State-based Marketplaces Research Articles

Availability Of Adult Dental Plans In The Affordable Care Act Marketplaces, 2016-23.

The Affordable Care Act Marketplaces may improve access to dental insurance, but little is known about the availability of such coverage. We used data from state and federal Marketplace sources to describe the availability of adult dental plans, including Stand-alone Dental Plans and those embedded in medical plans. We also examined the characteristics of counties with limited dental insurer participation and those that experienced a net loss of Stand-alone Dental Plan insurers between 2016 and 2023. We found that in 2023, at least one Stand-alone Dental Plan was offered in every state, and thirty-six states offered embedded dental plans. Most counties (63.6percent) had access to more than five insurers offering adult dental plans, whereas approximately 4percent had only one insurer offering adult dental plans. Counties in state-based Marketplaces, rural areas, and dentist shortage areas were more likely to be counties with limited dental insurer participation. The net loss of Stand-alone Dental Plans between 2016 and 2023 was more common in state-based Marketplaces and disadvantaged counties. Our findings can inform future policies to improve the dental insurance Marketplace and access to affordable dental care.

Availability of off-marketplace plans with lower premiums for higher-income families.

Families with incomes above 400% of the federal poverty level were ineligible for marketplace premium tax credits before 2021 and may again be after 2025. Current laws temporarily removed this income cap, but because credits cap out-of-pocket premiums for a reference plan as a share of income, some higher-income families still receive zero tax credits. We quantified (1) premium differences between on- and off-marketplace plans and (2) the association between these premium differences and state decisions to finance cost-sharing reductions (CSRs) for lower-income families. We created a comprehensive database of on- and off-marketplace plans in each county (including both federal and state-based marketplaces). By county and metal level, we compared on- and off-marketplace (1) plan premiums in 2020 and (2) growth rates in the numbers of plans. We contrasted outcomes for states by how insurers were instructed to finance CSRs. In 2020, 89% of the US population lived in counties where some plans were offered exclusively off-marketplace. In these counties, for a 45-year-old choosing among silver plans in 2020 and who did not qualify for premium subsidies, premiums for the lowest-cost off-marketplace plans averaged 11.3% less than premiums for the lowest-cost on-marketplace plans. In contrast, for bronze and gold plans, the lowest-cost off-marketplace plans were, on average, more expensive. Silver plan premiums were 6.1% higher off-marketplace than on-marketplace in states that loaded CSRs on all silver plans, and 13.5% lower in states that loaded CSRs only on on-marketplace silver plans. Higher-income individuals and families may consider purchasing Affordable Care Act-compliant silver plans off-marketplace and thereby reduce their premiums. State and federal policy makers should consider the impact of their decisions on the choice between on- and off-marketplace plans.

State versus federal health insurance marketplaces: A bigger deal for Medicaid and a smaller deal for the individual mandate

States retain significant power over key components of Affordable Care Act implementation. Using data from the US Census from 2010 to 2018, we examine how states’ decisions to either establish state-run marketplaces or to default to the federal marketplace influenced the distribution of health insurance types within states. We find, somewhat counterintuitively, that state-based marketplaces are associated with greater change in enrollment for Medicaid compared to the federal marketplace. These findings confirm that, at least until 2018, the most significant increases in insurance coverage resulting from the ACA were in public insurance, rather than private insurance. We explore a number of possible explanations to help explain these findings, raising important questions about the efficacy of the individual mandate (a key mechanism in legislative efforts to reduce the numbers of uninsured), the related administrative burdens associated with state and federal marketplaces, and, equally as important, differential access to Medicaid entitlements among citizens living in different states—access that hinges not only or always on Medicaid expansion, but also and perhaps more importantly, on policy decisions about insurance marketplaces.

Potential COVID-19 Vulnerabilities in Employment and Healthcare Access by Sexual Orientation

The 2019 coronavirus (COVID-19) pandemic has led to more than 235,000 deaths and 9 million reported positive cases in the United States. Most of the country implemented stay-at-home orders to prevent the spread of COVID-19, which has led to job losses and more than 40 million claims for unemployment insurance. The objective of this study was to estimate the potential impact of COVID-19-related closures in employment and healthcare access by sexual orientation. We used data from the 2015 to 2018 National Health Interview Survey and employment industry codes to describe the working adult population who may be vulnerable to COVID-19 job losses by sexual orientation. Multivariable logistic regression models identified the risk factors for working in a COVID-19-sensitive industry and differences in healthcare access by sexual orientation. We estimate that there may be approximately 1.7 million sexual minorities and 36.6 million heterosexual adults employed in industries that make them vulnerable to unemployment, uninsurance, and limited access to care. Nearly two-thirds of working adults—regardless of sexual orientation—are at risk of severe illness should they become infected with COVID-19. Almost half of the sexual minority and heterosexual adults in industries sensitive to COVID-19 may remain or become uninsured during the pandemic. Approximately 60% of sexual minorities and 40% of heterosexual adults in COVID-19-sensitive industries are renting their home or apartment (rather than owning their home). Because sexual minority adults vulnerable to the COVID-19 pandemic are renting or within family income ranges for premium tax credits in the individual insurance marketplaces, policymakers should consider expanding protections for renters and broadening special enrollment periods for people seeking coverage in the federal and state-based marketplaces.

Targeting of Enrollment Assistance Resources in Health Insurance Television Advertising: A Comparison of Spanish- Vs. English-Language Ads

Latinx adults, especially immigrants, face higher uninsurance and lower awareness of the Affordable Care Act’s (ACA) provisions and resources compared to other racial/ethnic groups. Television advertising of ACA health plans has directed many consumers to application assistance and enrollment, but little is known about how ads targeted Latinx consumers. We used Kantar Media/CMAG data from the Wesleyan Media Project to assess Spanish- vs. English-language ad targeting strategies and to assess which enrollment assistance resources (in person/telephone vs. online) were emphasized across three Open Enrollment Periods (OEP) (2013–14, 2014–15, 2015–16). We examined differences in advertisement sponsorship and volume of Spanish- versus English-language ads across the three OEPs. State-based Marketplaces sponsored 47% of Spanish-language airings; insurance companies sponsored 55% of English-language airings. The proportion of Spanish-language airings increased over time (8.8% in OEP1, 11.1% in OEP2, 12.0% in OEP3, p <.001). Spanish-language airings had 49% lower (95%CI: 0.50,0.53) and 2.20 times higher odds (95%CI: 2.17,2.24) of mentioning online and telephone/in-person enrollment assistance resources, respectively. While there was a significant decrease in mention of telephone/in-person assistance over time for English-language airings, these mentions increased significantly in Spanish-language airings. Future research should examine the impact of the drastic federal cuts to ACA outreach and marketing.

California's New Gold Rush: Marketplace Enrollees Switch To Gold-Tier Plans In Response To Insurance Premium Changes.

The individual health insurance market has grown significantly since the 2014 implementation of the Affordable Care Act's state-based and federally facilitated Marketplaces. During annual open enrollment periods, Marketplace enrollees can switch plans for the upcoming year. The percentage of reenrollees in California's state-based Marketplace, Covered California, who made changes to their coverage steadily increased between the 2014-15 and 2017-18 open enrollment periods. Following the implementation of "silver loading"-in which insurers raised 2018 silver-tier plan premiums to compensate for their loss of federal payments for cost-sharing reductions-the proportion of consumers who moved into gold plans during the 2017-18 open enrollment period dramatically increased, compared to previous years. Among bronze or silver plan enrollees who switched metal tiers during open enrollment, those who could enroll in gold plans that were no more than $49 per month more expensive than their initial bronze or silver plan had a significantly higher probability of switching to gold coverage than those who faced larger premium differences.

Texas Arguments Lead Heavy ACA Action.

Arguments in Texas raise questions about the ACA's fate as enrollment holds steady and new state reinsurance waivers are approved.

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

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

Public validation and its impact on the initial Affordable Care Act enrollment

The 2010 Affordable Care Act (ACA) resulted in the creation of state-based marketplaces (SBMs) and federally facilitated marketplaces (FFMs), and provided financial assistance to a portion of those eligible to enroll. This study looks at how choosing to create a SBM rather than a FFM, and the financial assistance provided to some, influenced enrollments rates as signals of support for the ACA in the eyes of those eligible to enroll. The findings show that the enrollment behavior of those most strongly in support of the ACA legislation was influenced by those external signals of support for the ACA.

Decision-Making Experiences Of Consumers Choosing Individual-Market Health Insurance Plans.

The health insurance Marketplaces established by the Affordable Care Act include features designed to simplify the process of choosing a health plan in the individual, or nongroup, insurance market. While most individual health insurance enrollees purchase plans through the federal and state-based Marketplaces, millions also purchase plans directly from an insurance carrier (off Marketplace). This study was a descriptive comparison of the decision-making processes and shopping experiences of consumers in two states who purchased a health insurance plan from the same large insurer in 2017, either through the federal Marketplaces or off Marketplace. In a survey, those who selected plans through the Marketplaces reported less difficulty finding the best or most affordable plan than did those enrolling off Marketplace. Respondents in families with chronic health conditions who enrolled through the Marketplaces reported better overall experiences than those who enrolled off Marketplace. Respondents with low health insurance literacy reported poor experiences in enrolling both through the Marketplaces and off Marketplace. Access to consumer assistance in the individual health insurance market should target off-Marketplace populations as well as all populations with low health insurance literacy.

Shopping on the Public and Private Health Insurance Marketplaces: Consumer Decision Aids and Plan Presentation.

The design of the Affordable Care Act's (ACA) health insurance marketplaces influences complex health plan choices. To compare the choice environments of the public health insurance exchanges in the fourth (OEP4) versus third (OEP3) open enrollment period and to examine online marketplace run by private companies, including a total cost estimate comparison. In November-December 2016, we examined the public and private online health insurance exchanges. We navigated each site for "real-shopping" (personal information required) and "window-shopping" (no required personal information). Public (n = 13; 12 state-based marketplaces and HealthCare.gov ) and private (n = 23) online health insurance exchanges. Features included consumer decision aids (e.g., total cost estimators, provider lookups) and plan display (e.g., order of plans). We examined private health insurance exchanges for notable features (i.e., those not found on public exchanges) and compared the total cost estimates on public versus private exchanges for a standardized consumer. Nearly all studied consumer decision aids saw increased deployment in the public marketplaces in OEP4 compared to OEP3. Over half of the public exchanges (n = 7 of 13) had total cost estimators (versus 5 of 14 in OEP3) in window-shopping and integrated provider lookups (window-shopping: 7; real-shopping: 8). The most common default plan orders were by premium or total cost estimate. Notable features on private health insurance exchanges were unique data presentation (e.g., infographics) and further personalized shopping (e.g., recommended plan flags). Health plan total cost estimates varied substantially between the public and private exchanges (average difference $1526). The ACA's public health insurance exchanges offered more tools in OEP4 to help consumers select a plan. While private health insurance exchanges presented notable features, the total cost estimates for a standardized consumer varied widely on public versus private exchanges.

Affordable Care Act Impact in Kentucky: Increasing Access, Reducing Disparities.

To examine health insurance disparities since Kentucky's implementation of the Affordable Care Act (ACA). Using the American Community Survey, we estimated coverage rates by race/ethnicity before and after implementation of the ACA (2013 and 2015), and we estimated whether groups were over- or underrepresented among the uninsured, compared with their share of the state population. Kentucky's uninsurance rate declined from 14.4% in 2013 to 6.1% in 2015 (P < .001). Uninsurance rates also declined for most racial/ethnic groups, including Blacks (16.7% to 5.5%; P < .001) and Whites (13.3% to 5.3%; P < .001). In 2015, Blacks were no longer overrepresented among Kentucky's uninsured, with a significant decline in the ratio of Blacks among the state uninsured population compared with their share of the state population (1.16-0.91; P = .045). In Kentucky, which mounted a robust implementation of the ACA-including Medicaid expansion, a state-based marketplace, and an extensive outreach and enrollment campaign-the state experienced not only a decline in the overall uninsurance rate but also an elimination in coverage disparities among Blacks, who historically were overrepresented among the uninsured.

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

The Affordable Care Act (ACA) made private nongroup health insurance more accessible to nonelderly adults with chronic conditions, with enrollment growth occurring through the federal and state-based Marketplaces. During the July through December reference period in 2014-15, 45percent of Marketplace enrollees ages18-64 were treated for chronic conditions, compared with 35percent of non-Marketplace nongroup enrollees and 38percent of adults with employer-sponsored insurance. Marketplace enrollees also had higher service use than other privately insured adults did, which likely contributed to rising premiums in the nongroup market. As repeal of the ACA individual mandate takes effect in 2019, protecting coverage gains for adults with chronic conditions while stabilizing nongroup premiums may depend on state-level efforts to spread the risk of Marketplace enrollees' health care costs across a balanced insurance pool.

Consumer Health Insurance Shopping Behavior and Challenges: Lessons From Two State-Based Marketplaces.

Selecting a health plan in a health insurance exchange is a critical decision, yet consumers are known to face challenges with health plan choice. We surveyed new enrollees in two state-based exchanges in 2015 to investigate how a nonelderly, primarily low-income population chose their health plans and the implications of shopping behavior for early experiences in their plans. Financial considerations were most important to enrollees. Prior Medicaid enrollees and the uninsured were more likely to have multiple shopping challenges (e.g., difficulty identifying the best or most affordable plan, fair/poor experience, unmet need for help) than enrollees with prior employer coverage (42.9% vs. 32.5% vs. 16.4%, respectively, p < .01). Shopping challenges were associated with difficulty finding a doctor, understanding coverage, and getting questions answered. Assistance targeting enrollees who previously had Medicaid or lacked insurance could improve both shopping experiences and downstream outcomes in plans.

Estimating Premium and Out-of-Pocket Outlays Under All Child Dental Coverage Options in the Federally Facilitated Marketplace

To estimate premium and out-of-pocket costs for child dental care services under various dental coverage options offered within the federally facilitated marketplace. We estimated premium and out-of-pocket costs for child dental care services for 12 patient profiles, which vary by dental care use and spending. We did this for 1039 medical plans that include child dental coverage, 2703 medical plans that do not include child dental coverage, and 583 stand-alone dental plans for the 2015 plan year. Our analysis is based on plan data from the Center for Consumer Information and Insurance Oversight and Data.HealthCare.Gov. On average, expected total financial outlays for child dental care services were lower when dental coverage was embedded within a medical plan compared with the alternative of a stand-alone dental plan. The difference, however, in average expected out-of-pocket spending varied significantly for our 12 patient profiles. Older children who are very high users of dental care, for example, have lower expected out-of-pocket costs under a stand-alone dental plan. For the vast majority of other age groups and dental care use profiles, the reverse holds. Our results show that embedding dental coverage within medical plans, on average, results in lower total financial outlays for child beneficiaries. Although our results are specific to the federally facilitated marketplace, they hold lessons for both state-based marketplaces and the general private health insurance and dental benefits market, as well.

Medicaid Expansion In 2014 Did Not Increase Emergency Department Use But Did Change Insurance Payer Mix.

In 2014 twenty-eight states and the District of Columbia had expanded Medicaid eligibility while federal and state-based Marketplaces in every state made subsidized private health insurance available to qualified individuals. As a result, about seventeen million previously uninsured Americans gained health insurance in 2014. Many policy makers had predicted that Medicaid expansion would lead to greatly increased use of hospital emergency departments (EDs). We examined the effect of insurance expansion on ED use in 478 hospitals in 36 states during the first year of expansion (2014). In difference-in-differences analyses, Medicaid expansion increased Medicaid-paid ED visits in those states by 27.1percent, decreased uninsured visits by 31.4percent, and decreased privately insured visits by 6.7percent during the first year of expansion compared to nonexpansion states. Overall, however, total ED visits grew by less than 3percent in 2014 compared to 2012-13, with no significant difference between expansion and nonexpansion states. Thus, the expansion of Medicaid coverage strongly affected payer mix but did not significantly affect overall ED use, even though more people gained insurance coverage in expansion states than in nonexpansion states. This suggests that expanding Medicaid did not significantly increase or decrease overall ED visit volume.

Differing Impacts Of Market Concentration On Affordable Care Act Marketplace Premiums.

Recent increases in market concentration among health plans, hospitals, and medical groups raise questions about what impact such mergers are having on costs to consumers. We examined the impact of market concentration on the growth of health insurance premiums between 2014 and 2015 in two Affordable Care Act state-based Marketplaces: Covered California and NY State of Health. We measured health plan, hospital, and medical group market concentration using the well-known Herfindahl-Hirschman Index (HHI) and used a multivariate regression model to relate these measures to premium growth. Both states exhibited a positive association between hospital concentration and premium growth and a positive (but not statistically significant) association between medical group concentration and premium growth. Our results for health plan concentration differed between the two states: It was positively associated with premium growth in New York but negatively associated with premium growth in California. The health plan concentration finding in Covered California may be the result of its selectively contracting with health plans.

State-based Marketplaces using 'clearinghouse' plan management models are associated with lower premiums.

The state-based and federally facilitated health insurance Marketplaces, or exchanges, enrolled more than eight million people during the first open enrollment period, which ended March31, 2014. There is significant variation in how states have designed and implemented their Marketplaces. We examined how premiums varied with states' involvement in the Marketplaces through governance, plan management authority, and strategy during the first year that the exchanges have been open. State-based Marketplaces using "clearinghouse" plan management models had significantly lower adjusted average premiums for all plans within each metal level compared to state-based Marketplaces using "active purchaser" models and the federally facilitated and partnership Marketplaces. Clearinghouse management models are those in which all health plans that meet published criteria are accepted. Active purchaser models are those in which states negotiate premiums, provider networks, number of plans, and benefits. Our baseline estimates provide valuable benchmarks for evaluating future performance of states' involvement in governance, plan management, and regulatory authority of the insurance Marketplaces.

ACA in 2014: What patients need to know

Some pharmacies will have information on ACA for patients. “We will be bringing awareness to the ACA,” Lynn E. Connelly, BSPharm, owner of Medicine Mart Pharmacy in West Columbia, SC, told Pharmacy Today. He plans to learn of new information for his pharmacy and the patients from various pharmacy meetings throughout the state and the country. “In turn, I will share this information with the staff and the patients when possible,” Connelly explained. “It’s important that ACA-related information is widely distributed and readily available for patients who have questions,” said Stacie Maass, BSPharm, JD, APhA Senior Vice President of Government Affairs. This article, last in a Today series on the health care reform law, looks at what patients need to know for 2014. The latest on ACA The law’s cap on out-of-pocket costs of $6,350 for individuals will not be enforced for some employer-based health plans until 2015, as reported by Kaiser Health News in April and the New York Times on August 13. Consumers affected by the 1-year delay may be required to pay $6,350 for medical costs and an additional $6,350 for drug costs if their large employer has two benefi t providers for medical and for drugs. “If a drug plan does not currently have a limit on out-ofpocket costs, it will not have to impose healthcarereform