A Look at Enrollee Access to Quality Marketplace Plans

Potential ACA Marketplace enrollees largely had access to medium- and high-quality plans in 2020, with no disparities for Black and Hispanic consumers overall, according to new findings.

“In 2020 more than 8 million consumers in 38 states obtained health coverage on the federally facilitated ACA Marketplace, and another 3 million obtained coverage on state-based Marketplaces,” researchers wrote. “Although health plan quality ratings were mandated in the ACA, delays in development prevented ratings covering a national set of health plans from being made publicly available until open enrollment began for the 2020 plan year.”

A total of 35 states were included for analysis, in which 38,562 plans were offered across 2,265 counties. In 61.4% (1390) of counties, the highest-rated plans had 3 stars. According to the findings, 50.5% of enrollees lived in these counties.

Plans by insurers rated 4 or 5 stars were available to 31% (703) of counties, and 46% of enrollees had access to at least one insurer with this rating. Data indicated 7.6% (172) of counties could only access insurers with 1 or 2 stars. Of the counties that could only access low-rated plans, 73.3% were rural.

“Counties within a state or region tended to have access to plans from insurers of similar quality,” authors said. “The benchmark plan premiums and number of Marketplace insurers per county also varied predominantly across states rather than within states.”

Larger populations had better access to higher-rated insurers. Median populations of 18,100, 28,200, and 32,500 residents were linked with access to low-, medium-, and high-rated insurers, respectively.

Access to high-rated plans was also associated with a greater number of plans available in a county. There were at least 3 insurers in 65.6% of counties that could access high-rated plans but only 6.6% of counties with access to low-rated plans.

“Counties with access to high-rated plans were associated with greater health care supply,” authors added. Per 10,000 residents, there were median 25 physicians and 62 hospital beds in counties with access to high-rated plans vs 11 physicians and 43 hospital beds in counties with access to low-rated plans.

Data also indicated average monthly premiums rose $27.69 per each increase in star rating (95% CI: $26.28, $29.11, P < .001).

Authors found no disparities in access to high-rated plans in counties with greater numbers of Black and Hispanic residents.

“If counties with a higher concentration of impoverished or racial and ethnic minority customers have access only to plans from lower-rated insurers, then underlying disparities in health care access could be exacerbated,” researchers noted.

Data on quality ratings were retrieved from the plan year 2020 Nationwide Quality Rating System Public Use File and the plan year 2020 Qualified Health Plan Landscape Medical Individual Market File. The analysis excluded state-based Marketplaces using state-based platforms but included state-based Marketplaces using the federal platform. The Health Resources and Services Administration’s 2020 Area Health Resources File was used for county-level data.

Researchers noted the study did not include newer plans since plans do not receive a star rating until they have been on the Marketplace for at least 3 years. Access to high-rated plans could increase going forward, they added, since 30 insurers entered the Marketplace in the 2021 plan year.

“Taken together, these results suggest that medium- and high-rated plans are widely available on the federally facilitated ACA Marketplace, but consumers will need to consider the potential trade-offs of quality vs premium cost,” authors concluded.

Reference:
Tsai TC, Jacobson BH, Griggs D, Jha AK, Orav EJ, Epstein AM. Marketplace health insurance ratings: most potential enrollees have access to plans of medium or high quality. Health Affairs. 2022;41(3). doi:10.1377/hlthaff.2021.00922