New Obligations of Health Insurance Review and Assessment Service: Taking Full-fledged Action Against the COVID-19 Pandemic.

In 2020, the coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented disruptions to global health systems. The Korea has taken full-fledged actions against this novel infectious disease, swiftly implementing a testing-tracing-treatment strategy. New obligations have therefore been given to the Health Insurance Review and Assessment Service (HIRA) to devote the utmost effort towards tackling this global health crisis. Thanks to the universal national health insurance and state-of-the-art information communications technology (ICT) of the Korea, HIRA has conducted far-reaching countermeasures to detect and treat cases early, prevent the spread of COVID-19, respond quickly to surging demand for the healthcare services, and translate evidence into policy. Three main factors have enabled HIRA to undertake pandemic control preemptively and systematically: nationwide data aggregated from all healthcare providers and patients, pre-existing ICT network systems, and real-time data exchanges. HIRA has maximized the use of data and pre-existing network systems to conduct rapid and responsive measures in a centralized way, both of which have been the most critical tactics and strategies used by the Korean healthcare system. In the face of new obligations, our promise is to strive for a more responsive and resilient health system during this prolonged crisis.

Terminating Cost-Sharing Reduction Subsidy Payments: The Impact Of Marketplace Zero-Dollar Premium Plans On Enrollment.

The termination of cost-sharing reduction subsidy payments to insurers in 2017 by the administration of President Donald Trump resulted in a proliferation of Marketplace plans having zero-dollar premiums in 2018 and 2019. While it is known that lower premiums increase Marketplace enrollment, it is not clear whether a zero-price effect exists in which enrollment spikes when health insurance is free. We examined whether such an effect exists and found that increased availability of zero-dollar premium plans would have caused a 14.1 percent enrollment increase among lower-income Marketplace enrollees in 2019. If zero-dollar premium plans had not been available in 2019, our simulation results suggest that enrollment in the federally facilitated Marketplace would have decreased by roughly 200,000 enrollees. When we accounted for this zero-price effect, we found that variation in premiums above zero dollars was not associated with enrollment changes. These results suggest that efforts to insure lower-income populations should focus on making health insurance free to potential enrollees, instead of simply reducing premiums. However, increased enrollment in zero-dollar premium plans could result in increased cost sharing among Marketplace enrollees and increased federal outlays for Advance Premium Tax Credits.

Rural-Urban Differences In Individual-Market Health Plan Affordability After Subsidy Payment Cuts.

This article investigates changes in the affordability of individual health plans (Marketplace plans) that were compliant with the Affordable Care Act following the termination of cost-sharing reduction subsidy payments in 2017. We examined how states' and insurers' responses to these cuts affected enrollees differently depending on whether they lived in rural or urban geographic areas and were or were not eligible for Advance Premium Tax Credits. Using data for 2014-19 from the Health Insurance Exchange Compare database and other sources, we found that subsidy-eligible enrollees in rural markets gained access to Marketplace plans that were more affordable than those available to their urban counterparts, after the cuts affected premiums in 2018. Average minimum net monthly premiums for subsidized enrollees in majority-rural geographic rating areas decreased from $288 in 2017 to $162 in 2019, while those of their urban counterparts decreased from $275 to $180. In contrast, rural enrollees without subsidies faced the least affordable premiums for Marketplace plans.

Trends in State-Level Opinions toward the Affordable Care Act.

CONTEXT: This article argues that the devolution of the Affordable Care Act (ACA) to the states contributed to the slow progression of national public support for health care reform. METHODS: Using small-area estimation techniques, the authors measured quarterly state ACA attitudes on five topics from 2009 to the start of the 2016 presidential election. FINDINGS: Public support for the ACA increased after gubernatorial announcement of state-based exchanges. However, the adoption of federal or partnership marketplaces had virtually no effect on public opinion of the ACA and, in some cases, even decreased positive perceptions. CONCLUSIONS: The authors' analyses point to the complexities in mass preferences toward the ACA and policy feedback more generally. The slow movement of national ACA support was due partly to state-level variations in policy making. The findings suggest that, as time progresses, attitudes in Republican-leaning states with state-based marketplaces will become more positive toward the ACA, presumably as residents begin to experience the positive effects of the law. More broadly, this work highlights the importance of looking at state-level variations in opinions and policies.

Who Entered and Exited the Individual Health Insurance Market Before and After the Affordable Care Act? Evidence from the Medical Expenditure Panel Survey.

Issue: The Affordable Care Act (ACA) made it easier for older adults and those with medical conditions to enroll in individual-market coverage by eliminating risk rating and limiting age rating. While the ACA also encourages young and healthy people to enroll through subsidies and the individual mandate, it's not clear whether these incentives have been sufficient to prevent the risk pool from becoming disproportionately old and sick. Goal: To assess whether patterns in individual-market participation changed following ACA implementation. Methods: Comparison of Medical Expenditure Panel Survey (MEPS) data for the periods 2003­09 and 2014­15. Findings and Conclusion: The analysis found few differences in individual-insurance market participation before and after the ACA. Adverse selection occurred during both: people switching into individual insurance coverage after being uninsured were higher utilizers prior to the switch than were those who remained uninsured. Those who disenrolled from individual plans tended to be lower utilizers of care before switching compared with those who kept their coverage. The main difference was that more people--especially young adults--switched from Medicaid to individual insurance, and vice versa, after the ACA. Adverse enrollment or disenrollment in the individual market did not increase following ACA implementation. The combination of easing rating rules and encouraging participation appears to have maintained market stability.

Diminishing Insurance Choices In The Affordable Care Act Marketplaces: A County-Based Analysis.

While the Affordable Care Act has expanded health insurance to millions of Americans through the expansion of eligibility for Medicaid and the health insurance Marketplaces, concerns about Marketplace stability persist-given increasing premiums and multiple insurers exiting selected markets. Yet there has been little investigation of what factors underlie this pattern. We assessed the county-level prevalence of limited insurer participation (defined as having two or fewer distinct participating insurers) in Marketplaces in the period 2014-18. Overall, in 2015 and 2016 rates of insurer participation were largely stable, and approximately 80 percent of counties (containing 93 percent of US residents) had at least three Marketplace insurers. However, these proportions declined sharply starting in 2017, falling to 36 percent of counties and 60 percent of the population in 2018. We also examined county-level factors associated with limited insurer competition and found that it occurred disproportionately in rural counties, those with higher mortality rates, and those where insurers had lower medical loss ratios (that is, potentially higher profit margins), as well as in states where Republicans controlled the executive and legislative branches of government. Decreased competition was less common in states with higher proportions of residents who were Hispanic or ages 45-64 and states that chose to expand Medicaid.

Health Insurance Marketplaces: Issuer Participation and Premium Trends in Rural Places, 2018.

Purpose: Since 2014, when the Health Insurance Marketplaces (HIMs) authorized by the Patient Protection and Affordable Care Act (PPACA) were implemented, considerable premium changes have been observed in the marketplaces across the 50 states and the District of Columbia. This policy brief assesses the changes in average HIM plan premiums from 2014 to 2018, before accounting for subsidies, with an emphasis on the widening variation across rural and urban places, providing information during Congressional debates on the future of the program. Key Findings: (1) Insurance issuers reduced HIM participation across both rural and urban places (with 1.7 and 2.2 issuers, respectively), both in states that expanded Medicaid under the PPACA and in non-expansion states. (2) The average adjusted premium (before premium subsidy) continues to rise across all of the above categories, and the gap has widened between the 32 Medicaid expansion and 19 non-expansion states. Average premiums in rural counties are higher than average premiums in urban counties in both expansion and non-expansion states (by $43 per month and $27 per month, respectively). (3) Prior trends of lower premium changes at greater population densities are no longer observed in the 2018 data. (4) In 2018, 1,581 counties (52 perent) have one participating insurance issuer. Nationwide, 42 percent of all urban counties and 55 percent of all rural counties only have one issuer.

ACA Marketplace Premiums Grew More Rapidly In Areas With Monopoly Insurers Than In Areas With More Competition.

Premiums have increased rapidly in the two most recent years of the health insurance Marketplaces, with notable variation across state rating areas. Some experts have speculated that these increases are due to greater enrollment among sicker patients, the expiration of market stabilization policies, or the federal government's discontinuation of funding for cost-sharing subsidies. However, these factors do not explain why some rating areas have experienced rapid premium growth, while others have experienced more modest increases. I used a comprehensive database of information about premiums and market characteristics for rating areas in states with federally facilitated Marketplaces to demonstrate that higher premiums are associated with local health insurance monopolies. In 2018, Marketplace premiums were 50 percent ($180) higher, on average, in rating areas with monopolist insurers, compared to those with more than two insurers. This was driven by large premium increases for the monopolist insurers' lowest-cost plans. Understanding how insurer competition has affected enrollment, costs, and quality will help guide future individual-market reforms.

State-Based Marketplaces Outperform Federally-Facilitated Marketplaces.

In response to regulatory changes at the federal level, states that run their own marketplaces have taken steps to stabilize their individual markets. In this comparison of state-based and federally-facilitated marketplaces from 2016-2018, we find that SBMs had slower premium increases (43% vs. 75%), and fewer carrier exits, than FFMs. The total population participating in FFMs declined by 10%, while the enrolled population in SBMs remained largely stable, increasing by 2%. We find that the performance of the ACA marketplaces varies by state and appears to cluster around marketplace types.

Competition and Premium Costs in Single-Insurer Marketplaces: A Study of Five Rural States.

Issue: In 2017, five states--Alabama, Alaska, Oklahoma, South Carolina, and Wyoming--had only one issuer participating in their health care marketplaces, limiting consumer choice and competition among insurers. Goal: Examine the history of participation in the individual market from 2010 (before the Affordable Care Act was enacted) to 2017, and analyze premium changes among marketplace plans. Methods: Robert Wood Johnson Foundation's HIX Compare, which provides national data on the marketplaces from 2014 to 2017. Findings and Conclusions: In 2010, the individual insurance market was already concentrated in the five study states, with Blue Cross and Blue Shield (BCBS) plans covering the majority of enrollees. By 2015, with the marketplaces in full swing, more issuers were competing in the five states. But by 2016, co-ops were facing bankruptcy and left the marketplaces in these states; and in 2017, citing large financial losses, national issuers UnitedHealthcare, Aetna, and Humana also exited, leaving only a single BCBS plan in each state. Three of the five states experienced substantially higher annual premium increases than the national average. Policy options with bipartisan support, such as resuming cost-sharing reduction payments and reestablishing reinsurance and risk corridors, could help attract new or returning issuers to marketplaces in these states.

The Affordable Care Act's Marketplaces Expanded Insurance Coverage For Adults With Chronic Health Conditions.

The Affordable Care Act (ACA) made private nongroup health insurance more accessible to nonelderly adults with chronic conditions, with enrollment growth occurring through the federal and state-based Marketplaces. During the July through December reference period in 2014-15, 45 percent of Marketplace enrollees ages 18-64 were treated for chronic conditions, compared with 35 percent of non-Marketplace nongroup enrollees and 38 percent of adults with employer-sponsored insurance. Marketplace enrollees also had higher service use than other privately insured adults did, which likely contributed to rising premiums in the nongroup market. As repeal of the ACA individual mandate takes effect in 2019, protecting coverage gains for adults with chronic conditions while stabilizing nongroup premiums may depend on state-level efforts to spread the risk of Marketplace enrollees' health care costs across a balanced insurance pool.

Idaho's Actions Continue Challenges For ACA.

The Trump administration proposed liberalizing rules governing non-ACA-compliant, short-term coverage; responding to state guidance, Blue Cross of Idaho filed health plans not meeting ACA requirements.

Exploring the decline of narrow networks on the 2017 ACA marketplaces.

The prevalence of narrow provider networks on the ACA Marketplace is trending down. In 2017, 21% of plans had narrow networks, down from 25% in 2016. The largest single factor was that 70% of plans from National carriers exited the market and these plans had narrower networks than returning plans. Exits account for more than half of the decline in the prevalence of narrow networks, with the rest attributed to broadening networks among stable plans, particularly among Blues carriers. The narrow network strategy is expanding among traditional Medicaid carriers and remains steady among provider-based carriers and regional/local carriers.

How Have Health Insurers Performed Financially Under the ACA' Market Rules?

Issue: The Affordable Care Act (ACA) transformed the market for individual health insurance, so it is not surprising that insurers' transition was not entirely smooth. Insurers, with no previous experience under these market conditions, were uncertain how to price their products. As a result, they incurred significant losses. Based on this experience, some insurers have decided to leave the ACA's subsidized market, although others appear to be thriving. Goals: Examine the financial performance of health insurers selling through the ACA's marketplace exchanges in 2015--the market's most difficult year to date. Method: Analysis of financial data for 2015 reported by insurers from 48 states and D.C. to the Centers for Medicare and Medicaid Services. Findings and Conclusions: Although health insurers were profitable across all lines of business, they suffered a 10 percent loss in 2015 on their health plans sold through the ACA's exchanges. The top quarter of the ACA exchange market was comfortably profitable, while the bottom quarter did much worse than the ACA market average. This indicates that some insurers were able to adapt to the ACA's new market rules much better than others, suggesting the ACA's new market structure is sustainable, if supported properly by administrative policy.

Health Care Market Concentration Trends In The United States: Evidence And Policy Responses.

Policy makers and analysts have been voicing concerns about the increasing concentration of health care providers and health insurers in markets nationwide, including the potential adverse effect on the cost and quality of health care. The Council of Economic Advisers recently expressed its concern about the lack of estimates of market concentration in many sectors of the US economy. To address this gap in health care, this study analyzed market concentration trends in the United States from 2010 to 2016 for hospitals, physician organizations, and health insurers. Hospital and physician organization markets became increasingly concentrated over this time period. Concentration among primary care physicians increased the most, partially because hospitals and health care systems acquired primary care physician organizations. In 2016, 90 percent of Metropolitan Statistical Areas (MSAs) were highly concentrated for hospitals, 65 percent for specialist physicians, 39 percent for primary care physicians, and 57 percent for insurers. Ninety-one percent of the 346 MSAs analyzed may have warranted concern and scrutiny because of their concentration levels in 2016 and changes in their concentrations since 2010. Public policies that enhance competition are needed, such as stricter enforcement of antitrust laws, reducing barriers to entry, and restricting anticompetitive behaviors.

Off-Marketplace Enrollment Remains An Important Part Of Health Insurance Under The ACA.

The introduction of Marketplaces under the Affordable Care Act greatly expanded individual-market health insurance coverage in 2014, but millions of adults continued to purchase individual coverage outside of the Marketplaces. They were more likely to be male, be white, have higher incomes, and be in excellent or very good health, compared to Marketplace enrollees.

How the ACA's Health Insurance Expansions Have Affected Out-of-Pocket Cost-Sharing and Spending on Premiums.

One important benefit gained by the millions of Americans with health insurance through the Affordable Care Act (ACA) is protection from high out-of-pocket health spending. While Medicaid unambiguously reduces out-of-pocket premium and medical costs for low-income people, it is less certain that marketplace coverage and other types of insurance purchased to comply with the law's individual mandate also protect from high health spending. Goal: To compare out-of-pocket spending in 2014 to spending in 2013; assess how this spending changed in states where many people enrolled in the marketplaces relative to states where few people enrolled; and project the decline in the percentage of people paying high amounts out-of-pocket. Methods: Linear regression models were used to estimate whether people under age 65 spent above certain thresholds. Key findings and conclusions: The probability of incurring high out-of-pocket costs and premium expenses declined as marketplace enrollment increased. The percentage reductions were greatest among those with incomes between 250 percent and 399 percent of poverty, those who were eligible for premium subsidies, and those who previously were uninsured or had very limited nongroup coverage. These effects appear largely attributable to marketplace enrollment rather than to other ACA provisions or to economic trends.

Who Are the Remaining Uninsured and Why Haven't They Signed Up for Coverage?

The number of uninsured people in the United States has declined by an estimated 20 million since the Affordable Care Act went into effect in 2010. Yet, an estimated 24 million people still lack health insurance. Goal: To examine the characteristics of the remaining uninsured adults and their reasons for not enrolling in marketplace plans or Medicaid. Methods: Analysis of the Commonwealth Fund ACA Tracking Survey, February--April 2016. Key findings and conclusions: There have been notable shifts in the demographic composition of the uninsured since the law's major coverage expansions went into effect in 2014. Latinos have become a growing share of the uninsured, rising from 29 percent in 2013 to 40 percent in 2016. Whites have become a declining share, falling from half the uninsured in 2013 to 41 percent in 2016. The uninsured are very poor: 39 percent of uninsured adults have incomes below the federal poverty level, twice the rate of their overall representation in the adult population. Of uninsured adults who are aware of the marketplaces or who have tried to enroll for coverage, the majority point to affordability concerns as a reason for not signing up.

Changes in premiums of cancelled nongroup plans under the Affordable Care Act.

OBJECTIVES: To examine the effect of the Affordable Care Act (ACA) on changes in premiums for subscribers of nongrandfathered, nongroup insurance plans that were "cancelled." STUDY DESIGN: Retrospective multivariate analyses. METHODS: Changes in annual premiums post ACA were evaluated across subgroups of subscriber and health plan characteristics. Data was derived from databases containing information on premiums, plan benefit, and demographics for subscribers aged 18 to 64 years within Kaiser Permanente of the Mid-Atlantic States. A linear regression model was used to examine the independent association between subscriber and health plan characteristics on the relative change in premiums. RESULTS: In 2013, 4169 nongroup subscribers were enrolled in plans that were cancelled as a result of the ACA. The median pre-ACA premium was $3240 (range = $780-$39,492), which increased by a median of 21.3% (range = -77.4% to 193.6%), or $685 (range = -$27,464 to $8676), post ACA in 2014. Premiums increased more for high-deductible plans (median = 63.7%) than standard-deductible plans (median = 8.4%). Due to shifts in the age curve, premiums decreased for more than half of women aged 18 to 44 years, but increased by 35.2% for women aged 55 to 64 years. Premiums fell by 15.5% for subscribers who did not pass standard medical underwriting due to preexisting conditions. CONCLUSIONS: Changes in premiums in the nongroup market post ACA, varied substantially across subgroups, primarily due to differences in the amount of coverage, changes in rating criteria, shifts in the age curve, and anticipated differences in risk selection and composition of the risk pool. Given the extent of this variation, it would be incorrect to conclude the ACA as being uniformly beneficial or detrimental to subscribers of these cancelled plans.