As we fall into autumn weather, CHIR continues to keep up with the latest health policy research. In September, we read about trends in individual market enrollment, mental health care networks available through the Affordable Care Act’s (ACA) Marketplace, and employers’ ability to negotiate lower prices for health care services.

Jared Ortaliza, Krutika Amin, and Cynthia Cox, As ACA Marketplace Enrollment Reaches Record High, Fewer Are Buying Individual Market Coverage Elsewhere, KFF. The authors look at enrollment in on- and off-Marketplace health plans as of 2023, as well as enrollment in non-ACA-compliant policies in 2022.

What it Finds

• Between the first quarter of 2020 and the first quarter of 2023, individual market enrollment grew from 14.1 million to 18.2 million (including ACA-compliant and non-ACA-compliant plans), primarily driven by enrollment in subsidized Marketplace plans.
  • Marketplace enrollment growth is largely due to temporary enhanced subsidies made available through the American Rescue Plan Act and extended under the Inflation Reduction Act. A record 79 percent of individual market enrollees now receive Marketplace subsidies, up from just 44 percent in 2015.
• An estimated 2.5 million people purchase unsubsidized, off-Marketplace coverage, including non-ACA-compliant coverage (such as short-term plans and “grandfathered” plans)
  • Off-Marketplace enrollment fell by 20 percent between early 2022 and early 2023.
  • Enrollment in non-ACA compliant health plans has dropped from 5.7 million enrollees in 2015 to 1.2 million enrollees in mid-2022.

Why it Matters

The shift in individual market enrollment from off-Marketplace coverage (including non-ACA-compliant policies) to subsidized Marketplace plans reflects the growing number of Americans who are able to access affordable, comprehensive health insurance under temporary subsidy expansion. The more generous financial assistance—currently available through the end of plan year 2025—has led to record Marketplace signups, and coincided with an historically low uninsured rate, alongside other policies to protect health insurance access. Still, millions of people remain uninsured or enrolled in non-ACA-compliant coverage that can leave consumers vulnerable to catastrophic medical bills. Despite Marketplace subsidy expansion, many people still do not qualify for financial help (including undocumented immigrants), and many who do are not aware of their eligibility. During the upcoming Marketplace open enrollment period, outreach efforts to broadcast the availability of financial assistance will be key to protecting coverage gains. Looking ahead, policymakers will need to consider an extension of the Inflation Reduction Act’s enhanced Marketplace subsidies to avoid significant coverage losses after plan year 2025.

Rebecca Silliman, Erin McNally, Cruz Vargas-Sullivan, and David Schleifer, Searching for In-network Mental Health Care with Marketplace Insurance, Public Agenda. Between October 11–November 14, 2022, researchers followed seventeen Marketplace enrollees seeking in-network mental health services to identify insurance-related barriers to mental health care and the impact of these obstacles on consumers. 

What it Finds

• After a three-week search, none of the seventeen study participants were able to schedule an appointment with an in-network mental health provider during the roughly month-long study period, including participants who spent three hours or more searching for a provider.
  • While six participants were ultimately able to schedule a future appointment, only two participants believed that the appointment would be covered by insurance, and all six cited trade-offs they had to make for these appointments, such as traveling over 90 minutes for the appointment or wait times of up to four weeks.
  • Eleven participants were unable to schedule even a future appointment, and only two of these participants were confident that they would find the right mental health provider for their needs; the nine others expressed concerns about affordability, convenience, appointment times, and finding a linguistic, cultural, or personal fit.
• The most common obstacles to finding mental health care amongst participants included providers not accepting their insurance, a lack of appointment times, and the time-consuming search process.
• All participants found that trying to schedule in-network appointments was time-consuming.
  • Participants identified that the process required coordinating across multiple entities (primary care, insurers, prospective providers, etc.) in order to answer questions, get referrals if needed, and book appointments.
  • In searching for providers, participants preferred using an online search function or finding providers through their insurer.
• Participants expressed a desire for broader mental health provider networks, an easier and more centralized way to identify in-network providers, ending referral requirements, and some coverage of out-of-network mental health care.
• Delayed access to mental health care had negative impacts on study participants, including a financial toll, harm to their mental and physical health and relationships, and difficulties at work or even job and income loss.

Why it Matters

There is a dire need for mental health services in the United States, particularly in the wake of the COVID-19 pandemic. Despite legislation like the Mental Health Parity and Addiction Equity Act (MHPAEA), even insured consumers face ongoing obstacles to accessing affordable and convenient mental health care. The inability of participants to schedule an appointment with an in-network mental health provider over the course of a month and the trade-offs associated with scheduling future appointments, such as cost and inconvenience, underscore the inadequacy of mental health provider networks and the lack of consumer-centered policies, like out-of-network coverage, to mitigate this shortcoming. Moreover, this study demonstrates the time and energy it takes to not only identify providers and appointments but to navigate processes such as referral requirements. The onerous search process also takes a toll on consumers’ health and financial wellbeing. As policymakers strive to improve mental health care access, studies like this show the many substantial hurdles that consumers must clear to obtain the care they need.

Aditi P. Sen, Jessica Y. Chang, and John Hargraves, Health Care Service Price Comparison Suggests That Employers Lack Leverage To Negotiate Lower Prices, Health Affairs. Using Health Care Cost Institute claims data, researchers compared prices for common services paid by self-insured and fully insured employer plans.

What it Finds

• In 2021, among consumers with employer-sponsored insurance (ESI), roughly 65 percent were enrolled in self-insured plans. When an employer plan is self-insured, the employer bears the financial risk of paying claims. When a plan is fully insured, the insurance company bears the risk of paying claims.
  • Across both self-insured and fully insured plans, most enrollees were in preferred provider organization (PPO) plans.
  • Fully insured plan enrollees were more likely to be enrolled in a Health Maintenance Organization (HMO) compared to self-insured plan enrollees.
  • Roughly 30 percent of self-insured plan enrollees were in point-of-service (POS) plans, as opposed to approximately 14 percent  of fully funded plan enrollees.
• Average annualized per person spending was approximately 10 percent higher for self-insured plans ($5,083) than it was for fully insured plans ($4,606), while average out-of-pocket spending was slightly lower for self-insured plan enrollees than it was for fully insured plans enrollees.
• The unadjusted mean prices for services in self-insured plans exceeded the unadjusted mean prices in fully insured plans for 13 of the 19 services investigated in this study.
  • For example, the average cost of an endoscopy was roughly 8 percent higher ($111) in self-insured plans than it was in fully insured plans and the cost of a colonoscopy was 6 percent higher ($109) in self-insured plans.
  • Many of the largest price differences were across POS plans, with the study showing more mixed results across other plan types.
  • Price differences between self-insured and fully insured plans were smaller when adjusted for enrollee distribution across different plan types (e.g., HMO versus PPO), geography, and patient characteristics; for instance, after adjusting for these three factors, self-insured plans paid roughly 2 percent more for endoscopies and colonoscopies than fully insured plans. Excluding controls for plan type increased price differentials, suggesting that differences in plan types drove disparities in prices paid by self-insured plans and fully insured plans.

Why it Matters

Rising health care costs are an increasing burden on payers as well as the insured. ESI covers roughly half of the U.S. population as a whole, and a majority of ESI enrollees are in self-insured plans, where employers negotiate prices with providers (typically through a third-party administrator). The results of this study suggest that employers have less power to negotiate rates than often believed; myriad factors, including increased hospital consolidation, the role of third party administrators (TPAs) and their lack of incentive to achieve lower rates, and employers’ limited negotiating power in any one market reduce the ability to achieve the lower rates necessary to curbing health spending in the group market. Evidence like this can inform the continued quest to contain health care costs and policies that can help support and sustain a source of coverage that a majority of Americans rely on.