By Rachel Swindle

The leaves are starting to change, and as autumn arrives we’ve raked in a pile of new health policy research. As open enrollment approaches, we read several studies that focus on consumers’ understanding of marketplace options, premium assistance, and downstream impacts of cost sharing trends.

Jennifer M. Haley and Erik Wengle, Uninsured Adults’ Marketplace Knowledge Gaps Persisted in April 2021, Urban Institute, September 28, 2021. Researchers reviewed data on consumers’ knowledge of the Affordable Care Act’s (ACA) marketplaces and federal financial assistance by analyzing responses to the Urban Institute’s Health Reform Monitoring Survey of uninsured nonelderly adults, fielded during the availability of a broad special enrollment period (SEP) and temporarily expanded premium subsidies under the American Rescue Plan (ARP).

What It Finds

• More than half (51.8 percent) of respondents reported hearing little or nothing about marketplace coverage options. Among this group:
  • A majority (55.1 percent) were ages 18-34;
  • More than a quarter (29.7 percent) were bilingual or Spanish-speaking;
  • Nearly half (49.2 percent) were unemployed at the time of the survey; and
  • Most (83.1 percent) had internet access at home.
• More than two-thirds (67.8 percent) of uninsured adults reported little or no knowledge of marketplace financial assistance. Among this group:
  • A majority (53.4 percent) were ages 18-34;
  • More than a quarter (27.7 percent) were bilingual or Spanish-speaking;
  • Nearly half (47.8 percent) were unemployed at the time of the survey; and
  • Most (84.5 percent) had internet access at home.
• The share of respondents who reported hearing a lot or some about marketplace coverage options and subsidies did not change significantly from the previous survey fielded in September 2020, despite the new availability of an SEP on the federal marketplace and the American Rescue Plan’s temporary subsidy expansion.
• Most uninsured adults who knew about marketplace coverage options reported cost as the primary reason that they had not sought or signed up for a marketplace plan.

Why It Matters

Despite the significant subsidy enhancements under the ARP, most uninsured adults were unaware of marketplace coverage and financial assistance in April 2021. Given the age range of surveyed uninsured adults reporting little or no knowledge of the marketplace coverage and subsidies, this report could be used as a guide to improve outreach and communication campaigns. Over half of adults who were unaware of marketplace options as well as a majority who did not know about financial assistance are under the age of 35, an age group with consistently high rates of social media usage. To reduce uninsurance rates among the nearly 30 percent of respondents who were not aware of opportunities for marketplace coverage and report speaking Spanish at home, some state-based marketplaces like California are expanding communications and outreach to Latino communities by increasing funding for multilingual marketing campaigns. At the federal level, the new Champions for Coverage program harnesses the organizing power of trusted community advocates to build awareness and hopefully increase enrollment. The findings from this Urban Institute survey highlight the need to increase awareness of marketplace coverage and financial assistance, and may contribute to developing effective outreach strategies ahead of the upcoming open enrollment period.

Cynthia Cox, Karen Pollitz, and Giorlando Ramirez, How Marketplace Costs and Premiums Will Change if Rescue Plan Subsidies Expire, KFF, September 24, 2021. The ARP dramatically increased the number of individuals and families eligible for financial assistance through the ACA marketplaces, as well as increasing premium subsidy amounts among many of those already receiving the tax credits. Alongside SEPs in federal and state-based marketplaces, the implementation of ARP subsidies led to year-over-year enrollment increases and premium savings, and helped stabilize the uninsured rate during the COVID-19 pandemic. This report by researchers at KFF estimates some of the impacts if the ARP subsidies are allowed to expire as scheduled in 2022.

What It Finds

• If ARP subsidies are not extended, marketplace enrollees who signed up prior to the ARP’s subsidy expansion would see their premiums nearly double, increasing annual costs by roughly $800.
• The lowest-income recipients would be disproportionately hit with premium and deductible increases; many individuals between 100 to 150 percent of the federal poverty level (FPL) enrolled in Silver plans in 2021 when ARP reduced their premiums to $0. These individuals will likely move to bronze plans with higher deductibles or drop coverage altogether without the ARP’s expanded premium assistance. This migration to bronze could result in a 30-fold increase in annual deductibles for impacted enrollees – from under $200 to over $7,000.
• Middle-income recipients losing subsidy eligibility would also be hard hit if the ARP’s subsidy expansion expires, with individuals just over 400 percent FPL projected to experience significant premium increases. For example, a 48-year-old with a $60,000 annual household income would see a 36 percent increase in premiums, while a 60-year-old with an income just over $51,000 would see a 165 percent increase in premiums.
• Extension of the ARP’s subsidy enhancements would increase federal costs, with current expenditures reaching $537 million each month, a cost that is expected to rise as more people sign up for marketplace plans during open enrollment.

Why It Matters

If the ARP’s subsidy expansion expires in December 2022, many individuals will be forced to drop their coverage or suffer reduced access to care due to switching to plans with higher cost sharing. Some states have implemented their own subsidies to supplement ARPA financial assistance. Programs in Massachusetts and Vermont, for example, will lessen some of the impact of the loss of ARPA subsidies, but they will not entirely protect consumers from the financial hit. Individuals in states without state-specific assistance will be even more vulnerable to loss of coverage and access to care. Ultimately, the budgetary impact of the ARP’s more generous subsidies may create political obstacles to extending the benefit. However, as this study points out, the timing of the current expiration date—where enrollees will learn of significantly higher premiums during the open enrollment period just before the 2022 midterm elections—may create additional political pressures. Regardless, policymakers should take note of the significant impact that terminating the enhanced subsidies could have on consumers, many of who may choose to go uninsured due to the sticker shock of higher premiums or lose meaningful access to care when their deductibles rise.

Loehrer et. Al, Association of Cost Sharing With Delayed and Complicated Presentation of Acute Appendicitis or Diverticulitis, JAMA, September 3, 2021. Building on findings from the Oregon Health Insurance Experiment and the RAND Health Insurance Experiment, which documented increased care utilization in connection with significantly reduced patient costs and that higher cost sharing reduced use of health services (respectively), this study evaluated whether increased cost sharing was associated with delayed care for two common conditions. Appendicitis and diverticulitis are simple to treat when patients seek care early in symptom progression, but can escalate to serious complications requiring more expensive and invasive care when patients delay treatment. Using Health Care Cost Institute (HCCI) claims data from 2013 to 2017 on over 150,000 nonelderly adult patients with employer-sponsored insurance, nongroup marketplace plans, and nonmarketplace individual plans, authors explored the relationship between patient financial burden and risk of disease complication and need for invasive treatment.

What It Finds

• The share of patients in the highest cost-sharing quartile (over $3,082 for the index hospitalization) increased between 2013 and 2017 from 20.9 percent of patients to 29 percent of patients.
• Compared to patients with lower cost-sharing amounts ($0-$502 for the index hospitalization), patients with higher cost-sharing amounts (over $3,082 for the index hospitalization) were significantly less likely to seek care at early stages of disease progression.
  • The comparative odds of patients with higher cost-sharing amounts seeking care at early stages of disease progression were similar when the threshold was set at over/under $800 for the index hospitalization (equivalent to the median annual out-of-pocket cost for insured patients in 2016 and 2017), suggesting that amounts likely considered to be manageable by many stakeholders may still be associated with dramatically different patient behavior and health outcomes.
  • These findings were consistent when researchers controlled for factors such as patient demographic characteristics, the time of year, geographic region and urban/rural characterization of provider and patient location, patient’s insurance plan type, and socioeconomic conditions of patient’s home zip code.

Why It Matters

Coverage gains since the ACA’s implementation have dramatically reduced the number of uninsured, but increased cost sharing in both employer-sponsored and marketplace insurance leaves many people underinsured. This study demonstrates how higher cost-sharing burdens correlate strongly with increased severity of certain health conditions that are easy to treat when treatment is sought early. While the authors make no causal claims from their results, this study does suggest that cost sharing is a deterrent to seeking care even among insured patients when symptoms are mild and manageable. Individuals with higher cost burdens might wait until symptoms are urgent and cannot be ignored, leading to a greater risk of long-term medical complications and greater financial strain to patients. While exposing consumers to some of the cost of care might reduce patient over-utilization, there is a fine line between limiting excessive care-seeking and imposing needless financial barriers through benefit designs that can lead to harmful long-term health consequences.