Munira Z. Gunja, Sara R. Collins, Michelle M. Doty, Sophie Beutel
M. Z. Gunja, S. R. Collins, M. M. Doty, and S. Beutel, Americans’ Experiences with ACA Marketplace Coverage: Affordability and Provider Network Satisfaction, The Commonwealth Fund, July 2016.
For people with low and moderate incomes, the Affordable Care Act’s tax credits have made premium costs roughly comparable to those paid by people with job-based health insurance. For those with higher incomes, the tax credits phase out, meaning that adults in marketplace plans on average have higher premium costs than those in employer plans. The law’s cost-sharing reductions are reducing deductibles. Lower-income adults in marketplace plans were less likely than higher-income adults to report having deductibles of $1,000 or more. Majorities of new marketplace enrollees and those who have changed plans since they initially obtained marketplace coverage are satisfied with the doctors participating in their plans. Overall, the majority of marketplace enrollees expressed confidence in their ability to afford care if they were to become seriously ill. This issue brief explores these and other findings from the Commonwealth Fund Affordable Care Act Tracking Survey, February–April 2016.
About 26 million Americans have health insurance through the Affordable Care Act’s coverage expansions, either through the state or federal marketplaces or through expanded eligibility for Medicaid.1 Estimates from a recent survey (The Commonwealth Fund’s Affordable Care Act Tracking Survey, conducted between February and April 2016) indicate this coverage is improving people’s ability to get health care. Sixty-one percent of respondents who were enrolled in marketplace plans or Medicaid said they would not have been able to access or afford their care before they got their new insurance.2
Using these survey data, this brief examines the costs of marketplace plans and how consumers view the affordability of their health insurance. We compare premiums and deductibles reported by marketplace enrollees with those reported by adults in employer plans and examine whether these costs have increased over time. We also investigate if enrollees are choosing plans that limit the number of providers offered (“narrow network” plans) and the level of consumers’ satisfaction with the doctors participating in their plans.
Of the 11.1 million people enrolled in marketplace plans in 2016, more than eight of 10 are paying for their premiums with the help of federal tax credits.3 The effect of these tax credits on consumers’ costs is reflected in this brief’s findings.
Among adults with single policies (i.e., those covering only themselves), those enrolled in marketplace plans reported that the amount they pay for their premiums is similar to what people with employer-based coverage pay. Fifty-seven percent of adults in marketplace plans and 60 percent in employer plans spent less than $125 per month on insurance premiums. These figures include the one of five people with either type of insurance who paid nothing (Exhibit 1).4
Most people who purchased marketplace plans were eligible for premium tax credits. Fifty-nine percent of people with marketplace coverage had incomes under 250 percent of the federal poverty level ($29,425 for an individual and $60,625 for a family of four), making them eligible for the most generous premium subsidies (Table 1). As a result, 66 percent of these adults paid less than $125 a month toward their premium, including 26 percent who paid nothing. Among people with employer coverage in this income range, 60 percent paid less than $125 per month, including 16 percent who paid nothing.
Under the ACA, adults with incomes between 250 percent and 400 percent of poverty ($29,425 to $47,080 for a single person) receive smaller tax credits for marketplace coverage, while those with incomes above 400 percent of poverty receive no tax credit and pay the full premium. In contrast, most people in employer plans, regardless of income level, receive premium contributions from their employers. Thus, among adults at 250 percent of poverty or higher, 58 percent of those with marketplace coverage spent $125 a month or more on premiums compared with only 34 percent of those in employer plans.
When we asked people their views on affordability, we limited the survey sample to respondents who paid all or part of their premium and knew the amount they paid.
Half (49%) of adults with marketplace coverage found it somewhat or very easy to afford their premium (Exhibit 2). This rate is statistically unchanged from April–June 2014, after the ACA’s first open enrollment season (data not shown).5 People with marketplace coverage—those with low as well as higher incomes—found it more difficult to afford their premiums than did people with employer coverage. Compared to other survey respondents, employer plan enrollees with higher incomes reported the easiest time affording their premiums.
Views of affordability diverge at higher income levels. This reflects the phase out of premium tax credits in marketplace plans at higher incomes and the fact that people in employer plans are much more likely to have higher incomes than are marketplace enrollees. Half (51%) of 19-to-64-year-old adults in employer plans had incomes of 400 percent of poverty or higher, compared with only 19 percent of those in marketplace plans (Table 1).
The ACA requires insurers that sell plans in the marketplaces to offer silver-level plans that come with cost-sharing reductions for adults earning between 100 percent and 250 percent of the federal poverty level. These reductions lower an individual’s deductible amount, copayments, and coinsurance, substantially so for enrollees with the lowest incomes.6 In 2016, 57 percent of marketplace enrollees are estimated to be covered by plans with these reductions.7
The effect is clear: among marketplace enrollees living under 250 percent of poverty, 30 percent said they had deductibles of $1,000 or more (Exhibit 3). But more than two-thirds (68%) of marketplace enrollees at 250 percent of poverty or more reported deductibles of $1,000 or greater. Cost-sharing reductions become less generous as income rises and are phased out completely at 250 percent of poverty. The share of adults with incomes between 138 percent and 250 percent of poverty with deductibles of $1,000 or greater was also significantly smaller than the share of adults with incomes of 250 percent of poverty or higher (45% vs. 68%) (data not shown).
Cost-sharing reductions have made deductibles similar to those incurred in employer plans for adults with lower incomes. The share of lower-income adults with high deductibles is similar in marketplace plans and in employer plans. At higher incomes, however, marketplace enrollees were significantly more likely than employer plan enrollees to have a high-deductible plan.
The survey finds evidence that the tax credits are protecting many enrollees from premium increases. Higher-income adults were much more likely to report premium increases than lower-income adults were (Exhibit 4). About two-thirds (64%) of people in marketplace plans with incomes of 250 percent of poverty or more reported their premiums had increased over the time they had their plan, compared to 45 percent of adults with lower incomes who receive the largest tax credits.
In contrast to premiums, deductibles and copayments on average were more likely to have stayed the same over the course of people’s enrollment in the marketplaces. Half (51%) of adults who had marketplace coverage since before January 2016 and whose plans had a deductible reported that their deductible amounts stayed the same, while 36 percent reported an increase and 10 percent reported a decrease (data not shown).8 These results were similar across income categories. Similarly, nearly half of adults with marketplace coverage since before January 2016 reported the amount they pay in either copayments or coinsurance for doctor visits (48%) and prescription drugs (45%) has stayed the same (data not shown). One-third (34%) of enrollees reported their copayments or coinsurance increased for doctor visits, while 29 percent reported an increase for prescription drugs.
We asked people about their confidence in their ability to afford care if they were to become seriously ill. Majorities of people with marketplace plans (61%) and employer plans (79%) were very or somewhat confident they could afford needed care if they became sick, but larger shares of those with employer plans expressed confidence (Exhibit 5).
Insurer competition in the marketplaces has led to the proliferation of health plans that offer a narrow, or limited, network of health care providers at a lower price than plans with broader networks. This has led to concerns over access to care.
In the survey, more than half (54%) of people who were enrolled in a marketplace plan for the first time or who had changed plans said they had the option of choosing a less expensive plan featuring fewer doctors or hospitals (Exhibit 6). Of those, 41 percent selected the limited network plan.
Across all marketplace plans, more than three-quarters (78%) of enrollees who either recently enrolled or had changed plans reported being very or somewhat satisfied with the doctors covered by their insurance (Exhibit 7). Among these adults, 64 percent reported their plans have some or all of the doctors they want. Sample size limitations prevented us from examining differences between people enrolled in narrow vs. broader network plans.
The proliferation of narrow network plans does not appear to be creating more problems with so-called surprise medical bills. Such bills arrive unexpectedly from an out-of-network provider, as when, for example, a patient is operated on by an in-network surgeon at an in-network hospital but is billed by an out-of-network anesthesiologist.9 We found no difference in the rate of reports of surprise bills between adults with employer coverage and adults with marketplace coverage: about one of five in both groups reported they had experienced a surprise medical bill (Exhibit 8).
Premiums and cost-sharing figured most prominently in people’s decisions regarding choice of marketplace plan (Exhibit 9). Six of 10 (62%) adults who either had enrolled in private plans through the marketplace for the first time or switched health plans said the premium amount (36%) or the amount of the deductible and copayments (26%) was the most important factor in their decision. Choice of doctors and hospitals was also important. More than one-quarter (28%) said the inclusion of their preferred provider (doctor, health clinic, or hospital) in their plan’s network was the most important factor in choosing a plan.
When asked about their experiences finding affordable plans and adequate coverage, adults’ views were the same as they were in April-to-June 2014 and March-to-May 2015 (see the Affordable Care Act Tracking Survey interactive). Low- and higher-income adults alike found it difficult to find affordable plans. This year, 42 percent of adults who visited the marketplace and whose incomes make them eligible for coverage said it was somewhat or very easy to find an affordable plan (Exhibit 10).10
Nearly half (46%) of adults with marketplace coverage since before the most recent open enrollment period said they have changed plans over the time they have had coverage.11 We asked why people had either changed or kept their plans.
Switching plans. Among adults who had changed their marketplace plans, 45 percent did so because their old plan was no longer being offered (Exhibit 11). Similar to their priorities in selecting a plan, 40 percent reported they switched plans for a lower premium, 30 percent did so for more of the doctors or hospitals they want, and 16 percent did so to obtain a lower deductible.
Keeping the same plan. Most adults (87%) reported they kept the same plan simply because it was easier to do so (Exhibit 12). About three-quarters (77%) of adults said they kept the same plan because they were satisfied with their coverage, and 64 percent did so because they liked the doctors in their network.
The affordability of marketplace plans continues to be the subject of considerable debate. A recent analysis of insurers’ 2017 rate requests in 14 large cities by the Kaiser Family Foundation finds a weighted average increase of 10 percent.12 While these preliminary requests are subject to state rate review, it is likely that premium increases will be higher in 2017 than in 2016.13
However, most consumers will be shielded from the full premium increase. More than eight of 10 marketplace enrollees have tax credits to help pay their premiums. The tax credit is calculated as the difference between what enrollees are required to pay as a share of their income and the premium of the benchmark silver plan in their market. This means that most of the premium increases next year will be absorbed by enrollees’ tax credits, particularly if they select the benchmark plan. An analysis by the U.S. Department of Health and Human Services (HHS) of 2016 premiums found that among people eligible for tax credits in marketplace plans, premiums rose by just 4 percent on average, or $4 per month, despite earlier predictions of much larger increases across plans offered in 2015.14 The large amount of plan switching found in this survey, as well as in HHS marketplace data, indicates that many people will likely shop for the best deal.
The findings present cautionary notes for policymakers. People with higher incomes with marketplace coverage who receive little to no subsidy are more likely to pay more for their premiums and have a high deductible than those in employer plans. Overall, people in marketplace plans are less likely than those in employer plans to view their plans as affordable; fewer than half of those who had shopped for a plan said it was easy to find a plan they could afford. Adjustments to the marketplaces will likely be needed to ensure that consumers can afford both the insurance and the health care they need. These could include changes to the marketplace subsidies and to the law’s premium stabilization programs—in particular, the reinsurance program—that have helped moderate premium growth in the marketplace’s first three years. However, the fundamental driver of premiums across all health insurance markets is the underlying rate of growth in medical costs. Therefore, ongoing systemwide efforts to slow the rate of increase in medical expenditures will be critical.
Table 1. Demographics of Overall Sample, Adults Enrolled in the Marketplace, and Adults Enrolled in Employer-Sponsored Insurance
(% ages 19–64)
|Enrolled in a private
health plan through
|Below 138% poverty||30||27||9|
|400% poverty or more||32||19||51|
| Fair/Poor health status, or any
chronic condition or disabilitya
|No health problem||48||52||55|
|Adult work status|
|Not working||33||32||17||Employer sizeb|
|500 or more employees||43||18||54|
a At least one of the following chronic conditions: hypertension or high blood pressure; heart disease; diabetes; asthma, emphysema, or lung disease; or high cholesterol.
b Base: full- and part-time employed adults ages 19–64.
Source: The Commonwealth Fund Affordable Care Act Tracking Survey, February–April 2016.
1 By the end of The Affordable Care Act’s third open enrollment period, marketplace plan enrollment had climbed to 11.1 million people and 15 million more people were enrolled in Medicaid compared to three years earlier. U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, March 31, 2016 Effectuated Enrollment Snapshot (CMS, June 30, 2016); U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, Medicaid & CHIP: April 2016 Monthly Applications, Eligibility Determinations and Enrollment Report (CMS, June 30, 2016).
2 S. R. Collins, M. Gunja, M. M. Doty, and S. Beutel, Americans’ Experiences with ACA Marketplace and Medicaid Coverage: Access to Care and Satisfaction (The Commonwealth Fund, May 2016).
3 The tax credits cap what people pay in premiums as a share of their income, and range from 2.03 percent to 9.66 percent for adults earning between 100 percent and 400 percent of poverty. U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, March 31, 2016 Effectuated Enrollment Snapshot (CMS, June 30, 2016).
4 A larger share of adults with employer plans (10%) did not know the amount of their premium costs than did those with marketplace plans (2%). This is likely because most people with employer health benefits receive and make premium contributions through their paychecks while those with marketplace plans shop for insurance and pay their premiums directly. Included in this response are some people who refused to answer the question.
5 In the Commonwealth Fund Affordable Care Act Tracking Survey, April–June 2014, 49 percent of adults ages 19 to 64 who paid all or some of their premiums and were aware of their premium amount found it somewhat or very easy to afford their premium costs for their health insurance.
6 S. R. Collins, M. Gunja, and S. Beutel, How Will the Affordable Care Act’s Cost-Sharing Reductions Affect Consumers’ Out-of-Pocket Costs in 2016? (The Commonwealth Fund, March 2016).
7 U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, March 31, 2016 Effectuated Enrollment Snapshot (CMS, June 30, 2016).
8 Seventy-six percent of adults ages 19 to 64 who have had marketplace coverage since before January 2016 reported their health plan has a deductible. We include adults who reported they currently do not have a deductible but have had a marketplace plan with a deductible in the past. These adults are considered to have deductibles that have decreased over the time they had marketplace coverage.
9 A 2011 survey found that 40 percent of the respondents that had used out-of-network care did so involuntarily, and a 2015 Consumers Union survey found that 30 percent of privately insured Americans received a surprise medical bill in the prior two years. K. A. Kyanko, L. A. Curry, and S. H. Busch, “Out-of-Network Physicians: How Prevalent Are Involuntary Use and Cost Transparency?” Health Services Research, June 2013 48(3):1154–72; and Surprise Medical Bills Survey, 2015 Nationally Representative Online Survey (Consumer Reports National Research Center, May 5, 2015). Recently some states have put in place measures to prevent consumers from receiving these bills. New York’s “Emergency Medical Services and Surprise Bills Law” went into effect in March 2015 and prohibits consumers in state-regulated health plans from being charged more than in-network cost-sharing for out-of-network services in both emergency and nonemergency situations. A number of other states also have limited regulations aimed at addressing surprise medical bills. See K. Pollitz, Surprise Medical Bills (Henry J. Kaiser Family Foundation, March 17, 2016); and J. Hoadley, S. Ahn, and K. Lucia, Balance Billing: How Are States Protecting Consumers from Unexpected Charges? (Robert Wood Johnson Foundation, June 2015).
10 Marketplace-eligible adults are those in Medicaid expansion states who have incomes above 138 percent of the federal poverty level and those in nonexpansion states who have incomes above 100 percent of poverty.
11 This switching rate is much higher than that in employer plans, the Federal Employees Health Benefits Program, and Medicare Part D. T. DeLeire and C. Marks, Consumer Decisions Regarding Health Plan Choices in the 2014 and 2015 Marketplaces, ASPE Issue Brief (U.S. Department of Health and Human Services, Oct. 28, 2015).
12 C. Cox, G. Claxton, L. Levitt et al., Analysis of 2017 Premium Changes and Insurer Participation in the Affordable Care Act’s Health Insurance Marketplaces (Henry J. Kaiser Family Foundation, June 15, 2016).
13 S. R. Collins, Consumer Experiences in the ACA Marketplaces, Marketplace Stability, and Remaining Challenges to Covering the Uninsured, Invited testimony, U.S. House of Representatives, Committee on Energy and Commerce, Subcommittee on Health, Hearing on “Advancing Patient Solutions of Lower Costs and Better Care,” June 10, 2016.
14 Assistant Secretary for Planning and Evaluation, Health Insurance Marketplace Premiums After Shopping, Switching, and Premium Tax Credits, 2015–2016, ASPE Issue Brief (U.S. Department of Health and Human Services, April 12, 2016).
The Commonwealth Fund Affordable Care Act (ACA) Tracking Survey, February–April 2016, was conducted by SSRS from February 2 to April 5, 2016. The survey consisted of 15-minute telephone interviews in English or Spanish, conducted among a random, nationally representative sample of 4,802 adults ages 19 to 64 living in the United States. Overall, 1,496 interviews were conducted on landline telephones and 3,306 interviews on cell phones.
This survey is the fourth in a series of Commonwealth Fund surveys to track the implementation and impact of the ACA. The first was conducted by SSRS from July 15 to September 8, 2013, by telephone among a random, nationally representative U.S. sample of 6,132 adults ages 19 to 64. The survey had an overall margin of sampling error of +/– 1.8 percentage points at the 95 percent confidence level.
The second survey in the series was conducted by SSRS from April 9 to June 2, 2014, by telephone among a random, nationally representative U.S. sample of 4,425 adults ages 19 to 64. The survey had an overall margin of sampling error of +/– 2.1 percentage points at the 95 percent confidence level. The sample for the April–June 2014 survey was designed to increase the likelihood of surveying respondents who were most likely eligible for new coverage options under the ACA. As such, respondents in the July–September 2013 survey who said they were uninsured or had individual coverage were asked if they could be recontacted for the April–June 2014 survey. SSRS also recontacted households reached through their omnibus survey of adults who were uninsured or had individual coverage prior to the first open enrollment period for 2014 marketplace coverage.
This third survey in the series was conducted by SSRS from March 9 to May 3, 2015, by telephone among a random, nationally representative U.S. sample of 4,881 adults ages 19 to 64. The March–May 2015 sample also was designed to increase the likelihood of surveying respondents who had gained coverage under the ACA. SSRS recontacted households reached through their omnibus survey of adults between November 5, 2014, and February 1, 2015, who were uninsured, had individual coverage, had a marketplace plan, or had public insurance. The survey had an overall margin of sampling error of +/– 2.1 percentage points at the 95 percent confidence level.
The February–April 2016 sample also was designed to increase the likelihood of surveying respondents who had gained coverage under the ACA. Interviews in wave 4 were obtained through two sources: stratified random-digit-dialing sample, using the same methodology as in waves 1, 2 and 3; and households reached through the SSRS omnibus survey, where interviews were previously completed with respondents ages 19 to 64 who were uninsured, had individual coverage, had a marketplace plan, or had public insurance.
As in all waves of the survey, SSRS oversampled adults with incomes under 250 percent of poverty to further increase the likelihood of surveying respondents eligible for the coverage options as well as allow separate analyses of responses of low-income households.
The data are weighted to correct for the stratified sample design, the use of recontacted respondents from the omnibus survey, the overlapping landline and cell phone sample frames, and disproportionate nonresponse that might bias results. The data are weighted to the U.S. 19-to-64 adult population by age, gender, race/ethnicity, education, household size, geographic division, and population density using the U.S. Census Bureau’s 2014 American Community Survey, and weighted by household telephone use using the U.S. Centers for Disease Control and Prevention’s 2014 National Health Interview Survey.
The resulting weighted sample is representative of the approximately 189 million U.S. adults ages 19 to 64. Data for income, and subsequently for federal poverty level, were imputed for cases with missing data, utilizing a standard regression imputation procedure. The survey has an overall margin of sampling error of +/– 2.0 percentage points at the 95 percent confidence level. The landline portion of the main-sample survey achieved a 22.6 percent response rate and the cellular phone main-sample component achieved a 13.9 percent response rate. The overall response rate, including the prescreened sample, was 13.9 percent.
The authors thank Robyn Rapoport and Arina Goyle of SSRS; and David Blumenthal, Don Moulds, Eric Schneider, Kathy Regan, Deborah Lorber, Chris Hollander, Paul Frame, Jen Wilson, David Squires, and Cornelia Hall of The Commonwealth Fund.