This May, we began to visit again with friends and family, attempt indoor restaurant dining, and enjoy maskless breathing. In between all that, we were able to dive into some great health policy research. We reviewed studies on the demographic makeup of the uninsured population eligible for marketplace coverage, the association between hospital-physician integration and unnecessary patient referrals, and rationales for replacing silver loading for Marketplace coverage.

McDermott, D. and Cox, C. A Closer Look at the Uninsured Marketplace Eligible Population Following the American Rescue Plan Act, KFF. May 27, 2021

In this analysis, KFF researchers examine demographic characteristics of uninsured people who are currently eligible for Marketplace subsidies under the American Rescue Plan Act (ARPA).

What it Finds

• KFF researchers examine the demographic characteristics of the 10.9 million uninsured people who are eligible for Marketplace subsidies under ARPA, including 6 million uninsured individuals who are eligible for tax credits that cover the full cost of a bronze or silver Marketplace plan. 
• Of the uninsured population eligible for Marketplace subsidies under ARPA:
  • Thirty percent are Hispanic.
  • Fifty-nine percent have a high school diploma or less.
  • Forty-two percent are young adults aged 19 to 34.
  • Sixteen percent live in rural areas.
  • Eleven percent do not have internet access at home. 
• Of the uninsured population eligible for zero-dollar premium plans under ARPA:
  • Most people who are eligible for any type of free Marketplace coverage live in Texas, Florida, North Carolina, and Georgia.
  • Thirty-two percent of those who are eligible for a free bronze plan and 41 percent of those who are eligible for a free silver plan are Hispanic.
  • Sixty-two percent of those who are eligible for a free bronze plan and 65 percent of those who are eligible for a free silver plan have a high school diploma or less.
  • Thirty-five percent of those who are eligible for a free bronze plan and 46 percent of those who are eligible for a free silver plan speak a language other than English at home.
  • Thirteen percent of those who are eligible for a free bronze plan and 15 percent of those who are eligible for a free silver plan do not have internet access at home.

Why it Matters

These findings can help inform targeted marketing and outreach strategies, as well as enrollment assistance activities, throughout the remainder of the 2021 special enrollment period. 

Young, G. et al. Hospital Employment of Physicians in Massachusetts Is Associated with Inappropriate Diagnostic Imaging Health Affairs. May 2021

Using 2009-2016 data from Massachusetts’ All Payer Claims Database, researchers investigated whether hospital-physician integration is associated with medically unnecessary referrals for magnetic resonance imaging (MRI) for selected clinical conditions in patients.

What it Finds

• Researchers compared the patient MRI referral rates of a study cohort of physicians who had recently transitioned to hospital employment during the study period to those of a comparison group who were not employed by a hospital during that period. They found: 
  • For the study cohort, the odds of a patient receiving an MRI referral increased by more than 30 percent after a physician transitioned to hospital employment.
    • For the comparison group, the change in odds was not statistically significant.
  • For the study cohort, the odds of a patient receiving an inappropriate MRI referral increased by 26 percent in relation to hospital employment.
    • For the comparison group, the change in odds was not statistically significant.
  • For the study cohort, most of the patients that hospital-employed physicians referred for MRI scans received those scans at the same hospital that employed the referring physician.

Why it Matters

These study findings suggest that physicians who are employed by hospitals are incentivized to refer patients for medically unnecessary testing, which can pose risks to patients and drive up costs for care. These findings are consistent with previous studies that link hospital-physician employment and increased health care spending. At the same time, hospitals are increasing their efforts to purchase physician group practices. Policymakers and anti-trust regulators need to take a hard look at this trend and consider policy and regulatory options to protect patients’ quality of care and lower the risk of increased, unnecessary spending. 

Fiedler, M. The Case For Replacing Silver Loading, Brookings Institute. May 20, 2021

In this report, Matthew Fiedler discusses various rationales for replacing silver loading for Marketplace coverage, and outlines options for its replacement. 

What it Finds

• Fiedler argues that, despite expanding Marketplace subsidies, silver loading has some drawbacks that merit future policy consideration, including:
  • A future Presidential Administration may seek to end silver loading administratively, which would have significant negative consequences for subsidy-eligible Marketplace consumers. 
  • Silver loading has caused silver plans to be overpriced for enrollees who are ineligible for more generous cost-sharing reductions. As a result, some of these enrollees have been driven into bronze plans with cost-sharing schemes that may not align well with their financial needs. 
  • Silver loading creates disincentives for states to expand Medicaid or adopt a Basic Health Program (BHP). Each of these measures would remove lower-income enrollees–who benefit the most from silver loading–from the Marketplace.
• Given these concerns, Fiedler outlines several mechanisms that can be used to replace silver loading:
  • Congress could enact an appropriation for cost-sharing reductions and use the savings to directly expand the ACA’s Marketplace subsidies.
  • In order to mirror the benefits of silver loading, policymakers could modify the benchmark premium used to calculate premium tax credits. For example, the benchmark premium could be set at some multiple of the second-lowest silver plan premium (rather than at the second-lowest silver plan premium). Or Congress could make the benchmark plan a gold plan (rather than silver).

Why it Matters

In this report, Fiedler outlines potential drawbacks of silver loading, and offers policymakers examples of strategies that can be used to mitigate coverage affordability barriers for subsidy-eligible Marketplace consumers. While silver loading has had beneficial effects in the short-term, it is an inefficient way to finance coverage and policymakers should consider alternatives that would be better for taxpayers and policyholders alike.