Health Care Use of ACA Marketplace Enrollees During the COVID-19 Pandemic.

The onset of the COVID-19 pandemic in March 2020 had a sudden and substantial impact on health care utilization for most, if not all, individuals. We study the impact the pandemic had on the population insured in the individual and small group markets under the Patient Protection and Affordable Care Act (ACA) of 2010, using administrative claims data from January 2019 through December 2021. Our results demonstrated how health care utilization differed between the acute phase (i.e., 2020) and the post-acute phase (i.e., 2021) compared with the pre-pandemic phase. We found that in the ACA markets, most spending and utilization categories decreased drastically during the initial months of the pandemic and recovered by the end of 2021. While the role of telehealth among office visits decreased substantially by the end of 2021, it remained the main mode of delivery for mental health services.

Overlap In Carriers And Networks In Medicaid And The Individual Marketplaces.

As people lose Medicaid because of the end of the COVID-19 public health emergency, many states will route former Medicaid managed care enrollees into Affordable Care Act Marketplace coverage with the same carrier. In 2021, 52.1 percent of Medicaid managed care enrollees were enrolled by a carrier that also had a plan on the Marketplace in the same county.

Health Insurance Coverage Projections For The US Population And Sources Of Coverage, By Age, 2024-34.

In the Congressional Budget Office's projections of health insurance coverage, 92.3 percent of the US population, or 316 million people, have coverage in 2024, and 7.7 percent, or 26 million, are uninsured. The uninsured share of the population will rise over the course of the next decade, before settling at 8.9 percent in 2034, largely as a result of the end of COVID-19 pandemic-related Medicaid policies, the expiration of enhanced subsidies available through the Affordable Care Act health insurance Marketplaces, and a surge in immigration that began in 2022. The largest increase in the uninsured population will be among adults ages 19-44. Employment-based coverage will be the predominant source of health insurance, and as the population ages, Medicare enrollment will grow significantly. After greater-than-expected enrollment in 2023, Marketplace enrollment is projected to reach an all-time high of twenty-three million people in 2025.

Effects of Affordable Care Act on uninsured hospitalization: Evidence from Texas.

OBJECTIVE: To examine the impact of the Affordable Care Act (ACA) health insurance exchanges (Marketplace) on the rate of uninsured discharges in Texas. DATA SOURCE AND STUDY SETTING: Secondary discharge data from 2011 to 2019 from Texas. STUDY DESIGN: We conducted a retrospective study estimating the effects of the ACA Marketplace using difference-in-difference regressions, with the main outcome being the uninsured discharge rate. We stratified our sample by patient's race, age, gender, urbanicity, major diagnostic categories (MDC), and emergent type of admissions. DATA COLLECTION/EXTRACTION METHODS: We used Texas hospital discharge records for non-elderly adults collected by the state of Texas and included acute care hospitals who reported data from 2011 to 2019. PRINCIPAL FINDINGS: The expansion of insurance through ACA Marketplaces led to reductions in the uninsured discharge rate by 9.9% (95% CI, -17.5%, -2.3%) relative to the baseline mean. The effects of the ACA were felt strongest in counties with any share of Hispanic, in counties with a larger population of Black, and other racial groups, in counties with a significant share of female and older age individuals, in counties considered to be urban, in high-volume diagnoses, and emergent type of admissions. CONCLUSIONS: These findings indicate that the ACA facilitated a shift in hospital payor mix from uninsured to insured.

Horizontal and vertical equity and public subsidies for private health insurance in the U.S.

The United States offers two markedly different subsidy structures for private health insurance. When covered through employer-based plans, employees and their dependents benefit from the exclusion from taxable income of the premiums. Individuals without access to employer coverage may obtain subsidies for Marketplace coverage. This paper seeks to understand how the public subsidies embedded in the privately financed portion of the U.S. healthcare system impact the payments families are required to make under both ESI and Marketplace coverage, and the implications for finance equity. Using the Household Component of the Medical Expenditure Panel Survey (MEPS-HC) and Marketplace premium data, we assess horizontal and vertical equity by calculating public subsidies for and expected family spending under each coverage source and using Lorenz curves and Gini and concentration coefficients. Our study pooled the 2018 and 2019 MEPS-HC to achieve a sample size of 10,593 observations. Our simulations showed a marked horizontal inequity for lower-income families with access to employer coverage who cannot obtain Marketplace subsidies. Relative to both the financing of employer coverage and earlier Marketplace tax credits, the more generous Marketplace premium subsidies, first made available in 2021 under the American Rescue Plan Act, substantially increased the vertical equity of Marketplace financing. While Marketplace subsidies have clearly improved equity within the United States, we conclude with a comparison to other OECD countries highlighting the persistence of inequities in the U.S. stemming from its noteworthy reliance on employer-based private health insurance.

The impact of terminating cost-sharing reductions payments on health insurance plan choices.

The Trump administration terminated cost-sharing reductions (CSRs) payments to health insurers in 2017, while still required insurers to provide CSRs to eligible enrollees in the Marketplace. Marketplace administration data reveals that, in response to this termination, insurers raised premiums to compensate for their loss. Consequently, premium increases led to more advanced premium tax credits for enrollees in the Marketplace. To investigate the impact of CSRs payment termination on low-income consumer insurance plan choices, I leverage variations in state price regulations and employed a difference-in-differences design. In a robustness analysis, I utilized differences in county income distributions to examine the effects of the termination on insurance choices. The results indicate that after the termination, more low-income enrollees opted for cheaper bronze plans, and fewer chose silver plans. These results suggest that alterations in subsidy channels may inadvertently encourage low-income individuals to purchase less expensive health insurance plans, highlighting an unintended consequence of the termination of cost-sharing subsidies.

The impact of the Affordable Care Act on health care access and self-assessed health in the Trump Era (2017-2018).

OBJECTIVE: To estimate the impact of the major components of the ACA (Medicaid expansion, subsidized Marketplace plans, and insurance market reforms) on health care access and self-assessed health during the first 2 years of the Trump administration (2017 and 2018). DATA SOURCE: The 2011-2018 waves of the Behavioral Risk Factor Surveillance System (BRFSS), with the sample restricted to nonelderly adults. The BRFSS is a commonly used data source in the ACA literature due to its large number of questions related to access and self-assessed health. In addition, it is large enough to precisely estimate the effects of state policy interventions, with over 300 000 observations per year. DESIGN: We estimate difference-in-difference-in-differences (DDD) models to separately identify the effects of the private and Medicaid expansion portions of the ACA using an identification strategy initially developed in Courtemanche et al (2017). The differences come from: (a) time, (b) state Medicaid expansion status, and (c) local area pre-2014 uninsured rates. We examine ten outcome variables, including four measures of access and six measures of self-assessed health. We also examine differences by income and race/ethnicity. PRINCIPAL FINDINGS: Despite changes in ACA administration and the political debate surrounding the ACA during 2017 and 2018, including these fourth and fifth years of postreform data suggests continued gains in coverage. In addition, the improvements in reported excellent health that emerged with a lag after ACA implementation continued during 2017 and 2018. CONCLUSIONS: While gains in access and self-assessed health continued in the first 2 years of the Trump administration, the ongoing debate at both the federal and state level surrounding the future of the ACA suggests the need to continue monitoring how the law impacts these and many other important outcomes over time.

Same Game, Different Names: Cream-Skimming in the Post-ACA Individual Health Insurance Market.

One of the Affordable Care Act's (ACA) signature reforms was creating centralized Health Insurance Marketplaces to offer comprehensive coverage in the form of comprehensive insurance complying with the ACA's coverage standards. Yet, even after the ACA's implementation, millions of people were covered through noncompliant plans, primarily in the form of continued enrollment in "grandmothered" and "grandfathered" plans that predated ACA's full implementation and were allowed under federal and state regulations. Newly proposed and enacted federal legislation may grow the noncompliant segment in future years, and the employment losses of 2020 may grow reliance on individual market coverage further. These factors make it important to understand how the noncompliant segment affects the compliant segment, including the Marketplaces. We show, first, that the noncompliant segment of the individual insurance market substantially outperformed the compliant segment, charging lower premiums but with vastly lower costs, suggesting that insurers have a strong incentive to enter the noncompliant segment. We show, next, that state's decisions to allow grandmothered plans is associated with stronger financial performance of the noncompliant market, but weaker performance of the compliant segment, as noncompliant plans attract lower-cost enrollees. This finding indicates important linkages between the noncompliant and compliant segments and highlights the role state policy can play in the individual insurance market. Taken together, our results point to substantial cream-skimming, with noncompliant plans enrolling the healthiest enrollees, resulting in higher average claims cost in the compliant segment.

Subscriber continuity in health insurance plans: factors associated with re-enrollment and coverage changes.

Aims: This study examined the extent to which Marketplace health insurance subscribers re-enroll a second year. Among re-enrollees, we sought to examine movement to more and less generous insurance plans (based on actuarial value), and the extent to which adverse selection, adverse retention, and aging in place are evident from re-enrollment choices made.Methods: Re-enrollment from 2015 to 2016 and 2016 to 2017 and movement to more and less generous insurance plans was examined using enrollment and insurance claims data from two US Federally-facilitated Marketplace insurance carriers operating in the state of New Mexico for 2015-2017. Insurance plans are assigned to metal levels based on estimated plan actuarial value: Bronze (60%), Silver (70%), and Gold (80%). Odds ratios (ORs) and 95% confidence intervals (OR CI) were estimated using logistic regressions for subscribers with base-year healthcare utilization. ORs were estimated for (1) re-enrollment in the year following the base year, and (2) movement to a higher or lower actuarial value plan.Results: Approximately 50% of subscribers re-enrolled with the same carrier for 2016 and 60% for 2017. Being enrolled 12 months was the strongest predictor for second year re-enrollment. Older individuals were more likely to re-enroll. Re-enrollment was lower for the insurance carrier with higher second year premium changes. Chronic condition utilization characteristics were positively associated with re-enrollment. Approximately 12% of Bronze subscribers moved to Silver or Gold, and had higher utilization after re-enrollment. Among Silver subscribers, 6% moved to Gold and 6% to Bronze. Approximately 37% of Gold subscribers moved to Silver or Bronze.Discussion: Re-enrollment was similar to published non-group insurance rates. Adverse selection and aging in place were observed. Evidence was weak for adverse retention. Some coverage change choices were rational, while others suggest subscribers may have difficulty making insurance choice decisions.

Comparison of Office-Based Physician Participation in Medicaid Managed Care and Health Insurance Exchange Plans in the Same US Geographic Markets.

Importance: Several recent policy proposals have sought to expand the role of Medicaid in providing health insurance for low-income Americans, but there is little recent information on how physician participation in Medicaid compares with alternative forms of coverage for low-income Americans. Objective: To compare the number of office-based physicians included in Medicaid managed care and health insurance exchange plans that operate in the same geographic markets. Design, Setting, and Participants: This cross-sectional study used administrative data from physician network directories and survey data from office-based physicians for Kansas, Nebraska, New York, Tennessee, and Washington. The number of participants totaled 67 057 office-based physicians in the 5 sample states. Data were collected and analyzed from May 2018 to June 2019. Exposures: Physician participation in a Medicaid managed care or health insurance exchange plan network. Main Outcomes and Measures: The percentage of office-based physicians in a county who indicated during a phone survey that they participated in Medicaid; the percentage of office-based physicians in a county who participated in each Medicaid managed care and health insurance exchange plan network; and the percentage of office-based physicians in a county who participated in at least 1 Medicaid managed care plan or, separately, at least 1 health insurance exchange plan. Results: Of the 67 057 office-based physicians in our sample, 49 983 reported in a telephone survey that they accepted Medicaid. This survey-based measure undercounted the percentage of physicians participating in Medicaid by 5.2% (95% CI, 2.3%-8.1%; P < .001) relative to a measure based on physician network directories. Medicaid managed care physician networks covered a median (interquartile range) of 63.4% (48.0%-81.3%) of office-based physicians compared with health insurance exchange physician networks, which covered 51.0% (31.0%-70.5%). In adjusted analyses, Medicaid managed care plans covered 6.2% (95% CI, 3.2%-9.3%, P < .001) more office-based physicians than health insurance exchange plans operating in the same counties. In the states where the same insurers participated in both markets (New York, Tennessee, Washington), the Medicaid managed care physician networks were 6.5% (95% CI, 3.2%-9.8%, P < .001) larger than the health insurance exchange networks offered by the same insurer. Conclusions and Relevance: In this cross-sectional study of physician network data, Medicaid managed care physician networks included more office-based physicians than the physician networks of health insurance exchange plans operating in the same geographic markets. This suggests that Medicaid remains a viable option for expanding coverage in the United States.

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.

Polarization, Participation, and Premiums: How Political Behavior Helps Explain Where the ACA Works, and Where It Doesn't.

CONTEXT: Political partisanship can influence whether individuals enroll in government programs. In particular, Republicans, ceteris paribus, are less likely to enroll in Affordable Care Act (ACA) individual marketplace insurance than Democrats. The logic of adverse selection suggests low uptake among Republicans would generally put upward pressure on marketplace premiums, especially in geographic areas with more Republican partisans. METHODS: Using data from Healthcare.gov at the rating area level, this article examines the association between Republican vote share and growth in ACA marketplace premiums, being careful to account for potential confounding variables. FINDINGS: Insurers have increased marketplace premiums at higher rates in areas with more Republican voters. In the preferred model specification, a 10-percentage-point difference in Republican vote share is associated with a 3.2-percentage-point increase in average premium growth for a standard plan. A variety of robustness and placebo checks suggest the relationship is driven by partisanship. CONCLUSIONS: Partisan polarization can threaten the successful implementation of policies that rely on high levels of citizen participation.

Sources of Success in California's Individual Marketplace under the Affordable Care Act.

When passed in 2010, the Affordable Care Act (ACA) became the greatest piece of health care reform in the United States since the creation of Medicare and Medicaid. In the 9 years since its passage, the law has ushered in a drastic decrease in the number of uninsured Americans and has encouraged delivery system innovation. However, the ACA has not been uniformly embraced, and states differ in their implementation of the law and in their individual health insurance marketplace's successfulness. Furthermore, under the Trump administration the law's future and the stability of the individual market have been uncertain. Throughout, however, California has been a leader. Today, the state's marketplace, known as Covered California, offers comprehensive, standardized health plans to over 1.3 million consumers. California's success with the ACA is largely attributable to its historical receptiveness to health reform; its early adoption of the law; its decision to have Covered California operate as an active purchaser, help shape the plans sold through the marketplace, and design a consumer-friendly enrollment experience; its engagement with stakeholders and community partners to encourage enrollment; and Covered California's commitment to continually innovate, improve, and anticipate the needs of the individual market as the law moves forward.

Health reform under the patient protection and Affordable Care Act: characteristics of exchange-based health insurance enrollees.

The Affordable Care Act (ACA) reformed and expanded healthcare coverage with an exchange-based health insurance program. While millions of Americans have benefited from enrollment in ACA marketplace insurance plans, many individuals are likely to be affected by potential future policy changes. Since few studies on the features of marketplace enrollees exist, we adopted a retrospective, cross-sectional study design using 2016 National Health Interview data to identify sociodemographic and health characteristics of enrollees, comparing them to those without insurance. Chi-square tests and logistic regression examined factors associated with enrollees. Adults with multiple chronic diseases (AOR = 1.90, 95% CI = 1.44, 2.50), a history of smoking (AOR = 2.44, 95% CI = 1.82, 3.26), females, married, age 50-64 years, higher educational attainment, and retirees (AOR = 1.86, 95% CI = 1.06, 3.27) were more likely to be enrollees. Since enrollees are largely higher risk individuals with greater healthcare needs, policies that modify the ACA should take these factors into account to reduce potential adverse impacts on enrollees.

Persisting Gaps in Coverage and Services of Illinois Women Who Acquired Insurance After Implementation of the Affordable Care Act.

OBJECTIVES: Before implementation of the Affordable Care Act, many uninsured women in Illinois received care through safety-net programs. The new law allowed them to acquire health insurance through Medicaid or the Illinois Health Exchange. We examined (1) the health care experiences of such women who previously used a safety-net program and acquired this new coverage and (2) persisting gaps in coverage for breast and cervical cancer services and other health care services. METHODS: We interviewed a stratified random sample of 400 women aged 34-64 in Illinois each year during 2015-2017 (total N = 1200). We used multivariable logistic regression models to determine the association between health insurance status (Illinois Health Exchange vs Medicaid) and past 12-month gaps in coverage (ie, delaying care, not having a recent mammogram, having a medical cost, and having a medical cost not covered) for the 360 women who were former participants of the Illinois Breast and Cervical Cancer Program. We calculated odds ratios (ORs) and 95% confidence intervals (CIs), adjusting for race/ethnicity, age, income, and education. RESULTS: We found no significant differences by health insurance status in the prevalence of delaying preventive, chronic, or sick care; timeliness of the most recent mammogram; and having a major medical cost. However, of women who reported a major medical cost, women with health insurance through the Illinois Health Exchange had a higher prevalence of not having a cost covered than women with Medicaid (adjusted OR = 4.86; 95% CI, 1.48-16.03). CONCLUSIONS: The results of this study suggest that many women who gained health insurance lacked adequate coverage and services. Safety-net programs will likely continue to play an essential role in supporting women as they navigate a complex system.

The Trump Effect: Postinauguration Changes in Marketplace Enrollment.

CONTEXT: On January 20, 2017, President Donald Trump penned his first executive order, which aimed to "minimiz[e] the economic burden" of the Affordable Care Act, signaling his intent to make good on promises to repeal and replace the law. This executive order, along with concurrent changes in political messaging associated with the transition in power and reductions in HealthCare.gov advertising, lowered Health Insurance Marketplace enrollment at the end of the 2017 open enrollment period. METHODS: The authors used difference-in-differences and event-study models with weekly county-level Marketplace application data from 1,476 counties in 37 states to estimate the incremental enrollment loss in the postinauguration period. FINDINGS: Estimates indicate a population-weighted decline of over 700 applications per county-week during the final 2 weeks of the 2017 open enrollment period relative to 2016, corresponding to a nearly 30% decline in applications submitted. A more flexible event-study approach that better accounts for time shifting of enrollment across open enrollment periods found a similar decline of approximately 660 applications per county-week associated with the postinauguration period (-24%). CONCLUSIONS: The lack of political support for the law by the incoming administration seemingly had an immediate and significant downward effect on Marketplace enrollment nationwide.

Plan Choice And Affordability In The Individual And Small-Group Markets: Policy And Performance-Past And Present.

The individual and small-group health insurance markets have experienced considerable changes since the passage of the Affordable Care Act in 2010, affecting access, choice, and affordability for enrollees in these markets. We examined how health plan access, choice, and affordability varied between the individual on-Marketplace, individual off-Marketplace, and small-group markets in 2018. We found relatively similar outcomes across the three markets with respect to deductibles and out-of-pocket spending maximums. However, the small-group market maintained greater plan choice and lower premiums-outcomes that appear to be associated with higher insurer participation. States may consider a variety of policy proposals such as reinsurance or the introduction of a public option to increase insurer participation and improve the plan choices offered in the individual market.

What are consumers willing to pay for a broad network health plan?: Evidence from covered California.

Health Insurance Marketplaces have received considerable attention for their narrow network health plans. Yet, little is known about consumer tastes for network breadth and how they affect plan selection. I estimate demand for health plans in California's Marketplace, Covered California. Using 2017 individual enrollment data and provider network directories, I develop a geospatial measure of network breadth that reflects the physical locations of households and network providers. I find that households are sensitive to network breath in their plan choices. Mean willingness to pay for a broad network plan relative to a narrow network plan, defined as a two standard deviation, 17.44 percentage point increase in network breadth, is $45.83 in post-subsidy monthly premiums. Variation in WTP indicates a selection mechanism exists whereby older households sort into broader network plans. I also find that households are highly premium sensitive, which may be a result of plan standardization in Covered California.