The Affordability Of Individual-Market Health Insurance In California Under The American Rescue Plan Act, 2021

In 2021 the American Rescue Plan Act increased premium subsidies for people purchasing insurance from the Affordable Care Act Marketplaces and provided zero-premium Marketplace plans that covered 94 percent of medical care costs (silver 94 plans) to recipients of unemployment compensation. Using data on adult enrollees in on- and off-Marketplace individual plans in California in 2021, we found that 41 percent reported incomes at or below 400 percent of the federal poverty level and that 39 percent reported living in households receiving unemployment compensation. Overall, 72 percent of enrollees reported having no difficulty paying premiums, and 76 percent reported that out-of-pocket expenses did not affect their seeking of medical care. The majority of enrollees eligible for plans with cost-sharing subsidies were enrolled in Marketplace silver plans (56-58 percent). Many of these enrollees, however, may have missed opportunities for premium or cost-sharing subsidies: 6-8 percent enrolled in off-Marketplace plans and were more likely to have difficulty paying premiums than those in Marketplace silver plans, and more than one-quarter enrolled in Marketplace bronze plans and were more likely to delay care because of cost than those in Marketplace silver plans. In the coming era of expanded Marketplace subsidies under the Inflation Reduction Act of 2022, helping consumers identify high-value and subsidy-eligible plans could mitigate remaining affordability problems.

Alleviating Financial Hardships Associated with High-Deductible Health Plans for Adults with Chronic Conditions Through Health Savings Accounts

BACKGROUND

High-deductible health plans (HDHPs) are becoming increasingly common, but their financial implications for enrollees with and without chronic conditions and the mitigating effects of health savings accounts (HSAs) are relatively unknown.

OBJECTIVE

Our aim was to compare financial hardship between non-HDHPs and HDHPs with and without HSAs, stratified by enrollees' number of chronic conditions.

DESIGN

We used data from 2015 to 2018 Medical Expenditure Panels Surveys (MEPS) to compare rates of financial hardship across individuals with HDHPs and non-HDHPs using linear and logistic regression models.

PARTICIPANTS

A nationally representative sample of 30,981 adults aged 18-64 enrolled in HDHPs and non-HDHPs.

MAIN MEASURES

We examined several measures of financial hardship, including total yearly out-of-pocket medical spending as well as rates of delaying medical care or prescriptions in the past year due to cost, forgoing medical care or prescriptions in the past year due to cost, paying medical bills over time, or having problems paying medical bills. We compared rates using the non-HDHP as the control.

KEY RESULTS

On most measures, HDHPs are associated with greater financial hardship compared to non-HDHPs, including average annual out-of-pocket spending of $637 for non-HDHPs, $939 for HDHPs with HSAs, and $825 for HDHPs without HSAs (p < 0.01). However, for HDHP enrollees with multiple chronic conditions, having an HSA was associated with less financial hardship (p < 0.05).

CONCLUSIONS

Our findings suggest that HSAs may be most beneficial for those with chronic conditions, in part due to the tax benefits they offer as well as the fact that those with chronic conditions are more likely to take advantage of their HSAs than their younger, healthier counterparts. However, as HDHPs are more likely to be correlated with worse financial outcomes regardless of health status, recent trends of increasing participation may be a reason for concern.

Preventing Financial Strain for Low- and Moderate-Income Adults: a Comparison of Medicaid, Marketplace, and Employer-Sponsored Insurance

BACKGROUND

Medicaid expansion and subsidized private plans purchased on the Affordable Care Act's (ACA) Marketplaces accounted for most of the ACA's coverage gains.

OBJECTIVE

Compare access to care and financial strain between Medicaid and Marketplace plans, and benchmark these against employer-sponsored insurance (ESI) plans.

DESIGN

Cross-sectional survey PARTICIPANTS: A nationally representative, non-institutionalized sample of 37,219 non-elderly adults with incomes up to 400% of the federal poverty level between 2015 and 2018, and a sub-group of individuals with chronic diseases.

MAIN MEASURES

Self-reported barriers to accessing care, cost-related medication non-adherence, and financial strain.

KEY RESULTS

Marketplace enrollees were more likely than Medicaid enrollees to delay or avoid care due to cost (19.3% vs 10.0%; adjusted difference (AD), 8.6 [95% CI, 6.8 to 10.4]) and report difficulties affording specialty care (7.7% vs 6.6%; AD, 1.8% [95% CI, 0.3% to 3.3%]), while there were no differences in having insurance accepted by a doctor or ability to afford dental care. Marketplace enrollees were also more likely to report cost-related medication non-adherence (21.5% vs 20.0%; AD, 4.0 [CI, 1.5 to 6.4]), be very worried about not being able to pay medical costs in case of a serious accident (32.3% vs 25.8%; AD, 6.4 [CI, 4.2 to 8.6]), have expenses exceeding $2000 (22.4% vs 5.4%; AD, 8.3 [CI, 6.2 to 10.3]), and have problems paying medical bills (18.4% vs 15.6%; AD, 1.8 [CI, 0.3 to 3.9]). Marketplace-Medicaid differences were larger among persons with a chronic disease. Individuals in ESI plans fared better for most, but not all, outcomes.

CONCLUSION

Medicaid offers better protections than Marketplace plans on most measures of access and financial strain.

Underinsurance Among Children in the United States

OBJECTIVES

We describe the change in the percentage of children lacking continuous and adequate health insurance (underinsurance) from 2016 to 2019. We also examine the relationships between child health complexity and insurance type with underinsurance.

METHODS

Secondary analysis of US children in the National Survey of Children's Health combined 2016-2019 dataset who had continuous and adequate health insurance. We calculated differences in point estimates, with 95% confidence intervals (CIs), to describe changes in our outcomes over the study period. We used multivariable logistic regression adjusted for sociodemographic characteristics and examined relationships between child health complexity and insurance type with underinsurance.

RESULTS

From 2016 to 2019, the proportion of US children experiencing underinsurance rose from 30.6% to 34.0% (+3.4%; 95% CI, +1.9% to +4.9%), an additional 2.4 million children. This trend was driven by rising insurance inadequacy (24.8% to 27.9% [+3.1%; 95% CI, +1.7% to +4.5%]), which was mainly experienced as unreasonable out-of-pocket medical expenses. Although the estimate of children lacking continuous insurance coverage rose from 8.1% to 8.7% (+0.6%), it was not significant at the 95% CI (-0.5% to +1.7%). We observed significant growth in underinsurance among White and multiracial children, children living in households with income ≥200% of the federal poverty limit, and those with private health insurance. Increased child health complexity and private insurance were significantly associated with experiencing underinsurance (adjusted odds ratio, 1.9 and 3.5, respectively).

CONCLUSIONS

Underinsurance is increasing among US children because of rising inadequacy. Reforms to the child health insurance system are necessary to curb this problem.

Health Care Access Among Essential Critical Infrastructure Workers, 31 States, 2017-2018

OBJECTIVES

Essential workers in the United States need access to health care services for preventive care and for diagnosis and treatment of illnesses (coronavirus disease 2019 [COVID-19] or other infectious or chronic diseases) to remain healthy and continue working during a pandemic. This study evaluated access to health care services among selected essential workers.

METHODS

We used the most recent data from the Behavioral Risk Factor Surveillance System, 2017-2018, to estimate the prevalence of 4 measures of health care access (having health insurance, being able to afford to see a doctor when needed, having a personal health care provider, and having a routine checkup in the past year) by broad and detailed occupation group among 189 208 adults aged 18-64.

RESULTS

Of all occupations studied, workers in farming, fishing, and forestry occupations were most likely to have no health insurance (46.4%). Personal care aides were most likely to have been unable to see a doctor when needed because of cost (29.3%). Construction laborers were most likely to lack a personal health care provider (51.1%) and to have not had a routine physical checkup in the past year (50.6%). Compared with workers in general, workers in 3 broad occupation groups-food preparation and serving; building and grounds cleaning and maintenance; and construction trades-had significantly lower levels of health care access for all 4 measures.

CONCLUSION

Lack of health insurance and underinsurance were common among subsets of essential workers. Limited access to health care might decrease essential workers' access to medical testing and needed care and hinder their ability to address underlying conditions, thereby increasing their risk of severe outcomes from some infectious diseases, such as COVID-19. Improving access to health care for all workers, including essential workers, is critical to ensure workers' health and workforce stability.