Reducing Uninsurance: Dr. Jessica Mulligan’s $450K AHRQ-Funded Study on Breaking Administrative Barriers to Health Coverage
Jessica Mulligan, Ph.D., professor of health sciences, is leading a research project examining the challenges people face when enrolling in health insurance. Drawing from her own experiences navigating complex bureaucratic systems as a college student, Dr. Mulligan explores how “administrative burdens” prevent many eligible individuals from obtaining coverage. Her interdisciplinary study—spanning health sciences, public policy, and anthropology—aims to uncover why millions of eligible Americans remain uninsured despite available subsidies, with support from a team of undergraduate researchers.
What inspired you to focus on administrative burdens as a key barrier to health insurance coverage?
My interest in how big bureaucracies work probably started as an undergraduate student trying to navigate the financial aid system so that I could afford a college degree. I will never forget how impersonal and opaque that system felt! Some parts of it seemed impossibly and unnecessarily hard and the stakes were high. Health insurance enrollment is pretty similar in the sense that there are many barriers that people must jump over like proving your household income, verifying your identity, and choosing the right plan.
Administrative burdens are the learning, compliance and psychological costs that prevent people from signing up for and using public services. Though the Affordable Care Act went into effect more than 10 years ago, too many people remain uninsured in the United States. According to 2023 Census data, 10.9% of the non-elderly population remain uninsured, millions of whom are eligible for generous subsidies to enroll in ACA coverage, yet they have not done so. It’s a bit of a mystery as to why and the hypothesis of this study is that administrative burdens play a big role in keeping people from getting connected to health coverage.
How will the interdisciplinary nature of your research—combining health sciences, public policy, and anthropology—strengthen the outcomes of this study?
This study explores the problem of uninsurance and administrative burdens from multiple perspectives. Some of my colleagues are analyzing big data sets of health insurance enrollment to see how policies like premium payments rules, reenrollment processes, and advertising exposure affect enrollment patterns. The portion of the study that I am working on generates qualitative data by interviewing insurance applicants and enrollment assisters to document how individuals encounter administrative burdens and which burdens are most important. We’re trying to learn from the people who are most impacted by admin burdens about how easy or hard it is to obtain and maintain coverage. We’ll also be exploring how other factors like affordability and how beliefs about the importance of insurance inform people’s enrollment decisions.
Your project will span five years and include collaboration with undergraduate students. How will this grant support student involvement, and what skills or experiences do you hope they will gain from this project?
One of the most satisfying parts of being a faculty member at a primarily undergraduate institution is conducting research with students. I am currently working with seven students enrolled in a research course who are helping create the infrastructure for this longitudinal project. Students are assisting with the creation of data collection tools and recruitment materials. They are also reaching out to community partners who will be integral to sustaining the project over time and making sure that we are responsive to local concerns and conditions. Students will assist with data collection by conducting interviews, coding and analyzing the data, and co-authoring study reports. Students will gain valuable skills in qualitative research, project management, and publishing through their work on the team. They will also learn about issues in contemporary health policy like Medicaid expansion, how health programs are funded, and health equity. Finally, they will learn form the wisdom and knowledge of everyday people who must navigate admin burdens to take care of themselves and their families.
What role did the Office of Sponsored Projects and Research Compliance play in helping you secure this grant? How important is institutional support in carrying out large-scale research projects like this?
The folks at SPARC have been amazing! PC has never been awarded an R1 AHRQ grant before and we were competing with research universities who have a lot more support for grant writing and administration (not to mention smaller teaching loads and fewer service responsibilities). It took three years from first submission until we were awarded the grant. During that time SPARC assisted with revisions and complying with the ins and outs of the federal grant process. Without Kris Monahan’s guidance, there is no way I would have secured this grant. PC punches far above its weight in grant activity thanks to the expertise of the SPARC office. Now, I just hope that the College will also invest in the grant management side of things to keep researchers successful, compliant with federal regs, and competitive for the next one.
Finally, looking ahead, what outcomes or impacts do you hope this research will have on public health and access to healthcare coverage in the U.S.?
We are hoping to identify policies that can facilitate enrollment in insurance coverage and make the whole experience less burdensome for applicants. The goal is to generate recommendations that stakeholders can use to streamline the process and make health insurance more accessible. This is also an equity issue because minoritized groups such as Hispanics and Latinos, Black Americans, and Native Americans and Pacific Islanders have higher uninsurance rates than their White and Asian counterparts. Making enrollment in insurance easier is a way to address health disparities. It’s also a research area that has some potential for support across the aisle since most policymakers can agree that government should be more efficient and cost effective.
