As we gathered around our tables and gave thanks last month, we also took a moment to be grateful for health policy researchers. This month, we dug into studies on health care financing equity, insurer and consumer participation in the individual market, consumer plan decision-making, and access to specialty providers.

Jacobs, P and Selden, T. Changes in The Equity of US Health Care Financing in the Period 2005–16. Agency for Healthcare Research and Quality (AHRQ); October 16, 2019 (Health Affairs, November 2019 Issue). With spending on health care reaching almost eighteen percent of the United States gross domestic product (GDP) in 2017, researchers from AHRQ analyzed our health care spending, and the impact it has had on American households from 2005 to 2016.

What It Finds

• The average share of household income spent to finance health care rose from 17.6 percent to 21.4 percent during the study period.
• In 2005, household spending on health care was highly inequitable: the lowest 20 percent of earners paid 26.8 percent of their income to finance health care, compared to the 13.8 percent of income paid by the top one percent.
• Private spending was the main driver of the regressive trends at the beginning of the study period, ranging from 14.5 percent of income spent to finance health care for earners in the lowest 20 percent compared to 3.3 percent for earners in the top one percent. In this study, private spending is the money spent on private insurance premiums, out of pocket costs, taxes related to premium and cost sharing financial assistance in the private insurance market.
• In 2016, household spending on health care was far more equitable: across all income levels, families spent roughly the same percentage of income to finance health care.
• The largest progressive shift in health care expenditures across income levels during the study period occurred between 2007 and 2009, during the Great Recession. Other significant shifts that made health spending more equitable are largely attributable to Affordable Care Act (ACA) policies financed by progressive federal tax policy, such as marketplace premium subsidies and Medicaid expansion.

Why It Matters

Consumers top health care concern is affordability. The ACA helped reduce disparities in coverage and spending across household income levels through reforms such as expanded public insurance and income-based financial assistance for private insurance. This study shows that the law was successful in promoting equity across income levels, so that the lowest earners are not paying a significantly higher share of income than the highest earners. Policymakers should take note of these gains, and work to prevent the reversal of this progress.

Crespin, D and DeLiere, T. As Insurers Exit Affordable Care Act Marketplaces, So Do Consumers. Health Affairs; November 4, 2019. In recent years, individual market insurer participation has declined significantly since the launch of the ACA marketplaces. Researchers from RAND and the Georgetown University McCourt School of Public Policy examined how insurer marketplace exits affected consumers’ re-enrollment decisions between 2015 and 2018.

What it Finds

• Over the study period, consumers were 7.1 to 12.9 percent more likely to forego marketplace coverage after their insurer stopped offering marketplace plans.
• Insurer exits affected unsubsidized consumers significantly more than subsidized consumers, with unsubsidized consumers facing disenrollment increases of 18.3 percentage points, compared to the 8.7 percentage point increase among subsidized consumers.
• The effects of insurer exits were driven not only by premiums, but also by confusion, and changes to provider networks, deductibles, and copayment amounts.

Why it Matters

Insurer exits from the individual market don’t only make big headlines, but cause tangible challenges for the people who rely on the market for access to health care. State and federal policymakers need to encourage insurer participation to create a competitive marketplace that gives consumers robust choice in health plan options.

Rasmussen, P., et al. California’s New Gold Rush: Marketplace Enrollees Switch to Gold-Tier Plans in Response to Insurance Premium Changes. Health Affairs; November 1, 2019. Experts at the UCLA Fielding School of Public Health examined how silver loading impacted plan selections on California’s individual marketplace.

What if Finds

• While approximately 4 percent of California marketplace enrollees switched their plan’s metal level during the first three Open Enrollment (OE) periods, over 7 percent of enrollees switched metal levels during the 2017-2018 OE.
• The rate at which consumers shopped around for insurers rose from less than 5 percent during 2014-15 to over 9 percent during the 2017-2018 OE.
• In the 2017-2018 OE, 36.69 percent of enrollees shifted to gold-level insurance plans compared to 9.55-12.21 percent in prior years; this increase is likely due in part to the impacts of silver loading on premiums and federal premium subsidies.
• Consumers receiving enrollment assistance were more likely to switch plans than those who received no enrollment assistance.

Why it Matters

In the wake of the Trump Administration decision to cease providing cost-sharing reductions (CSR) payments to insurers in 2017, many states worked with insurers to require or permit “silver loading,” or loading the cost associated with the loss of CSR funding onto silver-level premiums, which in turn increased premium subsidy amounts. In some states, depending on the premium spread, gold-level plans became less expensive relative to the now higher-premium silver level plans for some subsidized consumers. The effects of silver loading are important to track, especially as the Trump Administration weighs the option of banning silver loading. Policymakers should also take note of what drives enrollment behavior, such as the availability of enrollment assistance to help consumers understand their options.

Header, S., et al. A Consumer-Centric Approach to Network Adequacy: Access to Four Specialties in California’s Marketplace. Health Affairs; November 1, 2019. Health insurance can only do so much without an adequate network of providers. Researchers in public policy, political science and medicine collaborated to assess the availability of cardiologists, endocrinologists, OB/GYNs, and pediatricians for California marketplace enrollees compared to non-marketplace individual market enrollees.

What it Finds

• Large metropolitan areas in California offer the most choice in the provider specialties studied, followed by metropolitan, then “micropolitan” and rural areas in the state.
• On average, California’s marketplace plan networks have about half as many providers in the study specialties as off-marketplace commercial plans.
• Compared to a theoretical unrestricted fee-for-service (FFS) plan offering access to all providers in the study specialties, off-marketplace commercial plan networks only contain about one-third of providers in those specialties.
• “Artificial local provider deserts,” or areas where there are providers in a certain specialty that are excluded from provider networks are more common in micropolitan and rural areas, suggesting that issues with provider access are exacerbated by network design.

Why it Matters

Having health insurance coverage in the United States does not mean unfettered access to health care. Health insurers and providers negotiate contracts with providers that promise a volume of insured patients in exchange for a discounted reimbursement rate. In the face of evidence that ACA marketplace consumers are willing to trade network access for a lower premium, insurers in many areas are offering narrow network products. Although “narrow network” does not necessarily mean “inadequate” network, this study illustrates that certain regions, particularly rural and micropolitan areas, struggle with provider access, and that the issue is not restricted to marketplace plans. State and federal regulators should give studies like this a close look, especially in the wake of increased provider consolidation that could further make it difficult for insurers to negotiate for access to providers at a reasonable price.