To start with, the transition from children's Medicaid to adult coverage can be bumpy. Nineteen is the age at which kids from lower-income households are generally no longer eligible to be covered as children by the Medicaid or Children's Health Insurance Program. Options for them include moving to adult Medicaid in states that have expanded coverage to 138 percent of the federal poverty level (about $16,000) or buying a subsidized plan on the health insurance marketplace.
"I'm sure there are states that do transitions really well, but I can't point to one," said Shelby Gonzales, a senior health policy analyst who focuses on enrollment and eligibility issues for the Center on Budget and Policy Priorities. "In general, a lot of states are struggling, when [young adults are] being terminated from Medicaid, with getting them on a pathway that's smooth to the marketplace."
Although the transition to adult Medicaid can be problematic, she said, since 31 states and the District of Columbia have expanded coverage
, it is available for some of these young adults.
Clunky computer systems and uninformative coverage notices may make it easier to drop coverage at age 19 than continue it. Sometimes, for example, a young adult will receive a notice explaining that she's no longer eligible for Medicaid under a particular section of the law but not receive information about other coverage options. Or some states don't have a routine process to check if the 19-year-old is eligible for another category of Medicaid after aging out of child coverage. Or she may get sent to the marketplace for coverage, but wind up filling out all the application information from scratch even though her Medicaid file already has the information.
When young people try to apply for coverage on the marketplace, they may run into another snag: difficulty proving their identity
, the first step in the enrollment process. With little or no credit history, they may have to verify their identity by phone or submit documentation that proves they are who they say they are. Such frustrations can lead young people to walk away from the process.
"Any of these are points where you might lose someone," Gonzales said.
Since the health law passed, the uninsurance rate among young people between 19 and 25 has fallen by more than 50 percent, according to the Centers For Medicare & Medicaid Services. But young adults are still more likely than other adults to be uninsured.
The Obama administration has acknowledged the difficulty in transitioning young people from Medicaid or their parents' policies to other coverage. It noted that at age 19, the uninsured rate jumped nearly 7 percentage points in 2014, according to the Census data, while 26-year-olds' rate of uninsurance increased 4 percentage points as they aged off their parents' plans.
New restrictions on special enrollment periods (SEPs) may also pose a particular problem for young people, experts say. If people experience certain life events they can qualify for a special enrollment period during the middle of the year to pick a new plan. Insurers complained that people were using a special enrollment period to sign up for coverage in order to receive medical treatment, then dropping coverage after they got the care that they needed. So the Obama administration said that it will begin to require that people document
that they really did experience some of the most common life events that have triggered the new enrollment, including marriage, the birth of a child, loss of another type of coverage and a permanent move.
Young people are disproportionately affected by these events, experts say. In addition to marriage and childbirth, young adults between ages of 20 and 29 relocate at twice the rate
(PDF) of older adults, according to Young Invincibles, an advocacy organization for young people.
"I think the new documentation requirements regarding SEPs could really backfire, and the result could be different than the administration intends," said Sabrina Corlette, research professor at the Georgetown University Center on Health Insurance Reforms.
One of the challenges of insuring young adults is convincing them that they need it. Many young adults are relatively healthy, and when money is tight, health insurance may seem like a luxury they can forego. Young Invincibles is trying to get the word out that marketplace coverage can be extremely affordable with premium tax credits and cost-sharing subsidies, said Erin Hemlin, the group's national director of training and consumer education. They also highlight the preventive care benefits that are available in all marketplace plans at no charge to consumers.
For young women, the savings in the monthly cost of birth control pills alone may be enough to get them to sign up, Corlette said health insurance counselors have noted. "For young women, they say birth control is the No. 1 selling point."
In the long run, as having health insurance becomes routine for more and more people, that may affect young people as well, said Katherine Hempstead, who directs the Robert Wood Johnson Foundation's work on health insurance coverage.
"Think about how coverage by kids is growing," she said. "We may be talking about decades, but norms are changing."