Plan Selection, Enrollee Risk, and Health Spending on the Patient Protection and Affordable Care Act Individual Marketplaces, 2019

Abstract

Importance: The Patient Protection and Affordable Care Act (ACA) individual marketplaces are a source of insurance for millions of residents in the US. However, the association between enrollee risk, health spending, and metal tier selection remains unclear.

Objectives: To describe individual marketplace enrollees' metal tier selections by risk score and assess enrollees' health spending by metal tier, risk score, and spending type.

Design, setting, and participants: This retrospective, cross-sectional study analyzed claims data from the Wakely Consulting Group ACA database, a deidentified claims database built on data voluntarily submitted by insurers. Enrollees with continuous, full-year enrollment in on-exchange or off-exchange ACA-qualified health plans during the 2019 contract year were included. Data analysis was conducted from March 2021 to January 2023.

Main outcomes and measures: Enrollment totals, total spending, and out-of-pocket cost were calculated, stratified by metal tier and the Department of Health and Human Services (HHS) Hierarchical Condition Category (HCC) risk score for 2019.

Results: Enrollment and claims data were obtained for 1 317 707 enrollees (53.5% female; mean [SD] age, 46.35 [13.43] years) across all census areas, age groups, and sexes. Of these, 34.6% were on plans with cost-sharing reductions (CSRs), 75.5% did not have an assigned HCC, and 84.0% submitted at least 1 claim. Compared with enrollees in bronze plans (17.2%), enrollees were more likely to be classified in the top HHS-HCC risk quartile if they selected platinum (42.0%), gold (34.4%), or silver (29.7%) plans. The highest share of enrollees with $0 total spending was noted with the catastrophic (26.4%) and bronze (22.7%) plans, while gold plans had the lowest share (8.1%). Median total spending was lower among bronze plan enrollees ($593; IQR, $28-$2100) vs platinum ($4111; IQR, $992-$15 821) or gold ($2675; IQR, $728-$9070). Within the top risk score decile, CSR enrollees had less average total spending than any other metal tier by more than 10%.

Conclusions and relevance: In this cross-sectional study of the ACA individual marketplace, enrollees who selected plans with higher actuarial value also had greater mean HHS-HCC risk scores and health spending. The findings suggest these differences may be associated with variation in benefit generosity by metal tier, enrollee's perceptions of future health needs, or other barriers to care access.

Figure 1.. Metal Tier Enrollment by the Department of Health and Human Services (HHS) Risk Score Percentile

HHS-Hierarchical Condition Category risk scores for all enrollees were calculated using the coefficients for platinum tier insurance. Data obtained from the 2019 Wakely Consulting Group Affordable Care Act database.

Figure 2.. Total Spend Amount by Risk Score Decile and Metal Tier

Department of Health and Human Services’ Hierarchical Condition Category risk scores for all enrollees were calculated using the coefficients for platinum tier insurance. Data obtained from the 2019 Wakely Consulting Group Affordable Care Act database. CSR indicates cost-sharing reduction.

Figure 3.. Difference in Mean Total Spend by Metal Tier and Risk Score Decile

For each metal tier and decile, absolute difference in total spend was calculated by subtracting the bronze mean total spend from the given metal tier’s spend. Department of Health and Human Services’ Hierarchical Condition Category risk scores for all enrollees were calculated using the coefficients for platinum tier insurance. Data obtained from the 2019 Wakely Consulting Group Affordable Care Act database. CSR indicates cost-sharing reduction.

Figure 4.. Average Out-of-Pocket (OOP) Cost by Risk Score Decile and Metal Tier

Department of Health and Human Services’ Hierarchical Condition Category risk scores for all enrollees were calculated using the coefficients for platinum tier insurance. All silver plans are aggregated; eFigure 6 in Supplement 1 provides a breakdown by CSR type. Data obtained from the 2019 Wakely Consulting Group Affordable Care Act database.