college students were surveyed at two different universities, one public and the other a private institution. Questionnaires were distributed on campus in public areas and in classes that agreed to participate. No incentives were provided for participation. The questionnaire contained items pertaining to awareness of the PPACA, level of interest and support for provisions of the PPACA, perceptions of marketing strategies related to healthcare information, and demographics.

The demographic profile of the respondents is shown in Table 1. Most respondents were between the ages of 18 and 25 and were almost evenly divided between men and women. The respondents also represented a variety of ethnic/racial backgrounds. Answers to questions pertaining to the Affordable Care Act were compared between respondents from each institution. There were no significant differences.

Table 1.

Demographic profile of respondents

	N	%
Private university	90	71
Public university	36	29
18–25	118	94
26–64	8	6
Male	60	49
Female	63	51
Asian – Indian	2	2
Asian – Oriental	6	5
Black or African-American	6	5
Hispanic or Latino	48	39
Middle Eastern	1	1
White (not Hispanic)	51	41
Multi-ethnic	7	6
Other	3	2

Results

Students were asked about their awareness and perceptions of the PPACA. As shown in Table 2, fewer than half (44%) of the respondents had heard of the Patient Protection and Affordable Care Act that was passed in 2010. Yet slightly more than half (53%) believed that there is a need for such an act; even though only one-quarter (25%) believed that the PPACA would be beneficial to them, and another 4 out of 10 (38%) were uncertain whether they would benefit from the PPACA.

Table 2.

Questions about the PPACA (n = 126)

	%
Have you heard of the PPACA that was passed in 2010 as part of the U.S. government’s strategy for healthcare reform?
Yes	44.4
No	49.2
Not sure	6.3
Do you believe there is a need for an act such as the Affordable Care Act?
Yes	53.2
No	24.6
Not sure	22.2
Do you believe the Affordable Care Act will be beneficial to you?
Yes	24.6
No	37.3
Not sure	38.1
Would you participate in the government health insurance plan offered by the Affordable Care Act once it has fully taken effect in 2014?
Yes	22.2
No	29.4
Not sure	48.4
What age group do you believe will benefit most from the Affordable Care Act?
Under age 18	6.6
Ages 18–25	17.4
Ages 26–64	43.0
Ages 65 and over	33.1

PPACA, Patient Protection and Affordable Care Act.

Likewise, only 2 out of 10 (22%) college students would participate in the government health insurance plan offered by the Affordable Care Act once it fully takes effect in 2014, and almost half (48%) are not sure whether they would participate. Perhaps one reason that these students do not believe that they will benefit from the PPACA is that they believe that the groups who will benefit most are those aged 26–64 (43%) or 65 or over (33%).

Respondents were asked to evaluate the importance and their level of support for five provisions of the PPACA. As shown in Table 3, of those provisions evaluated, the pre-existing condition insurance plan that will ensure coverage for those who have been denied health insurance by private companies owing to pre-existing conditions was deemed most important (µ = 3.97), followed by the ability for parents to insure dependents under age 26 (µ = 3.69). There was also support for subsidies to buy insurance if, for example, a family of four is making less than $88,000 per year (µ = 3.39) and tax credits up to 35% for employers with fewer than 25 employees to provide health insurance coverage (µ = 3.14). The only provision that did not receive strong support was related to extending the Medicare Trust Fund to 2029 (µ = 2.90). While the level of support for these provisions generally mirrored the perceived importance, college students rated parents being able to insure children under 26 as the provision that they most supported (µ = 3.75), followed by coverage for pre-existing conditions (µ = 3.62).

Table 3.

Perceived importance and level of support for provisions of the Affordable Care Act

	Importance (mean)	Level of support (mean)
The Pre-Existing Condition Insurance Plan will ensure coverage for people who have been denied health insurance by private insurance companies because of a pre-existing condition	3.97	3.62
Parents will generally be able to insure children under age 26 as long as their policy allows for dependent coverage	3.69	3.75
Subsidies might be made available to buy insurance if the family is making less than $88,000 per year (per family of four)	3.39	3.14
Tax credits of up to 35% will be offered to employers with fewer than 25 employees to provide health insurance coverage	3.14	3.07
The life of the Medicare Trust fund is expected to be extended to at least 2029	2.90	2.89

1 = very unimportant; 5 = very important.

When asked whether they had seen any marketing materials regarding the Affordable Care Act, less than 10% of college students reported having seen such marketing, as shown in Table 4. Those who reported seeing marketing materials for the Affordable Care Act were asked which media the government had used for this purpose. All reported having seen marketing for the Affordable Care Act on television (100%), with the Internet (33.3%), radio (25%) and newspapers (25%) mentioned by three or more students. All respondents were then asked which media the government should use to market the Affordable Care Act. The Internet, other than social media, was the most popular response (81%) followed by television (77%), newspapers (63%), radio (46%), social media such as Facebook (44%), magazines (36%), direct mail (35%), signage such as billboards (22%), and sponsorships (18%).

Table 4.

Marketing and the Affordable Care Act

	N	(n = 12) Did use¹ (%)	(n = 126) Should use² (%)
Have you seen any marketing materials regarding the Affordable Care Act?
Yes	12
No	94
Not sure	20
Television		100.0	77.2
Radio		25.0	45.5
Internet, other than social media		33.3	81.3
Newspapers		25.0	62.6
Magazines		8.3	35.8
Direct mail		8.3	35.0
Social media (such as Facebook)		16.7	43.9
Signage (such as billboards)		8.3	22.0
Sponsorships		0.0	17.9

Which of the following media did the government use to market the Affordable Care Act?

Which of the following do you think the government should use to market the Affordable Care Act?

As shown in Table 5, when students were asked where they search for information about health insurance, the top answer given was the Internet (84%), followed by friends/family (63%), insurance company (43%), doctor (41%), broadcast media (28%), co-worker (18%), magazines (16%), and books (10%). Therefore, the government’s use of ‘www.healthcare.gov’ appears to be a good strategy for those seeking information. The challenge, however, appears to be creating marketing messages that generate awareness of the PPACA and the website.

Table 5.

Where would you search for information about health insurance?

	(n = 126) %
Internet	84.1
Friends/family	62.7
Insurance company	42.9
Doctor	41.3
Broadcast media	27.8
Co-worker	18.3
Magazines	15.9
Books	10.3

Discussion and limitations

This study offers the first examination of college students’ views of the PPACA. Overall, American college students are generally unaware of the PPACA and do not believe that it will benefit them. This low level of awareness is somewhat surprising given the amount of media coverage and political commentary devoted to the act over the past year and the prior calls for reform of the US healthcare system.²⁰ Even so, college students are generally supportive of the PPACA; especially the provisions related to the ability for parents to insure children up to age 26 and coverage for pre-existing conditions. These provisions are likely to be more central for college students who seek to remain on their parents’ health insurance policy while they are pursuing higher education and for those who may have pre-existing conditions that may impact obtaining insurance as they leave college and seek employer health coverage. Thus, these provisions may address the more immediate issues facing this population.

Interestingly, few college students believe they will participate in the government health insurance plan. Instead, they believe that middle-aged Americans will be the group most likely to benefit from the Affordable Care Act. Another US medical insurance plan, Medicare, currently provides insurance for persons with a disability and/or based on age (i.e. age 65 and above). Therefore, college students may believe that the PPACA is supplementary to Medicare and not intended to provide insurance coverage for those 65 and older.

This exploratory study also confirms the need to market the PPACA. Few college students reported having seen marketing for the PPACA, though they believed that modern approaches such as the Internet and social media, as well as traditional media such as television, radio, and newspaper, would be effective. The use of the Internet is particularly supported as this is the most cited tool used by college students when seeking health insurance information. Other sources that college students turn to for health insurance information include friends/family, insurance companies, and doctors. That college students turn to insurance companies for information may be problematic as they are among the potential ‘losers’ in the reform, and the National Association of Health Underwriters (NAHU) has repeated earlier calls for changes in the Affordable Care Act and vowed to re-fight PPACA battles.^6,21 The need to market the PPACA is further reinforced by those who claim that without a better understanding of and support for the act, it is doomed to fail.¹¹ While young Americans, it could be argued, have the most to lose financially from the PPACA they seem not to be aware that they could be negatively impacted.

This study reveals that college students are generally uninformed regarding the PPACA and its implications for them. Yet, it should be noted that this is an exploratory study among undergraduate college students at two universities. Future researchers are encouraged to expand the study and examine these issues for all provisions of the PPACA. Though no significant differences between the two types of university students (private vs. public) were identified, other characteristics of the population such as income, employment, political affiliation, and current insurance coverage may reveal differences in perceptions related to the PPACA. Therefore, future researchers are also encouraged to examine these demographic characteristics to determine whether they impact views of healthcare reform in general and the PPACA specifically. Furthermore, college students reflect a segment of the young adult population in the USA that is more highly educated than the average young adult. Those with less education should also be included in future research to determine whether there are difference in perceptions of the PPACA based on level of education.

Footnotes

Author's Biographies

Kristina K. Lindsey is the Cost Control Administrator at Creative Resource Group (CRG) for the Pandora Methanol LLC Startup Project, Nederland, TX, USA. She holds a BBA in Marketing from St. Mary’s University in San Antonio, TX, USA.

Deborah F. Spake is an Associate Dean and a Professor of Marketing at the Mitchell College of Business at University of South Alabama, Mobile, AL, USA. She holds MA and PhD degrees from the University of Alabama. She is the author of articles in the areas of health care marketing, service marketing, advertising management, business ethics, and marketing. education.

Mathew Joseph is the Emil C.E Jurica Distinguished Professor of Marketing at St. Mary’s University, San Antonio, TX, USA. He holds an MBA degree from the Southeast Missouri State University and a PhD degree from the University of Waikato in New Zealand. He is the author of a number of articles in the areas of cross cultural marketing, service quality, marketing strategy, health care marketing, electronic marketing, service technology, international advertising and promotion, marketing to Asia and Latin America, and marketing education.

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