One in three Americans who lack health coverage plan to remain uninsured, citing cost as their chief obstacle, according to Bankrate's latest Health Insurance Pulse survey.

Fewer than a third (30%) of the uninsured realize that federal tax credits available through the new Obamacare health exchanges can make health insurance affordable to lower-income individuals and families.

In a telephone survey of uninsured adults drawn from a nationally representative sample of more than 3,000 Americans, one-third (34%) said they intend to continue without health coverage. When asked why, 41% said health insurance is too expensive, 17% cited opposition to the Affordable Care Act, and 13% said they're healthy and don't need coverage.

Just over half (56%) of the uninsured said they plan to obtain health coverage.

'Not giving it a whole lot of attention'

If a late January Pulse survey demonstrated how familiar the overall population is with health reform penalties and deadlines that won't affect most Americans, this first Bankrate.com survey directed specifically at uninsured adults suggests that efforts to reach those most in need of affordable coverage may have fallen short.

"It's hard to generalize, but for some of these folks, it's a case of, 'I'm in pretty good health, I don't think about these things, I know I can't afford it now,'" says Michael Morrisey, professor of health economics at the University of Alabama at Birmingham School of Public Health. "I think it's just rolling past them, and they're not giving it a whole lot of attention."

Deborah Chollet, a health insurance research leader at Mathematica Policy Research in Washington, D.C., agrees.

"They may or may not have looked for insurance, they may or may not have talked to somebody who has insurance, but I'm guessing the overriding reason is that it's just not a priority for them," she says.

The following question was posed to a national sample of uninsured Americans:

As far as you know, are there tax credits available through the Affordable Care Act to reduce the monthly price of health insurance?

Source: Bankrate.com Health Insurance Pulse survey, March 17, 2014.

Highlights:

  • 42% of people who identify themselves as Republicans say there are no tax credits, compared with 20% of Democrats and 33% of independents.
  • Only 5% of Americans earning $75,000 per year or more knew about the tax credits, versus 30% of those making less than $30,000.
  • 35% of people in both the West and South say the tax credits don't exist, compared with 25% in the Northeast and just 13% in the Midwest.

The following question was posed to uninsured Americans in the survey who indicated they planned to remain that way, despite potential penalties under the Affordable Care Act:

Which is the main reason you will not sign up for health insurance this year?

Source: Bankrate.com Health Insurance Pulse survey, March 17, 2014.

Highlights:

  • 22% of men who won't obtain health insurance cite opposition to the Affordable Care Act, compared with just 8% of women who plan to remain uninsured.
  • 31% of people ages 18 to 29 who won't obtain insurance say they're healthy and don't need it, versus just 6% of respondents in the 30-49 age group.
  • 50% of Republicans who plan to stay uninsured say the main reason is that they don't like Obamacare, but only 5% of Democrats in that group say the same thing.

Messages missing the poor

Chollet suspects that Obamacare multimedia advertising campaigns, which have largely targeted the key "young invincibles" between ages 18 and 30, may have missed another group in need.

"Low-income, young families may have been overlooked. They're probably not spending a lot of time watching television, they never read a newspaper, and if they listen to radio, it's probably music in the car," she says.

"In communities of color, people might hear about (Obamacare) in church, but for people who are not attached to a church, I don't know how they get the information."

Too much carrot, not enough stick

Outreach efforts that emphasize Obamacare's positive tax subsidies rather than the punitive tax penalty for not having insurance may have failed to prompt action, says Sabrina Corlette, research professor at Georgetown University's Health Policy Institute.

"They found in Massachusetts, with "RomneyCare," that the individual mandate penalty absolutely motivated a lot of people to purchase insurance," she says. "The Obama administration understandably tried to emphasize the positive, but people need to understand that the mandate is not insignificant -- they could be hit with a big tax bill if they don't buy coverage."

But Morrisey says the more favorable message about the subsidies may have fallen flat with the uninsured as well.

"Someone who makes so little money that they haven't had to file taxes in the past might say, 'How is a tax credit going to help me? I don't even think about tax things because I don't have to file,'" he says.

Many are in the dark about the deadline

Also in the survey, fewer than half (48%) of the uninsured could correctly name March 31 as the deadline for obtaining health insurance to avoid the penalty.

"What people need to understand is that the door really closes on March 31," Corlette cautions. "It they don't sign up before then, they're out of luck until Nov. 15 unless they have one of the special enrollment situations, which happen if you lose your job or get a divorce."

Between now and March 31, "the administration needs to really amp up those marketing and outreach campaigns and meet people where they're at," she says. "It's got to be all about marketing and outreach now."

Role of states' Medicaid decisions?

One big unknown in the survey results is how many of the uninsured who plan to stay that way might qualify for Medicaid -- except that their state has chosen not to expand the program.

"If you're in one of the 24 states that did not expand their Medicaid program and you have income below 100% of the federal poverty line, you are not going to receive Medicaid and you're not eligible for the subsidies," says Morrisey.

"So it's not at all surprising that they're going to say it's too expensive and they're going to remain uninsured," he continues. "I'm guessing that a third of that 34% who will remain uninsured are in that group."

Bankrate's Health Insurance Pulse survey was conducted between Feb. 20 and March 9 by Princeton Survey Research Associates International with a nationally representative sample of 3,005 adults living in the continental United States. The questions were addressed specifically to the 299 respondents who identified themselves as uninsured. The margin of sampling error on their responses is plus or minus 6.1 percentage points.

Copyright 2014, Bankrate Inc.