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.

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.

Association of Changes in Primary Care Spending and Use With Participation in the US Affordable Care Act Health Insurance Marketplaces

This cross-sectional study examined whether the US Affordable Care Act (ACA) Marketplace was associated with changes in primary care spending and use.

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.

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.

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.

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.

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.

Demand for health insurance: Evidence from the California and Washington ACA exchanges

I estimate demand for health insurance using consumer-level data from the California and Washington ACA exchanges. I use the demand estimates to simulate the impact of policies targeting adverse selection, including subsidies and the individual mandate. I find (1) own-premium elasticities of -7.2 to -10.6 and insurance coverage elasticities of -1.1 to -1.2; (2) limited response to the mandate penalty amount, but significant response to the penalty's existence, suggesting consumers have a "taste for compliance"; (3) mandate repeal slightly increases consumer surplus because the ACA's price-linked subsidies shield most consumers from premium increases resulting from repeal and some consumers are not compelled to purchase insurance against their will; and (4) mandate repeal decreases consumer surplus if ACA subsidies are replaced with vouchers that expose consumers to premium increases. The economic rationale for the mandate depends on the extent of adverse selection and the presence of other policies targeting selection.

How does expansion of public health insurance affect risk pools and premiums in the market for private health insurance? Evidence from Medicaid and the Affordable Care Act Marketplaces

Private insurance market risk pools are likely to be directly affected by expansions of public insurance, in turn affecting premiums. We investigate the effects of Medicaid expansion on private health insurance markets using data on the plans offered through the health insurance "Marketplaces" (also known as Exchanges) established by the Affordable Care Act. We employ geographic matching to compare premiums for private plans in neighboring counties that straddle expansion and nonexpansion states and find that premiums of Marketplace plans are 11% lower in Medicaid expansion states, controlling for demographic and health characteristics as well as measures of health care access. These results are consistent with evidence on the composition of the private insurance risk pool in expansion versus nonexpansion states and associated differences in expected health spending.

Why Are the Health Insurance Marketplaces Thriving in Some States but Struggling in Others?

ISSUE

In 2017, health insurance marketplaces in some states were thriving, while those in other states were struggling. What explains these differences?

GOAL

Identify factors that explain differences in issuers’ participation levels in state insurance marketplaces.

METHODS

Analysis of the Robert Wood Johnson Foundation’s HIX Compare dataset, and the National Association of Insurance Commissioners’ 2010 Supplemental Health Care Exhibit Report.

FINDINGS AND CONCLUSIONS

State policies and insurance regulations were key factors affecting the number of issuers participating in the marketplaces in 2017. Marketplaces run by states had more issuers than states that rely on the federally facilitated marketplace. States with fewer than four issuers tended to have policies in place that could have been destabilizing--for example, permitting the sale of plans not compliant with the Affordable Care Act’s requirements regarding essential health benefits or guaranteed issue. Consumers in states that did not take steps to enforce these insurance market reforms still benefited from their protections, however; they were just enforced at the federal level. States with more issuers were also more likely to have expanded Medicaid. States with fewer issuers tended to be rural and have smaller populations, more concentrated hospital markets, and lower physician-to-population ratios.

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 2003–09 and 2014–15.

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.

Expanding Enrollment Without the Individual Mandate: Options to Bring More People into the Individual Market

ISSUE

Recent changes to the Affordable Care Act, including elimination of the individual mandate penalty, the halting of federal payments for cost-sharing reductions, and expanded access to short-term plans, may reduce enrollment in the individual market.

GOAL

Analyze options to increase enrollment, accounting for recent policy changes.

METHODS

RAND’s COMPARE microsimulation model is used to analyze six policies that would expand access to tax credits, increase their generosity, and fund a reinsurance program.

KEY FINDINGS AND CONCLUSIONS

The options would increase individual market enrollment by 400,000 to 3.2 million in 2020. Net increases in total enrollment (300,000 to 2.4 million) are smaller because of offsetting decreases in employer-sponsored insurance. The largest gains are possible through two options: large-scale investment in reinsurance, and extension of tax credits to higher-income people combined with increases in the generosity of existing tax credits. If funded through a fee on health plans, reinsurance could be implemented without increasing the federal deficit. Additional taxpayer costs would increase by $1 billion to $23 billion, depending on the policy. While enhanced tax credits for young adults would lead to small coverage gains, they would entail the lowest costs to taxpayers among the six options.

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.

How the Affordable Care Act Has Affected Health Coverage for Young Men with Higher Incomes

ISSUE

The Affordable Care Act (ACA) regulates the price of health plans sold in the nongroup market. Premiums cannot be based on gender or health status, and price increases related to age are limited. These changes have lowered premiums for older, sicker people but raised them for younger, healthier ones--especially young men ineligible for premium subsidies. This has raised concerns that the latter have failed to gain coverage.

GOAL

Compare the impact of the ACA's rating rules on the number of insured young men, older adults, and others.

METHODS

We compared overall and nongroup coverage trends pre- and post-ACA among demographic groups, comparing residents of states where the rule changes had little effect on premiums to states where the rules had greater effect.

FINDINGS

People whose premiums fell because of the ACA's rating rules were slightly more likely to get nongroup coverage than those whose premiums rose. All groups, including higher-income young men, gained coverage because of the combined effects of ACA changes.

CONCLUSION

Coverage rose after the ACA took effect among all demographic groups. Taken together, the ACA's individual mandate, marketing efforts, and effects on how people perceive the value of having insurance outweighed the impacts of changes in rating and benefit rules.

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.

Impact of Enroll America on the Number of Individuals Covered through the Federally Facilitated Marketplace

OBJECTIVE

To assess the impact of Enroll America's field outreach activities on the number of individuals enrolled in Marketplace coverage during the first open enrollment period.

DATA SOURCES/STUDY SETTING

Marketplace enrollment for the initial open enrollment period linked with data on Enroll America's field activities and baseline local-area demographic, economic, and health services characteristics.

STUDY DESIGN

We used a quasi-experimental design, comparing Marketplace enrollment during the first open enrollment period in local areas drawn from Enroll America field states to a comparison group of local areas drawn from states that were not served by Enroll America's field effort, but that otherwise match up well with Enroll America states.

PRINCIPAL FINDINGS

We find evidence of a large, positive effect of Enroll America's field outreach on Marketplace enrollment in non-Medicaid expansion states. Across model specifications, the Enroll America effects on Marketplace enrollment ranged between 10 and 15 percent, with most estimates statistically significant at the 5 percent level.

CONCLUSIONS

Enroll America played an important role in the success of individual states' efforts to boost Marketplace enrollment. Enroll American's evidence-driven, grassroots approach could serve as a model for others interested in conducting similar outreach campaigns for Affordable Care Act-related coverage.

ACA Marketplace premiums and competition among hospitals and physician practices

OBJECTIVES

To examine the association between annual premiums for health plans available in Federally Facilitated Marketplaces (FFMs) and the extent of competition and integration among physicians and hospitals, as well as the number of insurers.

STUDY DESIGN

We used observational data from the Center for Consumer Information and Insurance Oversight on the annual premiums and other characteristics of plans, matched to measures of physician, hospital, and insurer market competitiveness and other characteristics of 411 rating areas in the 37 FFMs.

METHODS

We estimated multivariate models of the relationship between annual premiums and Herfindahl-Hirschman indices of hospitals and physician practices, controlling for the number of insurers, the extent of physician-hospital integration, and other plan and rating area characteristics.

RESULTS

Premiums for Marketplace plans were higher in rating areas in which physician, hospital, and insurance markets were less competitive. An increase from the 10th to the 90th percentile of physician concentration and hospital concentration was associated with increases of $393 and $189, respectively, in annual premiums for the Silver plan with the second lowest cost. A similar increase in the number of insurers was associated with a $421 decrease in premiums. Physician-hospital integration was not significantly associated with premiums.

CONCLUSIONS

Premiums for FFM plans were higher in markets with greater concentrations of hospitals and physicians but fewer insurers. Higher premiums make health insurance less affordable for people purchasing unsubsidized coverage and raise the cost of Marketplace premium tax credits to the government.

What drives insurer participation and premiums in the Federally-Facilitated Marketplace?

We investigate determinants of market entry and premiums within the context of the Affordable Care Act's Marketplaces for individual insurance. Using Bresnahan and Reiss (1991) as the conceptual framework, we study how competition and firm heterogeneity relate to premiums in 36 states using Federally Facilitated or Supported Marketplaces in 2016. Our primary data source is the Qualified Health Plan Landscape File, augmented with market characteristics from the American Community Survey and Area Health Resource File as well as insurer-level information from federal Medical Loss Ratio annual reports. We first estimate a model of insurer entry and then investigate the relationship between a market's predicted number of entrants and insurer-level premiums. Our entry model results suggest that competition is increasing with the number of insurers, most notably as the market size increases from 3 to 4 entrants. Results from the premium regression suggest that each additional entrant is associated with approximately 4% lower premiums, controlling for other factors. An alternative explanation for the relationship between entrants and premiums is that more efficient insurers (who can price lower) are the ones that enter markets with many entrants, and this is reflected in lower premiums. An exploratory analysis of insurers' non-claims costs (a proxy for insurer efficiency) reveals that average costs among entrants are rising slightly with the number of insurers in the market. This pattern does not support the hypothesis that premiums decrease with more entrants because those entrants are more efficient, suggesting instead that the results are being driven mostly by price competition.

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.

Following the ACA Repeal-and-Replace Effort, Where Does the U.S. Stand on Insurance Coverage? Findings from the Commonwealth Fund Affordable Care Act Tracking Survey, March--June 2017

ISSUE

After Congress's failure to repeal and replace the Affordable Care Act, some policy leaders are calling for bipartisan approaches to address weaknesses in the law’s coverage expansions. To do this, policymakers will need data about trends in insurance coverage, reasons why people remain uninsured, and consumer perceptions of affordability.

GOAL

To examine U.S. trends in insurance coverage and the demographics of the remaining uninsured population, as well as affordability and satisfaction among adults with marketplace and Medicaid coverage.

METHODS

Analysis of the Commonwealth Fund Affordable Care Act Tracking Survey, March–June 2017

FINDINGS AND CONCLUSIONS

The uninsured rate among 19-to-64-year-old adults was 14 percent in 2017, or an estimated 27 million people, statistically unchanged from one year earlier. Uninsured rates ticked up significantly in three subgroups: 35-to-49-year-olds, adults with incomes of 400 percent of poverty or more (about $48,000 for an individual), and adults living in states that had not expanded Medicaid. Half of uninsured adults, or an estimated 13 million, are likely eligible for marketplace subsidies or the Medicaid expansion in their state. Four of 10 uninsured adults are unaware of the marketplaces. Adults in marketplace plans with incomes below 250 percent of poverty are much more likely to view their premiums as easy to afford compared with people with higher incomes. Policies to improve coverage include a federal commitment to supporting the marketplaces and the 2018 open enrollment period, expansion of Medicaid in 19 remaining states, and enhanced subsidies for people with incomes of 250 percent of poverty or more.

Narrow Networks on the Individual Marketplace in 2017

This Issue Brief describes the breadth of physician networks on the ACA marketplaces in 2017. We find that the overall rate of narrow networks is 21%, which is a decline since 2014 (31%) and 2016 (25%). Narrow networks are concentrated in plans sold on state-based marketplaces, at 42%, compared to 10% of plans on federally-facilitated marketplaces. Issuers that have traditionally offered Medicaid coverage have the highest prevalence of narrow network plans at 36%, with regional/local plans and provider-based plans close behind at 27% and 30%. We also find large differences in narrow networks by state and by plan type.

Effect of the Affordable Care Act on Health Care Access

ISSUE: The Affordable Care Act's (ACA) coverage provisions have extended health insurance coverage to millions of Americans. While the effects of the Medicaid expansion and marketplace establishments on coverage have been well studied, the resulting effects of coverage on access to health care remain unclear. GOAL: To examine how the 2014 coverage expansions affected health care access following the first open enrollment period of October 2013 to March 2014. METHODS: Analysis of data from the National Health Interview Survey (NHIS) and the Behavioral Risk Factor Surveillance System (BRFSS). FINDINGS AND CONCLUSIONS: We find that gaining insurance coverage through the expansions decreased the probability of not receiving medical care by between 20.9 percent and 25 percent. Gaining insurance coverage also increased the probability of having a usual place of care by between 47.1 percent and 86.5 percent. These findings suggest that not only has the ACA decreased the number of uninsured Americans, but has substantially improved access to care for those who gained coverage.

The Health Insurance Gap After Implementation of the Affordable Care Act in Texas

Households with incomes between 18% and 99% of the federal poverty level (FPL) are ineligible for Medicaid or enrollment in the health insurance exchange marketplace in Texas, resulting in the health insurance gap. We sought to determine the number of non-elderly adult Texans (NEATs) aged between 18 and 64 years in the insurance gap in rural vs urban areas in East Texas, West Texas, and South Texas. Data were obtained from the US Census Bureau website. In 2014, there were 1,101,000 NEATs in the insurance gap, accounting for 24.5% of all uninsured persons in Texas. The gap was significantly higher in rural vs urban areas in East and South Texas and in Texas as a whole. Large coverage gaps in states like Texas not expanding Medicaid under the Affordable Care Act pose major hurdles to reducing the number of uninsured individuals in these states.

Disaster Averted, For Now: How the American Health Care Act Would Have Affected Californians

Although the American Health Care Act (AHCA) was recently defeated, the policies in the bill represented a mix of ideas long favored by conservatives. If enacted, this repeal-and-replace bill would have had devastating consequences for most of the 5 million Californians currently receiving direct benefits from the Affordable Care Act (ACA), including more than 1 million who receive subsidies through Covered California and almost 4 million who have enrolled in the Medi-Cal expansion. Although the bill failed to garner enough votes for passage, it is likely that efforts to chip away at the ACA will continue and that some of the ideas contained within the AHCA will be revisited. This policy brief summarizes some of the most significant reversals that would have occurred under the Republican plan in the individual and small group insurance markets.

2016 Rural Enrollment in Health Insurance Marketplaces, by State

Purpose. In this brief, cumulative county-level enrollment in Health Insurance Marketplaces (HIMs) through March 2016 is presented for state HIMs operated as Federally Facilitated Marketplaces (FFMs) and for those operated as Federally Supported State-Based Marketplaces (FS-SBMs). Enrollment rates in metropolitan and non-metropolitan areas of each state, defined as the percentage of “potential market” participants selecting plans, are presented. Monitoring annual enrollment rates provides a gauge of how well state outreach and enrollment efforts are proceeding and helps identify states with strong non-metropolitan enrollment as models for other states to emulate. Key Findings. (1) Cumulative enrollment in the HIMs in non-metropolitan counties has grown to about 1.4 million in 2016, representing 40 percent of the potential market in non-metropolitan counties. (2) Estimated enrollment rates varied considerably across the United States. In particular, estimated enrollment rates in non-metropolitan areas were substantially higher than in metropolitan areas in Hawaii, Illinois, Michigan, Montana, Maine, Nebraska, Wisconsin, and Wyoming. (3) The states that achieved the highest absolute non-metropolitan enrollment totals were Michigan, Georgia, Missouri, North Carolina, Texas, and Wisconsin. Of these, Michigan, North Carolina, and Wisconsin also had non-metropolitan enrollment rates above 50 percent. (4) About half of all states, evenly distributed by Medicaid expansion status but mostly concentrated in the Midwestern census region, had higher enrollment growth in non-metropolitan areas from 2015 to 2016, and in fact aggregated non-metropolitan growth was greater than metropolitan growth in both expansion categories.

Insurance Coverage and Access to Care Under the Affordable Care Act

This brief details changes in insurance coverage and access to care under the Affordable Care Act. About 20 million individuals gained coverage under the law and access to care improved. Despite these gains, more than 27 million individuals are still uninsured, and many others face barriers in accessing care. As a result of the 2016 elections, the future of the ACA is uncertain. As the next Administration and policymakers debate further health system reforms, they should consider the scope of the ACA’s effects on their constituents.

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.

Americans' Experiences with ACA Marketplace Coverage: Affordability and Provider Network Satisfaction: Findings from the Commonwealth Fund Affordable Care Act Tracking Survey, February--April 2016

For people with low and moderate incomes, the Affordable Care Act's tax credits have made premium costs roughly comparable to those paid by people with job-based health insurance. For those with higher incomes, the tax credits phase out, meaning that adults in marketplace plans on average have higher premium costs than those in employer plans. The law's cost-sharing reductions are reducing deductibles. Lower-income adults in marketplace plans were less likely than higher-income adults to report having deductibles of $1,000 or more. Majorities of new marketplace enrollees and those who have changed plans since they initially obtained marketplace coverage are satisfied with the doctors participating in their plans. Overall, the majority of marketplace enrollees expressed confidence in their ability to afford care if they were to become seriously ill. This issue brief explores these and other findings from the Commonwealth Fund Affordable Care Act Tracking Survey, February--April 2016.

Factors Affecting Health Insurance Enrollment Through the State Marketplaces: Observations on the ACA's Third Open Enrollment Period

Issue: Nearly 12.7 million individuals signed up for coverage in the Affordable Care Act's (ACA) health insurance marketplaces during the third open enrollment period, and by the end of March there were 11.1 million consumers with active coverage. States that operate their own marketplaces posted a year-to-year enrollment gain of 8.8 percent. To maintain membership and attract new consumers, the state-based marketplaces must sponsor enrollment assistance programs and conduct consumer outreach. These marketplaces relied heavily on such efforts during the third enrollment period, despite declining funding. Goal: To learn which outreach strategies, assistance programs, and other factors marketplace officials viewed as having exerted the greatest influence on enrollment. Methods: Survey of officials representing each of the 17 state-based marketplaces (15 responses). Key findings and conclusions: The cost of coverage and low health insurance literacy pose significant barriers to enrollment for many consumers. Marketplaces sought to overcome them by encouraging consumers to obtain in-person enrollment assistance from ACA-created assistance programs and from insurance brokers, and by partnering with community organizations for outreach activities. Many marketplaces also enhanced their web portals to make them easier to navigate and to give consumers better tools with which to evaluate their coverage options.

How Much Financial Protection Do Marketplace Plans Provide in States Not Expanding Medicaid?

The Affordable Care Act's premium subsidies and cost-sharing reductions have helped to reduce out-of-pocket costs for low-income people enrolled in marketplace plans. This financial protection has been particularly important for people with incomes above 100 percent of poverty who live in states that have not expanded Medicaid. However, a key question for policymakers is how this protection compares to Medicaid. This brief analyzes a sample of silver plans offered in the largest markets in 18 states that use the federal website for marketplace enrollment and have not expanded Medicaid eligibility. It finds that marketplace enrollees at this income level in most plans analyzed are at risk of incurring premium and out-of-pocket costs that are higher than what they would pay under Medicaid. For people with significant health needs, costs are estimated to be much higher in marketplace plans than what they would be under Medicaid.

Changes in Consumer Cost-Sharing for Health Plans Sold in the ACA's Insurance Marketplaces, 2015 to 2016

This brief examines changes in consumer health plan cost-sharing--deductibles, copayments, coinsurance, and out-of-pocket limits--for coverage offered in the Affordable Care Act's marketplaces between 2015 and 2016. Three of seven measures studied rose moderately in 2016, an increase attributable in part to a shift in the mix of plans offered in the marketplaces, from plans with higher actuarial value (platinum and gold plans) to those that have less generous coverage (bronze and silver plans). Nearly 60 percent of enrollees in marketplace plans receive cost-sharing reductions as part of income-based assistance. For enrollees without cost-sharing reductions, average copayments, deductibles, and out-of-pocket limits remain considerably higher under bronze and silver plans than under employer-based plans; cost-sharing is similar in gold plans and employer plans. Marketplace plans are more likely than employer-based plans to impose a deductible for prescription drugs but no less likely to do so for primary care visits.

State Variation in Health Care Service Utilization: United States, 2014

Data from the National Health Interview Survey, 2014 •The percentage of adults without a usual place of medical care ranged from 2.8% in Vermont to 26.7% in Nevada. •The percentage of adults who did not have a general doctor visit in the past 12 months ranged from 15.9% in Vermont to 48.1% in Montana. •The percentage of adults without a usual place of medical care was lower in states that expanded Medicaid compared with nonexpansion states. •The percentage of adults without a usual place of medical care or who did not see a general doctor in the past 12 months was lower in states with partnership marketplaces compared with Federally Facilitated Marketplace states. State-level differences in the percentage of uninsured Americans, along with other factors, may affect health care access and utilization (1-4). This report examines the prevalence of two health care utilization measures among adults aged 18-64 by state. Additionally, differences by Medicaid expansion status and state Health Insurance Marketplace type are examined. Estimates are based on the 2014 National Health Interview Survey, a nationally representative sample of the noninstitutionalized U.S.

Health Insurance Marketplaces: Premium Trends in Rural Areas

Since 2014, when the Health Insurance Marketplaces (HIMs) authorized by the Patient Protection and Affordable Care Act (ACA) 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 2016, before accounting for subsidies, with an emphasis on the widening variation across rural and urban places. Since this brief focuses on premiums without accounting for subsidies, this is not intended to be an analysis of the "affordability" of ACA premiums, as that would require assessment of premiums, cost-sharing adjustments, and other factors.

The redesign of consumer cost sharing for specialty drugs at the California Health Insurance Exchange

This paper describes the redesign of health benefits at Covered California-the nation's largest health insurance exchange, which covers 1.3 million individuals, and its benefit designs extending to hundreds of thousands more enrollees through insurance products sold outside the exchange-with respect to specialty drugs for the 2016 enrollment year. The catalyst for benefit redesign came from advocacy organizations representing patients suffering from HIV, multiple sclerosis, epilepsy, hepatitis C, and other chronic conditions. The first component of the benefit redesign creates a separate deductible for pharmaceutical expenditures, with a commensurate reduction in the deductible for other (medical) expenditures. The second component requires health plans to assign at least 1 specialty drug for each therapeutic class to a nonspecialty tier, offering patients a treatment option for which they are not exposed to coinsurance. The third component imposes a monthly payment limit of $250 for each specialty drug prescription, thereby buffering patients using these drugs against the $6250 individual, or $13,500 family, annual medical payment limit. The pharmacy deductible and monthly out-of-pocket payment limit are substantially lower for low-income enrollees in the subsidized silver-tier products. The Covered California redesign indicates that patients can be shielded from the most onerous cost-sharing burdens while keeping premiums affordable for the entire enrolled population; however, sustainable access to care requires reductions in the underlying cost of new clinical technologies.

Implementing the Affordable Care Act: Promoting Competition in the Individual Marketplaces

A main goal of the Affordable Care Act is to provide Americans with access to affordable coverage in the individual market, achieved in part by pro­moting competition among insurers on premium price and value. One primary mechanism for meeting that goal is the establishment of new individual health insurance marketplaces where consumers can shop for, compare, and purchase plans, with subsidies if they are eligible. In this issue brief, we explore how the Affordable Care Act is influencing competition in the individual marketplaces in four states--Kansas, Nevada, Rhode Island, and Washington. Strategies include: educating consumers and providing coverage information in one place to ease decision-making; promoting competition among insurers; and ensuring a level playing field for premium rate development through the rate review process.

The CBO's Crystal Ball: How Well Did It Forecast the Effects of the Affordable Care Act?

The Congressional Budget Office (CBO), a nonpartisan agency of Congress, made official projections of the Affordable Care Act's impact on insurance coverage rates and the costs of providing subsidies to consumers purchasing health plans in the insurance marketplaces. This analysis finds that the CBO overestimated marketplace enrollment by 30 percent and marketplace costs by 28 percent, while it underestimated Medicaid enrollment by about 14 percent. Nonetheless, the CBO's projections were closer to realized experience than were those of many other prominent forecasters. Moreover, had the CBO correctly anticipated income levels and health care prices in 2014, its estimate of marketplace enrollment would have been within 18 percent of actual experience. Given the likelihood of additional reforms to national health policy in future years, it is reassuring that, despite the many unforeseen factors surrounding the law's rollout and participation in its reforms, the CBO's forecast was reasonably accurate.

Racial and Ethnic Disparities in Services and the Patient Protection and Affordable Care Act

OBJECTIVES

We examined prereform patterns in insurance coverage, access to care, and preventive services use by race/ethnicity in adults targeted by the coverage expansions of the Patient Protection and Affordable Care Act (ACA).

METHODS

We used pre-ACA household data from the Medical Expenditure Panel Survey to identify groups targeted by the coverage provisions of the Act (Medicaid expansions and subsidized Marketplace coverage). We examined racial/ethnic differences in coverage, access to care, and preventive service use, across and within ACA relevant subgroups from 2005 to 2010. The study took place at the Agency for Healthcare Research and Quality in Rockville, Maryland.

RESULTS

Minorities were disproportionately represented among those targeted by the coverage provisions of the ACA. Targeted groups had lower rates of coverage, access to care, and preventive services use, and racial/ethnic disparities were, in some cases, widest within these targeted groups.

CONCLUSIONS

Our findings highlighted the opportunity of the ACA to not only to improve coverage, access, and use for all racial/ethnic groups, but also to narrow racial/ethnic disparities in these outcomes. Our results might have particular importance for states that are deciding whether to implement the ACA Medicaid expansions.

Rural Enrollment in Health Insurance Marketplaces, by State

Since passage of the Patient Protection and Affordable Care Act (ACA), much attention has been focused on the functioning of Health Insurance Marketplaces (HIMs). In this brief, cumulative county-level enrollment in HIMs through March 2015 is presented for state HIMs operated as Federally Facilitated Marketplaces (FFMs) and Federally Supported State-Based Marketplaces (FS-SBMs). We provide comparisons between enrollment in urban and rural areas of each state and corresponding percentages of "potential market" participants enrolled. Given differences in populations eligible for HIM enrollment, we analyzed Medicaid expansion states separately. This analysis provides a gauge of how well outreach and enrollment efforts are proceeding in the states. Key Findings. (1) Overall, people living in metropolitan areas were more likely to enroll in HIMs than were people in non-metropolitan areas, as 38.9 percent of potentially eligible metropolitan residents in Medicaid expansion states and 47.5 percent in non-expansion states were enrolled in HIMs, compared to 33.9 percent and 37.3 percent in nonmetropolitan areas, respectively. (2) Estimated enrollment rates varied considerably across the United States. In particular, estimated enrollment rates in non-metropolitan areas are higher than in metropolitan areas in Illinois, Maine, Michigan, Montana, Nebraska, Nevada, New Hampshire, North Dakota, Wisconsin, and Wyoming. (3) The states with the highest rural enrollment percentages were Maine, Michigan, Montana, North Carolina, New Hampshire, South Carolina, and Wisconsin. States with high absolute rural enrollment were about as likely to be Medicaid expansion states to be as non-expansion states, and they were slightly less likely to belong to the South census region.

To Enroll or Not to Enroll? Why Many Americans Have Gained Insurance Under the Affordable Care Act While Others Have Not. Findings from the Commonwealth Fund Affordable Care Act Tracking Survey, March-May 2015

According to the most recent Commonwealth Fund Affordable Care Act Tracking Survey, March-May 2015, an estimated 25 million adults remain uninsured. To achieve the Affordable Care Act's goal of near-universal coverage, policymakers must understand why some people are enrolling in the law's marketplace plans or in Medicaid coverage and why others are not. This analysis of the survey finds that affordability--whether real or perceived--is playing a significant role in adults' choice of marketplace plans and the decision whether to enroll at all. People who have gained coverage report significantly more positive experiences shopping for health plans than do those who did not enroll. Getting personal assistance--from telephone hotlines, navigators, and insurance brokers, among other sources--appears to make a critical difference in whether people gain health insurance

Rural Enrollment in Health Insurance Marketplaces

Our previous analysis of 2015 Health Insurance Marketplace (HIM) data on plan availability and premiums in comparison to 2014 showed only modest premium increases in many rural areas and increased firm participation in most areas. To determine whether HIM enrollment also shows a positive trend, we analyzed county-level HIM enrollment data for 2015 by geographic categories, population density, premium, and firm participation, comparing enrollment outcomes in rural places to those in urban places. Key Findings. (1) In the Northeast, Midwest, and West census regions, estimated enrollment rates in rural (micropolitan and noncore) counties were similar to estimated rates in urban counties, while in the South, rural rates lagged behind urban rates. (2) Estimated enrollment rates at the rating area level increased as the population density of the rating area increased. (3) Various measures of rurality and geography indicate that HIMs performed well in many rural areas; however, this analysis suggests that in some rural areas, enrollment outcomes may have been weak due to factors such as the geographic scope of the rating areas, plan availability in these rating areas, or potentially fewer resources devoted to outreach and enrollment efforts. (4) In general, county-level, enrollment-weighted average premiums differed more by census region than by metropolitan, micropolitan, and noncore status. (5) Low enrollment rates at the rating area level were associated with a lower numbers of firms participating in HIMs. When three or more firms participated, enrollment rates were close to or above average.

Health Insurance Marketplaces: Early Findings on Changes in Plan Availability and Premiums in Rural Places, 2014-2015

The Patient Protection and Affordable Care Act established Health Insurance Marketplaces (HIMs) in all 50 states and the District of Columbia. This policy brief assesses the changes in HIMs from 2014 to 2015 in terms of choices offered and premiums charged, with emphasis on how these measures vary across rural and urban places. Key Findings. (1) In 74 percent of HIM rating areas, the number of firms operating increased by at least one, while the number of firms decreased in only about 6 percent of rating areas. Further, 64 percent of rating areas with fewer than 50 persons per square mile gained at least one firm. (2) There was no consistent pattern of premium increases with respect to rating area population density (used as a proxy here for the degree of "ruralness" of the rating areas). Nationally, rural areas are not experiencing higher premium increases than their urban counterparts. In fact, the lowest increases in second-lowest cost silver plan premiums occurred in the medium-density population rating areas of 51 to 300 persons per square mile. (3) Average adjusted premiums increased from 2014 to 2015 by 6.7 percent in Federally-Facilitated Marketplaces (FFMs) compared to just 1.4 percent in State-Based Marketplaces (SBMs). Regardless of SBM or FFM status, premium increases across the United States were negatively correlated with the number of firms entering the market. (4) Analysis of the most rural states, in terms of percentage of the population classified as nonmetropolitan, shows that, in general, premiums fell significantly in rural places where they had been rather high, and they increased in rural places where they had been rather low. The five rural states with the lowest premium increases had an average of 0.17 firms entering the market, while the five with the highest premium increases had an average of 0.50 firms exiting the market.