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Plan Selection, Enrollee Risk, and Health Spending on the Patient Protection and Affordable Care Act Individual Marketplaces, 2019
IMPORTANCE: The Patient Protection and Affordable Care Act (ACA) individual marketplaces are a source of insurance for millions of residents in the US. However, the association between enrollee risk, health spending, and metal tier selection remains unclear. OBJECTIVES: To describe individual market...
Autores principales: | , , , , , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
American Medical Association
2023
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10064254/ https://www.ncbi.nlm.nih.gov/pubmed/36995715 http://dx.doi.org/10.1001/jamanetworkopen.2023.4529 |
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author | Treasure, Graham Anderson, David M. Hatcher, Lauren Makhoul, Alexandra E. Johnson, Darren Stefan, Jenna Griffith, Kevin N. |
author_facet | Treasure, Graham Anderson, David M. Hatcher, Lauren Makhoul, Alexandra E. Johnson, Darren Stefan, Jenna Griffith, Kevin N. |
author_sort | Treasure, Graham |
collection | PubMed |
description | IMPORTANCE: The Patient Protection and Affordable Care Act (ACA) individual marketplaces are a source of insurance for millions of residents in the US. However, the association between enrollee risk, health spending, and metal tier selection remains unclear. OBJECTIVES: To describe individual marketplace enrollees’ metal tier selections by risk score and assess enrollees’ health spending by metal tier, risk score, and spending type. DESIGN, SETTING, AND PARTICIPANTS: This retrospective, cross-sectional study analyzed claims data from the Wakely Consulting Group ACA database, a deidentified claims database built on data voluntarily submitted by insurers. Enrollees with continuous, full-year enrollment in on-exchange or off-exchange ACA-qualified health plans during the 2019 contract year were included. Data analysis was conducted from March 2021 to January 2023. MAIN OUTCOMES AND MEASURES: Enrollment totals, total spending, and out-of-pocket cost were calculated, stratified by metal tier and the Department of Health and Human Services (HHS) Hierarchical Condition Category (HCC) risk score for 2019. RESULTS: Enrollment and claims data were obtained for 1 317 707 enrollees (53.5% female; mean [SD] age, 46.35 [13.43] years) across all census areas, age groups, and sexes. Of these, 34.6% were on plans with cost-sharing reductions (CSRs), 75.5% did not have an assigned HCC, and 84.0% submitted at least 1 claim. Compared with enrollees in bronze plans (17.2%), enrollees were more likely to be classified in the top HHS-HCC risk quartile if they selected platinum (42.0%), gold (34.4%), or silver (29.7%) plans. The highest share of enrollees with $0 total spending was noted with the catastrophic (26.4%) and bronze (22.7%) plans, while gold plans had the lowest share (8.1%). Median total spending was lower among bronze plan enrollees ($593; IQR, $28-$2100) vs platinum ($4111; IQR, $992-$15 821) or gold ($2675; IQR, $728-$9070). Within the top risk score decile, CSR enrollees had less average total spending than any other metal tier by more than 10%. CONCLUSIONS AND RELEVANCE: In this cross-sectional study of the ACA individual marketplace, enrollees who selected plans with higher actuarial value also had greater mean HHS-HCC risk scores and health spending. The findings suggest these differences may be associated with variation in benefit generosity by metal tier, enrollee’s perceptions of future health needs, or other barriers to care access. |
format | Online Article Text |
id | pubmed-10064254 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2023 |
publisher | American Medical Association |
record_format | MEDLINE/PubMed |
spelling | pubmed-100642542023-04-01 Plan Selection, Enrollee Risk, and Health Spending on the Patient Protection and Affordable Care Act Individual Marketplaces, 2019 Treasure, Graham Anderson, David M. Hatcher, Lauren Makhoul, Alexandra E. Johnson, Darren Stefan, Jenna Griffith, Kevin N. JAMA Netw Open Original Investigation IMPORTANCE: The Patient Protection and Affordable Care Act (ACA) individual marketplaces are a source of insurance for millions of residents in the US. However, the association between enrollee risk, health spending, and metal tier selection remains unclear. OBJECTIVES: To describe individual marketplace enrollees’ metal tier selections by risk score and assess enrollees’ health spending by metal tier, risk score, and spending type. DESIGN, SETTING, AND PARTICIPANTS: This retrospective, cross-sectional study analyzed claims data from the Wakely Consulting Group ACA database, a deidentified claims database built on data voluntarily submitted by insurers. Enrollees with continuous, full-year enrollment in on-exchange or off-exchange ACA-qualified health plans during the 2019 contract year were included. Data analysis was conducted from March 2021 to January 2023. MAIN OUTCOMES AND MEASURES: Enrollment totals, total spending, and out-of-pocket cost were calculated, stratified by metal tier and the Department of Health and Human Services (HHS) Hierarchical Condition Category (HCC) risk score for 2019. RESULTS: Enrollment and claims data were obtained for 1 317 707 enrollees (53.5% female; mean [SD] age, 46.35 [13.43] years) across all census areas, age groups, and sexes. Of these, 34.6% were on plans with cost-sharing reductions (CSRs), 75.5% did not have an assigned HCC, and 84.0% submitted at least 1 claim. Compared with enrollees in bronze plans (17.2%), enrollees were more likely to be classified in the top HHS-HCC risk quartile if they selected platinum (42.0%), gold (34.4%), or silver (29.7%) plans. The highest share of enrollees with $0 total spending was noted with the catastrophic (26.4%) and bronze (22.7%) plans, while gold plans had the lowest share (8.1%). Median total spending was lower among bronze plan enrollees ($593; IQR, $28-$2100) vs platinum ($4111; IQR, $992-$15 821) or gold ($2675; IQR, $728-$9070). Within the top risk score decile, CSR enrollees had less average total spending than any other metal tier by more than 10%. CONCLUSIONS AND RELEVANCE: In this cross-sectional study of the ACA individual marketplace, enrollees who selected plans with higher actuarial value also had greater mean HHS-HCC risk scores and health spending. The findings suggest these differences may be associated with variation in benefit generosity by metal tier, enrollee’s perceptions of future health needs, or other barriers to care access. American Medical Association 2023-03-30 /pmc/articles/PMC10064254/ /pubmed/36995715 http://dx.doi.org/10.1001/jamanetworkopen.2023.4529 Text en Copyright 2023 Treasure G et al. JAMA Network Open. https://creativecommons.org/licenses/by/4.0/This is an open access article distributed under the terms of the CC-BY License. |
spellingShingle | Original Investigation Treasure, Graham Anderson, David M. Hatcher, Lauren Makhoul, Alexandra E. Johnson, Darren Stefan, Jenna Griffith, Kevin N. Plan Selection, Enrollee Risk, and Health Spending on the Patient Protection and Affordable Care Act Individual Marketplaces, 2019 |
title | Plan Selection, Enrollee Risk, and Health Spending on the Patient Protection and Affordable Care Act Individual Marketplaces, 2019 |
title_full | Plan Selection, Enrollee Risk, and Health Spending on the Patient Protection and Affordable Care Act Individual Marketplaces, 2019 |
title_fullStr | Plan Selection, Enrollee Risk, and Health Spending on the Patient Protection and Affordable Care Act Individual Marketplaces, 2019 |
title_full_unstemmed | Plan Selection, Enrollee Risk, and Health Spending on the Patient Protection and Affordable Care Act Individual Marketplaces, 2019 |
title_short | Plan Selection, Enrollee Risk, and Health Spending on the Patient Protection and Affordable Care Act Individual Marketplaces, 2019 |
title_sort | plan selection, enrollee risk, and health spending on the patient protection and affordable care act individual marketplaces, 2019 |
topic | Original Investigation |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10064254/ https://www.ncbi.nlm.nih.gov/pubmed/36995715 http://dx.doi.org/10.1001/jamanetworkopen.2023.4529 |
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