1. © Transamerica Center for Health Studies, 2013 Transamerica Center for Health Studies SM Survey: Pulse Check on Health Care Coverage Perceptions and Readiness – 5 Weeks into Open Enrollment November 2013 TCRS 9999-9999

2. www.transamericacenterforhealthstudies.org/ About the Transamerica Center for Health Studies SM Page 3 About the SurveyPage 4 MethodPage 5 Executive SummaryPage 6 Detailed FindingsPage 8 Awareness of the ACA, Health Insurance Options and Preparedness Page8 Preparations for Individual MandatePage19 Pre-Existing Medical Condition and the ACA’s Impact on Health Insurance Page24 DemographicsPage 27 Table of Contents 2

3. www.transamericacenterforhealthstudies.org/ The Transamerica Center for Health Studies SM (TCHS) informs the national health care conversation, bringing clarity to the complex decision-making regarding health coverage and personal health and wellness. Through its broad-based analysis and research findings, TCHS offers consumers and employers a guide to navigate the financial implications of the health care decisions they are facing. TCHS engages with the American public through national surveys, its website, research findings and consumer guidance. TCHS also collaborates with health care experts and organizations that are equally focused on health coverage and personal health and wellness. A division of the Transamerica Institute, a nonprofit, private foundation, TCHS is dedicated to identifying, researching and analyzing the most relevant health care issues facing consumers and employers nationwide. The Transamerica Institute is funded by contributions from Transamerica Life Insurance Company and its affiliates (not a major medical insurer) and may receive funds from unaffiliated third parties. About the Transamerica Center for Health Studies SM 3

4. www.transamericacenterforhealthstudies.org/ In September 2013, TCHS released findings of its inaugural national survey of the U.S. General Adult Population and business Employers regarding their attitudes toward health care. The overall goals for the study were to illuminate emerging trends, promote awareness, and help educate the public. TCHS then conducted a brief follow-up survey among the General Adult Population regarding their attitudes towards health care in November 2013 – then five weeks into the ACA open enrollment period. Harris Interactive was commissioned to conduct the survey for TCHS. TCHS is not affiliated with Harris Interactive. About the Survey 4

5. www.transamericacenterforhealthstudies.org/ A 7-minute online survey was conducted November 5-11, 2013 among a nationally representative sample of 1,005 members of the U.S. General Adult Population using the Harris online panel. Among the respondents: All were U.S. residents aged 18–64. Data were weighted (statistically adjusted) on income, education, gender, race/ethnicity, region, employment status, number of employees in company, and health insurance status to: Account for differences between the population available via the Internet versus by telephone. Be a representative sample of the U.S. General Adult Population age 18-64. The following sub-samples were achieved: – Black/African American: 121 – Hispanic: 161 – Uninsured: 221 Percentages were rounded to the nearest whole percent. Differences in the sums of combined categories/answers are due to rounding. Terminology: – ACA: Affordable Care Act – Gen Pop: General adult population age 18-64 – *Denotes proportion between 0 and 0.5% (unless otherwise noted) Method 5

6. www.transamericacenterforhealthstudies.org/ Executive Summary The General Population is now more informed about the ACA and feels more prepared for the ACA now than they did in July. However, a majority has still not taken any action to prepare for the ACA in the last 12 months. Majorities of the General Population are informed about the ACA (60 percent) and feel prepared in the face of the ACA mandate (72 percent). Both of these measures are up from levels seen in July (48 percent and 63 percent, respectively). Though the level of preparedness has increased, this does not necessarily mean an increased level of activity among the General Population. Fifty-nine percent have done “nothing” in the past 12 months to prepare for the ACA. Six percent of the General Population responded that they plan to purchase health insurance through the new Exchange. However, to-date, 2 percent indicate having done so. A majority (57 percent) plan to keep their current insurance. Only 5 percent said they plan to not purchase health insurance and pay the tax penalty Many (21 percent) are still not sure what they will do when the insurance mandate takes effect. Over half (51 percent) of those employed say either their employer has not provided information to them about the ACA (34 percent) or that they do not know if their employer has done so (17 percent). A few of those employed say their employer has provided a summary or detailed description of the law and its impacts (15 percent) or even a comparison of how health insurance costs may change (11 percent). 6

7. www.transamericacenterforhealthstudies.org/ Executive Summary A notable portion of those with a pre-existing medical condition believe they stand to benefit from the implementation of the ACA. While nearly three in ten (29 percent) have a pre-existing condition, almost 10 percent of the General Population have had a pre-existing condition and were unable to find a provider that would provide them coverage (3 percent) or were unable to afford health insurance with the condition (6 percent). Among those unable to access or afford health insurance due to a pre-existing medical condition, 35% say they can now get health coverage as a result of the ACA. Although directly affected by the ACA, the uninsured now have more questions than answers as the deadline for the individual mandate approaches. Despite their low level of satisfaction with the quality of the health care system they have access to (34 percent versus 84 percent among both privately and publicly insured individuals), those uninsured are less informed about the ACA (42 percent being “very” or “somewhat” informed) as compared to those who are privately (64 percent) or publicly (65 percent) insured. In fact, 31 percent of those uninsured haven’t even heard of the new health insurance Exchanges. Further, a majority (55 percent) of those uninsured say they are “not sure” what they plan to do in response to the individual mandate. As the mandate approaches, the percentage of uninsured who feel informed about their healthcare options actually dropped, with those saying they are “very” or “somewhat” informed declining from 56 percent in July to 42 percent in November. A strong majority (71 percent) of the General Population have not noticed a change in their health care choices as a result of the ACA. A small portion of people (8 percent) reported their employers now offer health insurance due to the ACA, and even fewer (5 percent) reported their employers no longer offer health insurance. 7

8. www.transamericacenterforhealthstudies.org/ Detailed Findings: Awareness of the ACA, Health Insurance Options and Preparedness

9. © Transamerica Center for Health Studies, 2013 BASE: All Qualified Respondents (July n=2505; November n= 1005) Q1005. How informed do you feel about your current options for health insurance (i.e., major medical insurance)? B A 7570 Informed of Health Insurance Options However, the portion of the General Population who feel informed in November (70 percent) is smaller than the portion in July (75 percent). Most of the General Population are at least somewhat informed of their health insurance options. Letters denote significantly greater proportion than the proportion of the indicated group 9

10. © Transamerica Center for Health Studies, 2013 BASE: All Qualified Respondents (Privately insured: n=617; Public insured: n=177; Uninsured: n=211) Q1005. How informed do you feel about your current options for health insurance (i.e., major medical insurance)? Informed of Health Insurance Options by Insured Status However, fewer than half of the uninsured population feels informed about their current health insurance options. 81 71 42 Among uninsured, 56 percent felt “very” or “somewhat” informed in July In fact, the uninsured population is less informed now (42 percent) than they were in July (56 percent). 10

11. © Transamerica Center for Health Studies, 2013 BASE: All Qualified Respondents (July n=2505; November n= 1005) Q1915. How informed are you about the Affordable Care Act, also known as healthcare reform, the ACA or sometimes called Obamacare? A A B 48 60 A Informed about the ACA The General Population are more likely to say they are “very” or “somewhat” informed now (60 percent) than they were in July (48 percent). A majority of the General Population is at least somewhat informed about the ACA. Letters denote significantly greater proportion than the proportion of the indicated group 11

12. © Transamerica Center for Health Studies, 2013 BASE: All Qualified Respondents (Privately insured: n=617; Public insured: n=177; Uninsured: n=211) Q1915. How informed are you about the Affordable Care Act, also known as healthcare reform, the ACA or sometimes called Obamacare? Informed about the ACA by Insured Status 64 65 42 12 Those uninsured (42 percent) are less likely than those privately (64 percent) and publicly (65 percent) insured to say they are “very” or “somewhat” informed about the ACA. Less than half of the uninsured population feel at least somewhat informed about the ACA.

13. © Transamerica Center for Health Studies, 2013 BASE: All Qualified Respondents (n=1005) Q1950. How are you familiar with the new Exchanges such as healthcare.gov through which you can buy health insurance for 2014, if at all? Familiarity with New Health Insurance Exchanges While 85 percent of all the General Population are familiar with the new Exchanges, the uninsured population is less likely than those privately insured to be familiar with the new Exchanges (69 percent versus 90 percent). A vast majority of the General Population are familiar with the new health insurance Exchanges. Gen Pop Privately Insured Public Insured Uninsured Heard of Exchanges (NET) 85908269 I have visited one of the Exchange websites. 19181016 I have heard of the Exchanges and may go to one of the websites or call in the future. 1514827 I have called one of the Exchanges. 45** I have spoken to a navigator or guide for an Exchange. 4411 I have heard of them but have no need to visit the websites or call. 49576228 I haven’t heard of them. 15101831 13

14. © Transamerica Center for Health Studies, 2013 BASE: If Heard Of Exchanges (n=830) Q1955. From what source(s) did you hear about the new Exchanges such as healthcare.gov? Please select all that apply. Source of ACA Information A third (34 percent) have heard about them through advertising; and about three in ten heard about them from friends and family. Over half (58 percent) of those familiar with the new Exchanges heard about them through news programs on television or radio. 14

15. © Transamerica Center for Health Studies, 2013 BASE: All Qualified Respondents (July n=2505; November n= 1005) Q1940. As you may know, the ACA insurance mandate will go into effect in January 2014 and January 2015. In January 2014, individuals will need to have health insurance or pay a fine for opting out of health insurance. In January 2015, employers with 50 or more employees will be required to provide health insurance for all full-time employees. Knowing this, how prepared are you to make decisions regarding your health insurance choices by then? A B 63 72 A Preparedness to Make Health Insurance Choices after the ACA Mandate The General Population’s level of preparedness has increased since July (63 percent) with now 72 percent feeling at least somewhat prepared. Over seven in ten feel prepared to make decisions once faced with the ACA mandate on January 1*. *Survey was administered before open enrollment was extended to March 31. Letters denote significantly greater proportion than the proportion of the indicated group 15

16. © Transamerica Center for Health Studies, 2013 BASE: All Qualified Respondents (Privately insured: n=617; Public insured: n=177; Uninsured: n=211) Q1940. Knowing this, how prepared are you to make decisions regarding your health insurance choices by then? 82 72 Preparedness to Make Health Insurance Choices after the ACA Mandate by Insured Status While a majority of the General Population feels prepared, only slightly over a third of those uninsured say they are prepared. 35 There is a sizeable gap between those uninsured (35 percent) and those privately (82 percent) and publicly (72 percent) insured in feeling at least somewhat prepared to make health insurances choices by the ACA mandate deadline. 16

17. © Transamerica Center for Health Studies, 2013 BASE: All Qualified Respondents (July n=2505; November n= 1005) Q730. Overall, how satisfied are you with the quality of the healthcare system you have access to today? 79B73 Satisfaction of Quality of Health Care System Though the portion of the General Population saying they are “very” or “somewhat” satisfied is lower now (73 percent) than it was in July (79 percent). A majority are still satisfied with the Quality of the Health Care System. Letters denote significantly greater proportion than the proportion of the indicated group 17

18. © Transamerica Center for Health Studies, 2013 BASE: All Qualified Respondents (Privately insured: n=617; Public insured: n=177; Uninsured: n=211) Q730. Overall, how satisfied are you with the quality of the healthcare system you have access to today? Satisfaction of Quality of Health Care System by Insured Status Satisfaction with the Health Care system largely depends on an individual’s access to health insurance. 84 34 Only a third of those uninsured (34 percent) are satisfied with the quality of the health care system they have access to. 18

19. www.transamericacenterforhealthstudies.org/ Detailed Findings: Preparations for Individual Mandate

20. © Transamerica Center for Health Studies, 2013 BASE: All Qualified Respondents (July n=2505; November n= 1005) Q1945. What actions, if any, have you taken in the past 12 months to prepare for the ACA? Please select all that apply. July (A) November (B) Discussed it with my friends/family 23 B17 Researched possible new health insurance options 1513 Calculated healthcare expenses for me and/or my family 89 Spoken to my healthcare providers about possible changes in access to their services 8 B5 Spoken to my employer or HR about possible changes in healthcare benefits 8 B5 Spoken to my current health insurance company about possible changes in service 65 Started saving more money to cover future healthcare expenses 9 B4 Applied for health insurance through a government-sponsored program such as Medicare, Medicaid, veteran’s benefits, etc. n/a4 Purchased insurance through the traditional insurance market n/a3 Switched to my spouse’s health coverage n/a2 Purchased health insurance for 2014 through the new Exchanges such as healthcare.gov n/a2 Obtained coverage through my college/university n/a1 Was added to my parent(s)’s health coverage n/a1 Other 33 Nothing 5759 Actions Taken to Prepare for the ACA Most commonly, the General Population say they have discussed the ACA with friends/family (17 percent). Nearly six in ten (59 percent) have not taken any action to prepare for the ACA. Letters denote significantly greater proportion than the proportion of the indicated group 20

21. © Transamerica Center for Health Studies, 2013 BASE: All Qualified Respondents (Currently insured through employer: n=504; currently insured; not through employer: n=290; uninsured: n=211) Q1942. With the ACA's insurance mandate for individuals beginning in January 2014, which of the following do you plan to do? Intentions in Response to ACA Mandate Among those uninsured, however, 55 percent are “not sure” what they will do when faced with the ACA mandate. Majorities of those insured intend to either continue to receive coverage through their employer or keep the same insurance they have. Currently Insured through Employer Currently Insured, not through employerUninsured Continue to receive coverage through an employer 81n/a Keep the same insurance I currently have n/a53n/a Purchase health insurance through the new Exchanges such as healthcare.gov by the deadline 3510 Not purchase health insurance and pay the tax penalty 1512 Apply for new health coverage through a government sponsored program such as Medicare, Medicaid, veteran's benefits, etc. 3712 Purchase new coverage through the traditional insurance market 262 Other *69 Not sure 101855 Of those planning on paying the penalty, 68% are currently uninsured 21

22. © Transamerica Center for Health Studies, 2013 BASE: If Planning to Pay Penalty (n=39) *Caution: Small base size Q1965. For what reason will you choose not to purchase health insurance? Please select the answer that best represents your reason. Reasons for Not Purchasing Health Insurance* Of those who intend to pay the penalty in lieu of purchasing insurance, nearly half (48 percent) say their health expenses plus the penalty would be less expensive than the options available to them. 22 A sizeable portion (38 percent) will not purchase health insurance on principle.

23. © Transamerica Center for Health Studies, 2013 BASE: Employed and Qualified (n=608) Q1960. What has your employer done for you regarding the ACA, its requirement that individuals have health insurance by January 2014, or the new Exchanges such as healthcare.gov through which you can buy health insurance? Employer’s Action Regarding ACA Only 15 percent of those who are employed say their employer provided a detailed description of the ACA and its impacts. Of those employed, fewer than half recall receiving any information from their employer about the ACA. Over half (51 percent) of those employed say their employer has not provided information or is unaware of employer-provided information 23

24. www.transamericacenterforhealthstudies.org/ Detailed Findings: Pre-Existing Medical Condition and the ACA’s Impact on Health Insurance

25. © Transamerica Center for Health Studies, 2013 BASE: All Qualified Respondents (n=1005) Q735. Do you currently have or have you ever had a pre-existing medical condition that has made it difficult to get or afford health insurance? 9 percent of Americans are either priced out of or do not have access to health insurance due to a pre-existing condition Impact of Pre-Existing Medical Condition Almost 10 percent of the General Population claim that they have a pre-existing condition and are unable to find (3 percent) or afford (6 percent) health insurance. About three in ten (29 percent) of the General Population have a pre-existing medical condition. 25

26. © Transamerica Center for Health Studies, 2013 BASE: All Qualified Respondents (n=1005) Q1966. How have your health insurance choices for 2014 been directly impacted by the ACA? Please select all that apply. ACA’s Impact on Health Insurance Options A majority (71 percent) of the General Population is unaware of any impact the ACA has had on their health insurance options. “Costs have gone up” “Fewer coverage options” “My employer has raised the employee contribution” “More difficult for me to obtain health care” Among those unable to access or afford health insurance due to a pre-existing medical condition, 35% say they can now get health coverage* 26 Among those who have suffered insurance limitations due to a pre-existing condition, over a third (35 percent), say they can now get health coverage thanks to the ACA. *Base among those unable to access or afford health insurance due to a pre-existing medical condition: n=79

27. © Transamerica Center for Health Studies, 2013 Demographics Gender July (n=2505) November (n=1005) Male 47% Female 53% Age 18-34 33%35% 35-49 34% 50-59 23%19% 60+ 11%12% Ethnicity White71%67% Hispanic14%16% Black10%12% Asian or Pacific Islander2% Native American or Alaskan Native** Mixed Race-* Some other race1% Employment StatusJulyNovember Employed full time 53%50% Employed part time 10%12% Self-employed 5%7% Not employed, but looking for work 8%7% Not employed and not looking for work 1% Not employed, unable to work due to a disability or illness 4% Retired 5%6% Student 5%7% Stay-at-home spouse or partner 8%7% Employer Size (n=1704)(n=608) 1 – 9 16%20% 10 – 24 8% 25 – 49 8%7% 50 – 99 10%7% 100 – 499 14%13% 500 – 999 9%7% 1000 or more 34%38% 27

28. © Transamerica Center for Health Studies, 2013 Demographics Primarily Receive Health Insurance July (n=2505) November (n=1005) PRIVATELY INSURED 67%65% I receive benefits through an employer57%52% I buy my own health insurance, not through any organization 8%10% I receive benefits through a union2%3% I receive benefits through a trade association*1% PUBLIC INSURED 13% I receive benefits through Medicare 5% I receive benefits through Medicaid or another state funded program 5%4% I receive VA benefits from my own service or through my spouse 2% I receive benefits through military service 1%2% UNINSURED (I do not have health insurance at this time) 21%22% Insured(n=2150)(n=794) The primary insured 74%73% A dependent or spouse 26%27% 28

29. © Transamerica Center for Health Studies, 2013 www.transamericacenterforhealthstudies.org/