By Kennah Watts 

In February, CHIR used Leap Day to catch up on the latest health policy research. This month we read studies on the uninsured rate, dynamics between the small-group market and individual Marketplace, and the availability of mental telehealth services. 

Assistant Secretary for Planning and Evaluation, National Uninsured Rate Remains Largely Unchanged at 7.7 Percent in the Third Quarter of 2023, ASPE Office of Health Policy, February 2024. ASPE researchers analyzed newly released data from the National Health Interview Survey (NHIS)—one of the largest nationally representative surveys on health—to estimate health insurance coverage for the civilian, noninstitutionalized population in the third quarter (Q3) of 2023.

What it Finds

• In Q3 2023, the national uninsured rate across all ages reached an historic low of 7.7 percent (approximately 25.6 million individuals).
• Children under the age of 18 experienced a lower uninsured rate than non-elderly adults (3.4 percent and 11.4 percent, respectively).
  • Since Q1 2020, there has been a statistically significant decline in the uninsured rate among children and adults.
  • The share of insured children and non-elderly adults with public coverage was 44.8 percent and 22.9 percent, respectively.
    • The authors anticipate that the share of Americans with public coverage will decline with further Medicaid “unwinding”—the end of continuous Medicaid enrollment as states begin to redetermine eligibility and disenroll ineligible individuals.
• Uninsured rates among non-elderly adults have varied across racial and ethnic groups.
  • Asian, non-Hispanic adults had the lowest uninsured rate in Q3 2023 (3.8 percent), followed by White, non-Hispanic adults (6.6 percent) and Black, non-Hispanic adults (10.9 percent).
  • Hispanic adults experienced the highest uninsured rate, not just in Q3 (27.3 percent), but in all quarters since 2020. Black, non-Hispanic adults consistently had the second-highest uninsured rate during the same time period.

Why it Matters

The steady decline in uninsurance since 2020 underscores the successes of several policies to support health insurance coverage, including the continuous Medicaid coverage provision of the Families First Coronavirus Response Act, the subsidy expansion under the American Rescue Plan Act and the Inflation Reduction Act, and recent Medicaid expansion in several states. Despite these gains, coverage disparities remain, particularly between racial and ethnic groups. Further, the unwinding of continuous Medicaid coverage and expiration of enhanced subsidies could lead to a spike in uninsurance unless policymakers protect access to affordable, comprehensive health insurance.

John Holahan, Erik Wengle, and Michael Simpson, Comparing Pricing and Competition in Small-Group Market and Individual Marketplaces, Urban Institute, February 2024. Researchers at the Urban Institute examined insurer participation and premium rates using the Robert Wood Johnson Foundation’s HIX Compare datasets to evaluate trends in and differences between the small-group market and individual Affordable Care Act (ACA) Marketplace.

What it Finds

• Enrollment in the small-group market has remained stable while a record number of individuals are signing up for individual Marketplace plans.
• Cost containment incentives in the small-group market are different from those in the individual ACA Marketplace; in the small-group market, employer decisions are influenced by factors beyond premium prices, such as broader networks and more generous benefit packages.
  • In 2024, the vast majority of small-group enrollees are in gold or platinum plans (92 percent), while bronze and silver plans are more common for Marketplace enrollees (89 percent).
    • Employers and employees may be more incentivized to enroll in gold- or platinum-level plans because their premium contributions are excluded from taxation.
  • Per-capita spending levels are higher in the small-group market, partly due to the richer benefits of small-group plans.
• Small-group market enrollees tend to be younger, in better health, and wealthier than individual Marketplace enrollees.
• According to 2022 data, premiums in the small-group market and individual Marketplace vary by plan type, state, and market concentration. 
  • In 2022, premiums for the lowest-cost plans in the small-group market tended to be 12 percent less than the lowest-cost plans in the individual Marketplace.
  • The number of insurers and hospitals in a market is highly correlated to premium costs in the small-group market and individual Marketplace; the more concentrated the market, the higher the premiums.
• Per-person expenditures for small-group enrollees tended to be higher than those enrolled in the Marketplace, regardless of health status, age, or income.
• Although the small-group market historically had greater insurer participation than the individual market, as of 2022, most of the 15 largest states had more insurers participating in the individual Marketplace than the small-group market.
  • Unlike the small-group market, the individual market tends to see participation by Medicaid plans, which has been associated with lower premiums.
• Individual market plans tended to be HMO or closed-network, while most small-group plans are open-network or PPO.

Why it Matters

The ACA reformed the small-group and individual markets, making coverage more affordable and accessible. Despite predictions that the ACA Marketplaces would lead small employers to cease offering coverage, enrollment data shows that even with record Marketplace signups, small-group enrollment has remained relatively stable. Though the two markets adhere to a similar set of rules, this research reveals that the individual Marketplace and small-group market profiles are somewhat distinct. For example, while the individual Marketplace sets up strong cost containment incentives, factors beyond costs influence plan selection in the small-group market—employer decisions may consider price, but provider networks and generous benefit packages can outweigh the cost savings of a lower premium. These dynamics have implications for future market reforms, such as cost containment strategies, as well as policy innovations, such as a public option; the authors point out that while a case can be made for a public option in either market, the argument may be stronger in the individual Marketplace, where consumers tend to shop for the lowest-cost premium.

Jonathan Cantor, Megan S. Schuler, Samantha Matthews, Aaron Kofner, Joshua Breslau, and Ryan K. McBain, Availability of Mental Telehealth Services in the US, JAMA Health Forum, February 2, 2024. Researchers from the RAND Corporation conducted a cross-sectional secret shopper survey of mental health treatment facilities (“facilities”) between December 2022 and March 2023. The authors combined the survey results with facility- and county-level data to quantify the availability of mental telehealth services for adults.

What it Finds

• Of surveyed facilities accepting new patients (87 percent), more than three-quarters (80 percent) offered telehealth services (“telehealth facilities”).
  • Private facilities were more than twice as likely to offer telehealth compared to public facilities.
  • Almost all telehealth facilities accepting new patients (97 percent) reported availability of counseling services, while roughly three-quarters offered medication management (77 percent), and fewer offered diagnostic services (69 percent).
    • Facilities accepting Medicaid were more likely to offer telehealth counseling, while facilities accepting private insurance were more likely to offer medication management, and private for-profit facilities were more likely to offer diagnostic services.
• Services offered and number of facilities available varied by geographic location. 
  • Compared to non-metropolitan facilities, metropolitan facilities were more likely to offer medication management but less likely to offer diagnostic services.
  • Significant variation exists at the state level: while all contacted facilities in Delaware, Maine, New Mexico, and Oregon offered telehealth services, less than half of facilities in Mississippi and South Carolina had telehealth options.
  • Across all states, the median wait time for a telehealth appointment was 14 days. Maine was the state with the longest median wait time (75 days) while North Carolina had the shortest (4 days). 
• Around 1 in 5 facilities (21 percent) did not respond during the secret shopper survey despite multiple contact attempts, indicating a potential obstacle for patients looking for specialty mental health services.
• Researchers did not observe a difference in availability based on the perceived race, ethnicity, or sex of the prospective patients, but the authors found a correlation between low facility response rate and counties with larger Black and Hispanic populations. The authors noted that residential segregation could inhibit access to mental telehealth services for marginalized groups.

Why it Matters Barriers to mental health services continue to plague the American health care system. Telehealth offers a potential avenue for expanding access, but trends in availability underscore ongoing issues. While telehealth utilization and availability increased substantially during the pandemic, there are still disparities for patients seeking care, for example, between metropolitan and non-metropolitan areas and across facilities with different patient populations. Policymakers looking to telehealth to facilitate care access should consider research that shows gaps and disparities among patients seeking care, such as availability of services and broadband access.