Along with the cherry blossoms, new health policy research was in full bloom this month. In addition to filling out our March Madness brackets, the CHIR team reviewed studies on health insurance rates during the pandemic, how the Affordable Care Act (ACA) impacted women’s health coverage, and consumer access to high-quality marketplace plans.

Stacy McMorrow, Michael Karpman, Andrew Green, and Jessica Banthin, Bolstered by Recovery Legislation, the Health Insurance Safety Net Prevented a Rise in Uninsurance between 2019 and 2021, Urban Institute, March 11, 2022. Researchers analyzed data from the National Health Interview Survey (NHIS), Health Reform Monitoring Survey (HRMS) and Current Population Survey (CPS) to analyze health coverage trends among adults aged 18 to 64 in the United States between early 2019 and early 2021.

What it Finds

• The health insurance safety net, augmented by the Medicaid continuous coverage requirement in the Families First Coronavirus Response Act and the American Rescue Plan’s (ARP) temporary enhancements to marketplace subsidies, did its job of preventing “catastrophic coverage losses” during the pandemic.
  • All three surveys showed statistically insignificant increases in the uninsurance rate from early 2019 to early 2021.
  • Authors suggested Medicaid and subsidized marketplace coverage not only prevented the large increase in the uninsured rate predicted at the start of the pandemic but may have “reduced uninsurance from prepandemic levels” due to enrollment in Medicaid continuing to increase after the survey periods and record marketplace enrollment gains following implementation of the ARP’s subsidy enhancements.
• Researchers found statistically significant changes in types of coverage that survey respondents were enrolled in from early 2019 to early 2021.
  • In particular, the HRMS showed a 2.7 percentage point decline in the share of adults covered by employer-sponsored insurance (ESI) and NHIS data showed a 2.4 percentage point decline in the private insurance rate (including ESI).
  • Declines in ESI and other private insurance enrollment were apparently offset by gains in public insurance coverage: NHIS and HRSM data showed 2.1 and 3.9 percentage point increases in public coverage, respectively.
    • These results are substantiated by Medicaid administrative enrollment data: Medicaid enrollment increased by over 15 percent between March 2019 and March 2021, largely due to the continuous coverage requirement which prevented millions of enrollees from losing their coverage.
  • Marketplace enrollment increased 6.7 percent between February 2019 and February 2021 (prior to the ARP’s premium subsidies, which resulted in even greater enrollment gains). The marketplaces saw less attrition throughout the year in 2020 than prior years, which authors attribute in part to new special enrollment periods (SEPs) offered during the pandemic.

Why it Matters
This study affirms the importance of the health insurance safety net as a tool to mitigate widespread coverage losses amidst a disruptive event like the COVID-19 pandemic. Without recovery legislation aimed at protecting and expanding access to Medicaid and marketplace coverage, these data would likely tell a very different story. However, when Medicaid’s continuous coverage requirement expires, millions of people are at risk of losing their health insurance. Unless the ARP’s temporary premium subsidy expansion is extended, these consumers could face affordability barriers to accessing marketplace plans. In addition to the need for coordination between state Medicaid agencies and marketplaces and initiatives to help consumers transitioning between coverage programs, federal policymakers should prioritize extending the ARP’s subsidy increases to ensure those losing Medicaid are met with a robust coverage safety net.

Sarah Sugar, Joel Ruhter, Sarah Gordon, Amelia Whitman, Christie Peters, Nancy De Lew, and Benjamin D. Sommers, Health Coverage for Women Under the Affordable Care Act, HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE), March 21, 2022. On the ACA’s twelfth birthday, ASPE used data from the American Community Survey (ACS) to examine insurance trends to determine how the landmark law impacted coverage rates among women, and estimated the impact of a state’s decision to not expand Medicaid.

What it Finds

• Over 10 million adult women (ages 19-64) gained health insurance coverage between the ACA’s passage in 2010 and 2019. These coverage gains translated to an 8 percentage point drop in the uninsurance rate for adult women, from 19 percent to 11 percent.
  • Uninsurance rates for women of reproductive age (ages 15-44) saw a slightly larger decline, falling from 21 percent in 2010 to 12 percent in 2019.
• In addition to increasing coverage rates for women, the ACA also expanded access to essential preventive care. When the ACA eliminated cost-sharing for contraceptives in most private health plans, women saved an estimated $483 million to $1.4 billion in out-of-pocket costs in 2013, and studies show an associated increase in prescription contraception use.
• Despite these improvements, researchers estimate that 11 million women under age 65 were uninsured as of 2019.
  • Among the 7.9 million uninsured women of reproductive age, 48 percent had Medicaid-qualifying incomes in a Medicaid-expansion state and 52 percent were likely eligible for subsidized marketplace coverage under the ARP’s expanded subsidies (42 percent under the pre-ARP subsidy structure).
• Women living in Medicaid non-expansion states saw less of a coverage impact from the ACA, with only a 28 percent decrease in the uninsurance rate among women ages 19-44, compared to a more than a 50 percent decrease in expansion states.
  • Over 50 percent of reproductive-age women with incomes at or below 138 percent of the federal poverty level live in non-expansion states, meaning they could fall into the “coverage gap.” Black women make up a higher portion of uninsured women in non-expansion states compared to expansion states.
  • If the 12 states that have not yet expanded Medicaid did so, researchers estimate that 1.9 million low-income women (primarily women of color) would be newly eligible for coverage.

Why it Matters
ASPE’s findings show that the ACA led to significant coverage gains for women, but also demonstrate the stark contrast between women’s coverage status at the state level, based on whether a state chose to expand Medicaid. Many racial and ethnic minority and low-income women continue to face larger barriers to accessing comprehensive, affordable health insurance. State and federal policymakers should implement ASPE’s policy recommendations to further improve health coverage for women, including extending the ARP’s temporary marketplace subsidy expansion, closing the Medicaid coverage gap, and investing in outreach and enrollment assistance.

Thomas C. Tsai et al., Marketplace Health Insurance Ratings: Most Potential Enrollees Have Access to Plans of Medium or High Quality, Health Affairs, March 2022. Researchers analyzed quality ratings data (measured from one to five stars) for 38,562 health care plans offered in 35 states on the federal marketplace (including state-based marketplaces on the federal platform) in 2020. Quality scores rate plans across 41 measures related to medical care, plan administration, and member experience.

What it Finds

• For the majority (61.4 percent) of counties studied, a three-star plan was the highest-rated option; about half of marketplace enrollees lived in these counties. Only 31 percent had four- or five-star rated plans offered, but 46 percent of marketplace enrollees had access to these plans. In a very small share of counties (7.6 percent) consumers only had access plans rated lower than three stars.
• Plans offered within states or geographic regions usually had similar quality ratings. However, researchers did find a distinction based on population size.
  • More populous counties tended to have access to higher-rated plans (four to five stars), and counties with the highest percentage of marketplace enrollees were seventeen times more likely to have access to high-rated plans. On the other hand, 73.3 percent of counties with access to only lower-rated plans (one to two stars) were rural, compared to only 56.9 percent of counties with access to high-rated plans.
• There was also a strong association between the number of insurers offering plans in a county and plan quality rating – 65.6 percent of counties with high-rated plans were served by three or more insurers, and only 6.6 percent of counties whose access was limited to low-rated plans had three or more insurers.
• Access to high-rated plans was also associated with greater health care supply: more physicians and hospital beds were available to counties with high-rated plans.
• Researchers also found that high-rated plans tended to charge higher premiums; excluding a state with only one insurer (offering only one-star plans), a one-star increase in plan rating was associated with an increase in average monthly premiums of $27.69.

Why it Matters
Quality ratings provide information about the value of health insurance available on the ACA’s marketplaces. This study suggests that on the federal marketplace, most marketplace-eligible consumers can access medium- or high-quality plans. As the authors point out, the strong correlation between market participation and access to high-rated plans suggests that increased insurer participation in marketplaces that currently have limited plan options could lead to quality improvements. On the other hand, previous research has also established that having too many plan choices, often described as “choice overload,” can make it more difficult for consumers to shop and enroll in the right plan for them. Policymakers should therefore strive to increase the availability of high-quality plans—particularly in rural areas—and improve their display on HealthCare.gov while mitigating the negative impact of too many plan options.