Insights into Health Insurance Marketplaces
M
a
r
k
e
t
p
l
a
c
e
m
o
d
e
l
s
a
n
d
p
r
e
m
i
u
m
s
:
E
v
i
d
e
n
c
e
f
r
o
m
t
h
e
f
i
r
s
t
o
p
e
n
e
n
r
o
l
l
m
e
n
t
p
e
r
i
o
d
K
e
l
l
y
K
r
i
n
n
,
U
n
i
v
e
r
s
i
t
y
o
f
M
i
n
n
e
s
o
t
a
P
i
n
a
r
K
a
r
a
c
a
-
M
a
n
d
i
c
,
U
n
i
v
e
r
s
i
t
y
o
f
M
i
n
n
e
s
o
t
a
a
n
d
N
B
E
R
L
y
n
n
B
l
e
w
e
t
t
,
U
n
i
v
e
r
s
i
t
y
o
f
M
i
n
n
e
s
o
t
a
Hallmark of ACA
•
The Affordable Care Act (ACA) of 2010
included many provisions to make
health insurance coverage more
accessible and more affordable
•
ACA health insurance marketplaces
enrolled over 8 million individuals during
the first open enrollment period
Marketplace Models
•
S
i
g
n
i
f
i
c
a
n
t
v
a
r
i
a
t
i
o
n
i
n
s
t
a
t
e
d
e
c
i
s
i
o
n
s
r
e
g
a
r
d
i
n
g
t
h
e
d
e
s
i
g
n
a
n
d
i
m
p
l
e
m
e
n
t
a
t
i
o
n
o
f
s
t
a
t
e
s
’
m
a
r
k
e
t
p
l
a
c
e
•
E
x
c
h
a
n
g
e
G
o
v
e
r
n
a
n
c
e
•
P
l
a
n
M
a
n
a
g
e
m
e
n
t
S
t
r
a
t
e
g
y
•
P
l
a
n
M
a
n
a
g
e
m
e
n
t
A
u
t
h
o
r
i
t
y
G
o
v
e
r
n
a
n
c
e
•
State-Based
•
Manage the marketplace
•
Online portal for consumers
•
Raising revenue to fund the marketplace
•
Encourage enrollment through
marketing/consumer assistance
•
State-Federal Partnership
•
Federally Facilitated
P
l
a
n
M
a
n
a
g
e
m
e
n
t
S
t
r
a
t
e
g
y
•
State-Based Marketplace
•
Clearinghouse model (SBM-C)
•
All health plans that meet the published criteria
are accepted to the Marketplace
•
Active purchaser (SBM-A)
•
States can directly negotiate premiums,
provider networks, number and benefits of
plans; and can contract with a select group of
health plans
•
Partnership Marketplaces and Federally Facilitated
Marketplaces all had the clearinghouse model
P
l
a
n
M
a
n
a
g
e
m
e
n
t
A
u
t
h
o
r
i
t
y
•
In state-based marketplaces (SBMs) and in state-
federal partnership marketplaces (SPM), state has
the plan management authority
–
For example on approving qualified plans and
being proactive in contracting with plans in regard
to quality targets and premium rates
•
In federally facilitated marketplaces
•
State conducts plan management (FFMS)
•
Federal government conducts plan
management (FFM)
Each state is divided into geographic rating areas
for regulation purposes
SBM-A: 10 states; 67 rating areas
SBM-C: 7 states; 39 rating areas
SPM : 7 states; 56 rating areas
FFMS : 8 states; 58 rating areas
FFM : 19 states; 281 rating areas
Important questions
•
Did plan premiums vary across state-based,
partnership, federally facilitated governance models?
•
Did premiums in state-based marketplaces with
active purchaser models (SBM-A) differ from those
with clearinghouse models (SBM-C)?
•
Did premiums in federally facilitated marketplaces
with states performing plan management (FFMS)
differ others with federal plan management authority
(FFM)?
Our study
•
First look at marketplace implementation
and assesses the premium differences
across different marketplace models
–
Stratified analysis by plan type (bronze,
lowest silver, second lowest silver and gold),
and
–
Controlled for a rich set of plan
characteristics and rating-area
characteristics
Dependent variable: Premiums
•
State marketplace websites and U.S. HHS website
–
By rating area: premiums and plan information for
•
Lowest cost bronze, lowest cost silver, lowest cost
gold and second lowest cost silver plans
•
Premiums for a 29 year old non-smoker individual
•
Health Insurance Exchange (HIX) Compare dataset
–
By rating area: premiums and plan information for all
silver plans
•
Premiums for a 27 year old and a 50 year old non-
smoker individual
Control variables at the rating
area level - baseline
•
Number of participating insurance companies
•
Hospital HHI
•
Age-Race/ethnicity composition of population
•
Uninsurance rate, unemployment rate, median household
income
•
Population health: Health status, diabetes, obesity, per-
capita medical costs
Sources: Exchange websites, County Health Rankings, Dartmouth Atlas
Variables collected at the county level, and aggregated to rating area level
Control variables at the state
level - baseline
•
Rate review authority: prior approval or not
•
Medicaid fee index
•
Baseline average premiums
•
Whether state recommended an
essential health benefit
(EHB) benchmark beyond the ACA default
•
Whether the state expanded Medicaid under the ACA
Medicaid expansion option.
Sources: Kaiser Family Foundation and the National Conference of State
Legislatures
Statistical model
•
Analysis 1: examined premiums of lowest cost plans by
metal-type (bronze, silver, gold) as well as the second-
lowest silver plans in each rating area
–
Unit of analysis: plan type for each rating area
•
Analysis 2: examined premiums of all silver plans
–
Unit of analysis: each silver plan in each rating area
•
Generalized estimating equations model
–
Log link, gamma distribution
–
Allow for correlation of errors within states
•
Key independent variables: marketplace model indicators
(SBM-A, SBM-C, SPM, FFMS, FFM)
–
Also control for plan benefit design (copay, deductible, OOP
max) and other controls listed earlier
Selected rating area characteristics by
marketplace model
Standard deviations in parentheses
Selected rating area characteristics by
marketplace model
Standard deviations in parentheses
Selected rating area characteristics by
marketplace model
Standard deviations in parentheses
Selected rating area characteristics by
marketplace model
Standard deviations in parentheses
Adjusted premiums by metal-type
and marketplace model
Adjusted premiums by metal-type
and marketplace model
Adjusted premiums by metal-type
and marketplace model
Adjusted premiums by metal-type
and marketplace model
Adjusted premiums of all silver plans
by marketplace model
Adjusted premiums of all silver plans
by marketplace model
Discussion
•
First look at ACA marketplace premiums by
marketplace model
•
SBM with clearinghouse had the lowest premiums
–
Clearinghouse encourages more competition?
–
Maybe too early for active purchaser model to
be active
•
No statistically significant difference between SPM,
FFMS and FFM
•
Limited to first year of the marketplaces
•
Provide a benchmark going forward
Thank You
The study delves into the varying state decisions and models of health insurance marketplaces established under the Affordable Care Act, focusing on governance, plan management strategies, and authority. It highlights the significant variations across states and the implications for marketplace functionality and premium management.
Download Presentation
Please find below an Image/Link to download the presentation.
The content on the website is provided AS IS for your information and personal use only. It may not be sold, licensed, or shared on other websites without obtaining consent from the author.If you encounter any issues during the download, it is possible that the publisher has removed the file from their server.
You are allowed to download the files provided on this website for personal or commercial use, subject to the condition that they are used lawfully. All files are the property of their respective owners.
The content on the website is provided AS IS for your information and personal use only. It may not be sold, licensed, or shared on other websites without obtaining consent from the author.
E N D
Presentation Transcript
Marketplace models and premiums: Evidence from the first open enrollment period Kelly Krinn, University of Minnesota Pinar Karaca-Mandic, University of Minnesota and NBER Lynn Blewett, University of Minnesota
Hallmark of ACA The Affordable Care Act (ACA) of 2010 included many provisions to make health insurance coverage more accessible and more affordable ACA health insurance marketplaces enrolled over 8 million individuals during the first open enrollment period
Marketplace Models Significant variation in state decisions regarding the design and implementation of states marketplace Exchange Governance Plan Management Strategy Plan Management Authority
Governance State-Based Manage the marketplace Online portal for consumers Raising revenue to fund the marketplace Encourage enrollment through marketing/consumer assistance State-Federal Partnership Federally Facilitated
Plan Management Strategy State-Based Marketplace Clearinghouse model (SBM-C) All health plans that meet the published criteria are accepted to the Marketplace Active purchaser (SBM-A) States can directly negotiate premiums, provider networks, number and benefits of plans; and can contract with a select group of health plans Partnership Marketplaces and Federally Facilitated Marketplaces all had the clearinghouse model
Plan Management Authority In state-based marketplaces (SBMs) and in state- federal partnership marketplaces (SPM), state has the plan management authority For example on approving qualified plans and being proactive in contracting with plans in regard to quality targets and premium rates In federally facilitated marketplaces State conducts plan management (FFMS) Federal government conducts plan management (FFM)
Each state is divided into geographic rating areas for regulation purposes SBM-A: 10 states; 67 rating areas SBM-C: 7 states; 39 rating areas SPM : 7 states; 56 rating areas FFMS : 8 states; 58 rating areas FFM : 19 states; 281 rating areas
Important questions Did plan premiums vary across state-based, partnership, federally facilitated governance models? Did premiums in state-based marketplaces with active purchaser models (SBM-A) differ from those with clearinghouse models (SBM-C)? Did premiums in federally facilitated marketplaces with states performing plan management (FFMS) differ others with federal plan management authority (FFM)?
Our study First look at marketplace implementation and assesses the premium differences across different marketplace models Stratified analysis by plan type (bronze, lowest silver, second lowest silver and gold), and Controlled for a rich set of plan characteristics and rating-area characteristics
Dependent variable: Premiums State marketplace websites and U.S. HHS website By rating area: premiums and plan information for Lowest cost bronze, lowest cost silver, lowest cost gold and second lowest cost silver plans Premiums for a 29 year old non-smoker individual Health Insurance Exchange (HIX) Compare dataset By rating area: premiums and plan information for all silver plans Premiums for a 27 year old and a 50 year old non- smoker individual
Control variables at the rating area level - baseline Number of participating insurance companies Hospital HHI Age-Race/ethnicity composition of population Uninsurance rate, unemployment rate, median household income Population health: Health status, diabetes, obesity, per- capita medical costs Sources: Exchange websites, County Health Rankings, Dartmouth Atlas Variables collected at the county level, and aggregated to rating area level
Control variables at the state level - baseline Rate review authority: prior approval or not Medicaid fee index Baseline average premiums Whether state recommended an essential health benefit (EHB) benchmark beyond the ACA default Whether the state expanded Medicaid under the ACA Medicaid expansion option. Sources: Kaiser Family Foundation and the National Conference of State Legislatures
Statistical model Analysis 1: examined premiums of lowest cost plans by metal-type (bronze, silver, gold) as well as the second- lowest silver plans in each rating area Unit of analysis: plan type for each rating area Analysis 2: examined premiums of all silver plans Unit of analysis: each silver plan in each rating area Generalized estimating equations model Log link, gamma distribution Allow for correlation of errors within states Key independent variables: marketplace model indicators (SBM-A, SBM-C, SPM, FFMS, FFM) Also control for plan benefit design (copay, deductible, OOP max) and other controls listed earlier
Selected rating area characteristics by marketplace model SBM-A SBM-C SPM FFMS FFM Number of insurers participating in the marketplace % in a state with Medicaid expansion % in a state with state recommended EHB % obese 4.1 (2.7) 3.9 (1.5) 3.2 (1.8) 5 (2.5) 4.5 (1.4) 100 (0) 82.1 (38.9) 98.2 (13.4) 29.3 (45.9) 4.3 (20.3) 100 (0) 59.0 (49.8) 67.9 (47.1) 37.9 (48.9) 11.7 (32.3) 25.9 (4.2) 24.9 (4.6) 30.8 (2.8) 29.2 (2.9) 31.0 (4.5) % diabetes 8.6 (1.5) 7.5 (1.6) 10.1 (1.9) 9.4 (1.6) 10.9 (2.1) % uninsured 15.3 (5.9) 17.2 (5.3) 15 (3.3) 15.8 (2.7) 20.3 (5.2) Standard deviations in parentheses
Selected rating area characteristics by marketplace model SBM-A SBM-C SPM FFMS FFM Number of insurers participating in the marketplace % in a state with Medicaid expansion % in a state with state recommended EHB % obese 5 (2.5) 4.5 (1.4) 4.1 (2.7) 3.9 (1.5) 3.2 (1.8) 100 (0) 82.1 (38.9) 98.2 (13.4) 29.3 (45.9) 4.3 (20.3) 100 (0) 59.0 (49.8) 67.9 (47.1) 37.9 (48.9) 11.7 (32.3) 25.9 (4.2) 24.9 (4.6) 30.8 (2.8) 29.2 (2.9) 31.0 (4.5) % diabetes 8.6 (1.5) 7.5 (1.6) 10.1 (1.9) 9.4 (1.6) 10.9 (2.1) % uninsured 15.3 (5.9) 17.2 (5.3) 15 (3.3) 15.8 (2.7) 20.3 (5.2) Standard deviations in parentheses
Selected rating area characteristics by marketplace model SBM-A SBM-C SPM FFMS FFM Number of insurers participating in the marketplace % in a state with Medicaid expansion % in a state with state recommended EHB % obese 5 (2.5) 4.5 (1.4) 4.1 (2.7) 3.9 (1.5) 3.2 (1.8) 29.3 (45.9) 4.3 (20.3) 100 (0) 82.1 (38.9) 98.2 (13.4) 59.0 (49.8) 67.9 (47.1) 37.9 (48.9) 11.7 (32.3) 100 (0) 25.9 (4.2) 24.9 (4.6) 30.8 (2.8) 29.2 (2.9) 31.0 (4.5) % diabetes 8.6 (1.5) 7.5 (1.6) 10.1 (1.9) 9.4 (1.6) 10.9 (2.1) % uninsured 15.3 (5.9) 17.2 (5.3) 15 (3.3) 15.8 (2.7) 20.3 (5.2) Standard deviations in parentheses
Selected rating area characteristics by marketplace model SBM-A SBM-C SPM FFMS FFM Number of insurers participating in the marketplace % in a state with Medicaid expansion % in a state with state recommended EHB % obese 5 (2.5) 4.5 (1.4) 4.1 (2.7) 3.9 (1.5) 3.2 (1.8) 100 (0) 82.1 (38.9) 98.2 (13.4) 29.3 (45.9) 4.3 (20.3) 100 (0) 59.0 (49.8) 67.9 (47.1) 37.9 (48.9) 11.7 (32.3) 30.8 (2.8) 29.2 (2.9) 31.0 (4.5) 25.9 (4.2) 24.9 (4.6) % diabetes 10.1 (1.9) 9.4 (1.6) 10.9 (2.1) 8.6 (1.5) 7.5 (1.6) % uninsured 15.3 (5.9) 17.2 (5.3) 15 (3.3) 15.8 (2.7) 20.3 (5.2) Standard deviations in parentheses
Adjusted premiums by metal-type and marketplace model Lowest cost bronze Lowest cost silver Second lowest cost silver Lowest cost gold Mean P Mean P Mean P Mean P Diff from SBM-C Diff from SBM-C Diff from SBM-C Diff from SBM-C SBM-A $179.49 0.008 $225.37 0.006 $245.27 <0.001 $266.91 0.007 SBM-C $157.53 Ref $196.92 Ref $205.30 Ref $233.96 Ref SPM $182.51 0.004 $229.87 0.003 $242.72 0.001 $272.92 0.003 FFMS $185.14 0.003 $224.02 0.019 $234.91 0.014 $268.97 0.012 FFM $189.94 <0.001 $233.16 <0.001 $241.63 <0.001 $277.35 <0.001
Adjusted premiums by metal-type and marketplace model Lowest cost bronze Lowest cost silver Second lowest cost silver Lowest cost gold Mean P Mean P Mean P Mean P Diff from SBM-C Diff from SBM-C Diff from SBM-C Diff from SBM-C SBM-A 0.008 0.006 <0.001 0.007 $179.49 $225.37 $245.27 $266.91 SBM-C Ref Ref Ref Ref $157.53 $196.92 $205.30 $233.96 SPM $182.51 0.004 $229.87 0.003 $242.72 0.001 $272.92 0.003 FFMS $185.14 0.003 $224.02 0.019 $234.91 0.014 $268.97 0.012 FFM $189.94 <0.001 $233.16 <0.001 $241.63 <0.001 $277.35 <0.001
Adjusted premiums by metal-type and marketplace model Lowest cost bronze Lowest cost silver Second lowest cost silver Lowest cost gold Mean P Mean P Mean P Mean P Diff from SBM-C Diff from SBM-C Diff from SBM-C Diff from SBM-C SBM-A $179.49 0.008 $225.37 0.006 $245.27 <0.001 $266.91 0.007 SBM-C Ref Ref Ref Ref $157.53 $196.92 $205.30 $233.96 SPM 0.004 0.003 0.001 0.003 $182.51 $229.87 $242.72 $272.92 FFMS 0.003 0.019 0.014 0.012 $185.14 $224.02 $234.91 $268.97 FFM $189.94 <0.001 $233.16 <0.001 $241.63 <0.001 $277.35 <0.001
Adjusted premiums by metal-type and marketplace model Lowest cost bronze Lowest cost silver Second lowest cost silver Lowest cost gold Mean P Mean P Mean P Mean P Diff from SBM-C Diff from SBM-C Diff from SBM-C Diff from SBM-C SBM-A $179.49 0.008 $225.37 0.006 $245.27 <0.001 $266.91 0.007 SBM-C $157.53 Ref $196.92 Ref $205.30 Ref $233.96 Ref SPM $182.51 0.004 $229.87 0.003 $242.72 0.001 $272.92 0.003 FFMS 0.003 0.019 0.014 0.012 $185.14 $224.02 $234.91 $268.97 FFM <0.001 <0.001 <0.001 <0.001 $189.94 $233.16 $241.63 $277.35
Adjusted premiums of all silver plans by marketplace model 27 year old 50 year old Mean P Mean P Diff from SBM-C Diff from SBM-C SBM-A $258.25 0.023 0.56 395.56 SBM-C Ref Ref $221.64 380.46 SPM $273.70 0.004 450.24 0.021 FFMS $279.63 0.003 473.79 0.005 FFM $263.79 0.012 446.62 0.020
Adjusted premiums of all silver plans by marketplace model 27 year old 50 year old Mean P Mean P Diff from SBM-C Diff from SBM-C SBM-A $258.25 0.023 395.56 0.56 SBM-C $221.64 Ref 380.46 Ref SPM $273.70 0.004 450.24 0.021 FFMS 0.003 0.005 $279.63 473.79 FFM 0.012 0.020 $263.79 446.62
Discussion First look at ACA marketplace premiums by marketplace model SBM with clearinghouse had the lowest premiums Clearinghouse encourages more competition? Maybe too early for active purchaser model to be active No statistically significant difference between SPM, FFMS and FFM Limited to first year of the marketplaces Provide a benchmark going forward
