The weather’s getting sunny and warm, and we can’t imagine anything nicer than some excellent health policy research while outside on your deck, patio, or a park bench. This month we reviewed studies on demographic characteristics of the people who fall into the ACA family glitch, trends in contraceptive use among women enrolled in high-deductible health plans after the passage of the ACA, and state policy considerations given the American Rescue Plan’s premium tax credit expansions.

Cox, C. et al. The ACA’s Family Glitch and Affordability of Employer Coverage, KFF. April 7, 2021

In this report, KFF researchers use 2019 data from the Current Population Survey to identify demographic characteristics of people who fall into the family glitch and discuss how many people may benefit from policies aimed at eliminating the family glitch.

What it Finds

• Over 5.1 million people currently fall into the family glitch. Of this number:
  • 4.4. million are currently enrolled in employer coverage;
  • 315,000 are currently purchasing unsubsidized individual market coverage;
  • 451,000 are uninsured;
  • 2.8 million are children under the age of 18 who do not qualify for the Children’s Health Insurance Program (CHIP).
• Among the adults who fall into the family glitch, 59 percent are women and 41 percent are men.
• The states with the largest number of people who fall into the family glitch are Texas (671,00 people), California (593,000 people), Florida (269,000 people), and Georgia (206,000 people).
• Eliminating the family glitch, including accounting for people whose incomes are above 400 percent of the federal poverty level, would cost an estimated $45 billion over 10 years.
  • Over 1 million people who fall into the family glitch have incomes above 400 percent of the federal poverty level.
• Ninety-four percent of those who fall into the family glitch are in good health, and 94 percent of people who are currently insured through the individual market are in good health as well. 
  • The individual market risk pool may remain unchanged or even benefit if healthy people who currently have employer coverage or who are uninsured were to enroll in ACA marketplace coverage.  

Why it Matters

Millions of people face persisting barriers to coverage due to the ACA’s family glitch. Congress could eliminate the glitch through legislation, or the Biden administration could do so through executive action, and a recent executive order opens the door. As the KFF study indicates, allowing spouses and dependents who face high premiums for employer-based coverage to access premium tax credits could significantly improve access to coverage and reduce the numbers of uninsured.    

Becker, N. et al. ACA Mandate Led to Substantial Increase in Contraceptive Use Among Women Enrolled in High-Deductible Health Plans, Health Affairs. April 2021

In this report, researchers use data from a national commercial claims database to examine contraceptive use among continuously enrolled reproductive-age women between 2010 and 2017. They compare 9,014 women enrolled in high-deductible health plans with 443,363 women enrolled in non-high-deductible health plans. 

What it Finds

• Researchers tracked out-of-pocket expenditures of women enrolled in high-deductible health plans (HDHPs) compared to those of women enrolled in traditional health plans in response to the ACA contraceptive coverage mandate. Between January 2010 and December 2017, they found that: 
  • For women enrolled in traditional health plans, average quarterly out-of-pocket expenditures for long-acting reversible contraceptives (LARCs) ranged from $53.22 to $122.73 before the ACA mandate was implemented, and dropped to a range of $9.66 to $28.15 after the mandate was implemented
  • For women enrolled in HDHPs, average quarterly out-of-pocket expenditures for LARCs ranged from $119.62 to $580.30 before the ACA mandate was implemented, and dropped to a range of $0.36 to $22.95 after the mandate was implemented
• Overall, as costs decreased rates of LARC use increased in both groups of women over the same period, although LARC rates increased more for women enrolled in HDHPs than for women enrolled in traditional health plans
  • There was a 35 percent greater increase in LARC use among women enrolled in HDHPs than seen among women enrolled in traditional health plans

Why it Matters

Before the passage of the ACA, LARCs were subject to cost sharing, which subjected many women enrolled in HDHPs to high out-of-pocket costs. These findings demonstrate that the ACA’s mandate, which required that private health insurance plans cover prescription contraception without cost sharing, had a significant impact for women enrolled in these plans. However, the preventive services coverage mandate in the ACA has recently been challenged in federal district court, and in July 2020 the Supreme Court ruled that employers could opt out of the mandate for religious reasons without having to ensure other means of contraceptive coverage for their employees. This makes the future of insurance coverage of contraceptives for many women uncertain. Federal judges and policymakers need to understand the extent to which these cases will reverse significant gains in affordability of contraceptive coverage for women.

Levitis, J. and Meuse, D. The American Rescue Plan’s Premium Tax Credit Expansion- State Policy Considerations, Brookings Institute. April 19, 2021

This report outlines a number of policy considerations for state legislatures based on the American Rescue Plan’s premium tax credit expansions.

What it Finds

• The authors note that the American Rescue Plan’s (ARP) expansion of premium tax credits (PTCs) gives states the opportunity to build on federal law to make coverage even more affordable and accessible.
• The authors recommend that states consider: 
  • providing supplemental premium subsidies in addition to the broad PTCs that target specific populations, such as people who fall into the ACA’s family glitch or people who are undocumented;
  • improving affordability by providing subsidies that supplement federal cost-sharing reductions; and
  • expanding outreach efforts to people who are eligible but not enrolled in coverage.
• The authors anticipate that the new PTC structure will make the impact of health reimbursement arrangements for employer coverage, reinsurance programs (such as Section 1332 waivers), and Basic Health Plans uncertain. 
• Because the ARP’s PTC expansions may significantly change the cost-benefit calculus for a wide range of cost saving measures, researchers recommend that states exercise caution in immediate decision-making, and develop flexible statutes and systems with potential future changes in mind.

Why it Matters

The ARP temporarily makes premiums more affordable for most consumers while laying the groundwork for more expansive and permanent federal legislation, and for states to develop unique strategies to eliminate persisting health care affordability barriers. Over the next few years, it will be helpful for policymakers to refer to the recommendations offered here as they navigate a changing policy landscape.