Nongroup Health Insurance Market Research Articles

Medical Financial Burden Declined For Consumers In The Nongroup Market.

The share of consumers in the nongroup health insurance market who spent more than 10percent of family income on medical expenses declined by 6.7 percentage points after Affordable Care Act implementation (2013-15), and after adjustments for other factors. Average family medical expenses declined by $811 for nongroup consumers.

The impact of the Affordable Care Act on self-employment.

This paper estimates the impact of the implementation of the Affordable Care Act (ACA) in 2014 on the decision to be self-employed. Using data from the Current Population Survey, we employ two identification strategies. Utilizing prereform variation in state nongroup health insurance market regulations, we find that the ACA did not increase self-employment overall in states that lacked similar provisions in their nongroup markets prior to 2014. In specifications that utilize variation across individuals in characteristics that could make it harder for them to purchase insurance if they left their current employer, we also do not find that the ACA differentially increased self-employment. However, in states that lacked the ACA nongroup market provisions, we do find a statistically significant increase in the second year of implementation (when individuals had more time to adjust behavior and the exchanges functioned properly) among individuals eligible for insurance subsidies, suggesting that a combination of time to adjust, low uncertainty and low insurance costs may be necessary for nongroup health insurance reforms to impact self-employment.

Plan Selection in the Non-Group Market in the First Year of the Health Insurance Marketplace.

BACKGROUND The Affordable Care Act (ACA)-created Marketplaces reduced barriers to entry in the non-group health insurance market. Although tax credits were available to individuals who enrolled in qualified health plans (QHPs) beginning in 2014, many individuals chose not to switch plans. We examined characteristics associated with switching from a non-ACA compliant plan to a QHP in 2014 and, conditional on switching, the characteristics associated with selection of a specific plan level.METHODS Using claims data from a large commercial insurer, we examined characteristics associated with switching to a QHP in 2014. For those who did switch, we used a multinomial logit model to estimate odds of selecting different metal levels-representing varying degrees of coverage-for a group of the highest and lowest risk individuals.RESULTS We found individuals most likely to benefit from the premium and benefit requirements on QHPs were more likely to switch to QHPs. Individuals at high-risk for high health care expenditures who had advance premium tax credits (APTCs) had lower odds of choosing a less generous plan compared to individuals without APTCs (odds of bronze plan over silver: 0.40, CI: 0.30 - 0.55), while individuals at low-risk of being high cost with APTCs were more likely to select a plan with a lower premium (odds bronze plan over silver: 1.35, CI: 1.09 - 1.66).LIMITATIONS This study was conducted with data from 1 health plan, limiting its national generalizability; however, this study is a good representation of activity within the state.CONCLUSIONS APTCs are important for ensuring that less healthy individuals are able to afford adequate levels of coverage.

DID REFORM OF THE NON‐GROUP HEALTH INSURANCE MARKET AFFECT THE DECISION TO BE SELF‐EMPLOYED? EVIDENCE FROM STATE REFORMS IN THE 1990s

This paper estimates whether state-level implementation of community rating and guaranteed issue regulations in the non-group health insurance market during the 1990s affected the decision of taxpayers to be self-employed. Using a panel of tax returns that span 1987-2000, we find no statistically significant effect of the reforms on the propensity to be self-employed overall, although we find evidence of an increase in self-employment among older taxpayers and weaker evidence of decreases among younger cohorts.

'Long Time Coming': Are We on the Brink of Universal Health Care Coverage?

The financial meltdown and bailout of September-October 2008 have shocked everyone. The headlines tell it all: Wall Street, R. I. P. (Creswell & White, 2008), Retirement accounts have lost $2 trillion so (J. H. Davis, 2008), Greenspan's free-market faith shaken (Irwin & Paley, 2008). Bernstein (2008), a well-known investment adviser and historian, described the bailout as an earth-shaking blow to the most basic principle of our economic namely, faith in individual decision-making in free markets (p. 8). Despite the severity of this crisis, we should not allow it to deflect attention from the ongoing meltdown of our health care system (http://medicine.plosjournals.org/perlserv/?request=getdocument &doi=10.1371/journal.pmed.0050208). In recent months, several studies and reports have examined the dimensions of this crisis: * The Commonwealth Fund Commission on a High Performance gave the U.S. health care system a score of 65 out of 100 on 37 core indicators of performance (http://www.commonwealthfund.org/publications/ publications_show.htm?doc_id=692682). * In 2007, 45 million people were without health insurance. Although this represented a decline from 2006, when 46.5 million people had no coverage, the improvement was due to an increase in through public programs (Fronstin, 2008). The uninsured population is likely to increase in 2008. * Twenty-five million people have inadequate coverage, which ensures neither access to care nor financial protection (K. Davis, 2008). Low-income people have particular difficulty finding adequate coverage. * Medical debt has become a serious problem, with a third of the population reporting their families have had difficulty paying medical bills (http://www.kff.org/newsroom/ posr102108nr.cfm). One study suggests that health care issues, including sickness and medical debt, may play a central role in home foreclosures (http://works.bepress.com/cgi/ viewcontent.cgi?article=1001&context= christopher_robertson). * Between 1999 and 2007, while health insurance premiums grew by 114 percent, earnings grew by just 27 percent (http://www.rwjf. org/pr/product.jsp?id=35368). * Women buying in the nongroup health insurance market often pay far more than men do for identical coverage (Pear, 2008). These grim realities are not new to social workers or readers of Health & Social Work. What is new is their context. Whatever we may think of the bailout, it has undermined two central ideological objections to universal health care (UHC).The first is that we need to limit the role of government. It is difficult to oppose an expanded role for government when perhaps the most conservative administration since the 1920s not only partially nationalized our banking system, but also gave bankers no choice in the matter. In addition, the Bush administration is developing a plan to assist homeowners facing foreclosure (Bajaj, 2008). If we can take radical steps like these, why not regulate our health care system and extend to people without insurance? The second objection is that government provision of health care promotes what economists call moral hazard (Nyman, 2004). Moral hazard occurs when insurance insulates or protects individuals from the consequences of their actions (Gladwell, 2005). In terms of health care, if individuals know that the government or an insurance company will pay their bills, they will be more willing to engage in reckless behavior than they would if the burden of cost fell to them. Nyman (cited in Gladwell, 2005) argued that concern about moral hazard explains 'the general lack of enthusiasm by U.S. health economists for the expansion of health insurance coverage.' However, the financial bailout has made a mockery of concern about moral hazard. Once the federal government declares, 'Thou shalt not fail,' there are no limits to how far future risk-takers will go (Bernstein, 2008, p. …

The Adequacy of Household Survey Data for Evaluating the Nongroup Health Insurance Market

To evaluate the accuracy of household survey estimates of the size and composition of the nonelderly population covered by nongroup health insurance. Health insurance enrollment statistics reported to New Jersey insurance regulators. Household data from the following sources: the 2002 Current Population Survey (CPS)-March Demographic Supplement, the 1997 and 1999 National Surveys of America's Families (NSAF), the 2001 New Jersey Family Health Survey (NJFHS), a 2002 survey of known nongroup health insurance enrollees, a small 2004 survey testing alternative health insurance question wording. To assess the extent of bias in estimates of the size of the nongroup health insurance market in New Jersey, enrollment trends are compared between official enrollment statistics reported by insurance carriers to state insurance regulators with estimates from three general population household surveys. Next, to evaluate possible bias in the demographic and socioeconomic composition of the New Jersey nongroup market, distributions of characteristics of the enrolled population are contrasted among general household surveys and a survey of known nongroup subscribers. Finally, based on inferences drawn from these comparisons, alternative health insurance question wording was developed and tested in a local survey to test the potential for misreporting enrollment in nongroup coverage in a low-income population. Data for nonelderly New Jersey residents from the 2002 CPS (n=5,028) and the 1997 and 1999 NSAF (n=6,467 and 7,272, respectively) were obtained from public sources. The 2001 NJFHS (n=5,580 nonelderly) was conducted for a sample drawn by random digit dialing and employed computer-assisted telephone interviews and trained, professional interviewers. Sampling weights are used to adjust for under-coverage of households without telephones and other factors. In addition, a modified version of the NJFHS was administered to a 2002 sample of known nongroup subscribers (n=1,398) using the same field methods. These lists were provided by four of the five largest New Jersey nongroup insurance carriers, which represented 95 percent of all nongroup enrollees in the state. Finally, a modified version of the NJFHS questionnaire was fielded using similar methods as part of a local health survey in New Brunswick, New Jersey, in 2004 (n=1,460 nonelderly). General household sample surveys, including the widely used CPS, yield substantially higher estimates of nongroup enrollment compared with administrative totals and yield estimates of the characteristics of the nongroup population that vary greatly from a survey of known nongroup subscribers. A small survey testing a question about source of payment for direct-purchased coverage suggests than many public coverage enrollees report nongroup coverage. Nongroup health insurance has been subject to more than a decade of reform and is of continuing policy interest. Comparisons of unique data from a survey of known nongroup subscribers and administrative sources to household surveys strongly suggest that the latter overstates the number and misrepresent the composition of the nongroup population. Research on the nongroup market using available sources should be interpreted cautiously and survey methods should be reexamined.

Reinsuring Risk to Increase Access to Health Insurance.

At least 41 million Americans are currently without health insurance in any given month (U.S. Bureau of the Census, 2002). They are uninsured for a variety of reasons, and most people who lack coverage are affected by more than one reason. Two generalizations can be made, however. First, a majority simply cannot afford to purchase health insurance unless it is heavily subsidized. Most do not have access to employer-sponsored coverage and so must purchase any insurance in the non-group (individual) health-insurance market - a market where, as I explain below, insurance is typically twice as expensive as employer-group coverage if it is not denied outright. Since about two-thirds of the uninsured have incomes below $35,000, non-group health-insurance premiums often exceed 10 percent of their incomes. The second generalization is that, to an important extent, high premiums in the non-group market and denial of coverage reflect market failure due to asymmetric information. Insurers can never know as much as an individual does about his or her health, family history of health problems, and tendency to seek medical care. Because of this asymmetry, it is impossible for an insurer to set premiums that accurately reflect the non-random portion of health-care costs for different individuals. The non-group market is the only health-insurance option for people without employersponsored coverage. Tax-related subsidies as proposed by members of Congress and the Bush administration do not address the market-failure problems and so are unlikely to make insurance much more affordable. To increase access to health insurance, risk in the non-group market needs to be shifted to a broader population base. In what follows, I first describe the three distinct health-insurance markets in which people can obtain health insurance, and the special nature of competition among insurance companies in the non-group market. Then I make the case for government to act as reinsurer and assume the risk of extremely high-cost people. Efficiency in the non-group health-insurance market would be improved if the government reinsured the market. Equity also would be increased if the government acted as reinsurer because more uninsured people would have access to insurance. Finally, I describe precedents for this role for government in other markets, and why tax-related subsidies will not succeed in increasing health-insurance coverage unless the risks of extremely high costs are shifted to the government.