A reporter reads a summary of the performance and usage of the Massachusetts ACA health insurance exchange, Boston, November 17, 2014

commentary

(The Health Care Blog)

February 11, 2015

Open Enrollment, Take 2: What Matters for the ACA Marketplace?

A reporter reads a summary of the performance and usage of the Massachusetts ACA health insurance exchange, Boston, November 17, 2014

Photo by Brian Snyder/Reuters

by Laurie T. Martin

By the end of 2014, more than 6.5 million people were enrolled in health insurance plans through the Affordable Care Act (ACA) Marketplace, also called the “exchanges.” In some cases, this was relatively easy. But for many, the ACA's first open-enrollment period was a confusing and frustrating time, compounded by a lack of clear, easy-to-understand information about plan options, coverage, and cost.

As the second open-enrollment period draws to its February 15 close, people eligible to use the Marketplace fall into one of two groups: those who didn't enroll in 2014; and those who enrolled last year, but must re-enroll in 2015.

Current efforts are largely focused on reducing the number of uninsured. That means zeroing in on the first group: those who didn't enroll last year. Lots of time and resources are required to help these harder-to-reach individuals enroll. This may leave less time and resources to help the second group—those who enrolled last year—reconsider their 2014 choices.

Why is this an issue? Because it's not just the number of people enrolled that matters. The plan they select is important, too.

Everyone using the Marketplace should have an affordable plan that meets their needs, with accessible and respectful providers. It's also important that plans match consumers' values and expectations. If people are enrolled in plans that don't meet their needs; grant insufficient access to convenient, high-quality providers; or result in unexpected out-of-pocket costs, they're less likely to use health care at all.

Before President Barack Obama signed the ACA into law in 2010, Vice President Joe Biden remarked, “Tens of millions of Americans will be a whole lot healthier from this moment on.” While the Affordable Care Act's name implies an obvious focus, it's important to remember that affordability is intended as a means to improve population health. That won't happen if the post-ACA world is one where newly insured people don't like their plans and don't access health care.

Thus, it's imperative to start thinking about the quality of health insurance in terms of alignment between what the plan offers and individual or family needs regarding access, cost, clarity, and transparency.

Despite many more plan options being added to Marketplaces across the country, and a corresponding reduction in premiums, relatively few of the millions of people eligible to switch plans in 2015 have revisited their options.

Why is this? What actions can be taken to ensure that people know they have the right to a new choice each year? And how can stakeholders help them find the best fit? Here are three possible solutions.

Tell people they have choices. Despite the abundance of messaging about signing up for health insurance coverage, very little explicitly states that the options consumers have may change from year to year. During open enrollment, people should be told that they can change plans if they don't like the one they have or their needs have changed. They can switch plans within the same health insurance company or change companies altogether. Choice needs to be emphasized in ACA outreach to all individuals, not just those enrolling for the first time.

Focus on how and where information appears. Millions of Americans have low health literacy, meaning they struggle finding, understanding, and using health-related information to make informed decisions. Health insurance terminology is incredibly complex and difficult to understand, even for the most educated Americans. This must change. Stakeholders must find ways to present information about benefits, providers, and costs in easy-to-use ways that help people not only understand a particular plan, but how it compares to others. Though there has been progress toward this goal, continued confusion among consumers using informational materials suggests that there's plenty of room for additional improvement.

Make costs of health insurance transparent. There's a tremendous emphasis placed on the affordability of monthly premiums, but this is just one small piece of health care costs. Copayments, coinsurance, deductibles, and out-of-pocket maximums are all fancy words for money people must pay over and above the monthly premium to seek care. Figuring out what these might be is complicated. They're usually a percentage of a cost for a given service, which varies across providers. Plus, they're very difficult to find. Tools like insurance calculators, which use information people input about themselves, their family, and anticipated health needs, are a helpful first step. But finding ways to help individuals determine true out-of-pocket costs will help them find a plan that aligns with their values and expectations.

Though helping millions of Americans acquire health insurance coverage was an imperative first step to implementing the ACA, it's time to refine priorities and focus. People must use health insurance to access routine and preventive care and begin to have longer-term engagement with a provider.

Critical to this process is having health insurance coverage that allows people to do so in a way that meets their needs, preferences, financial expectations, and values. Helping those using the Marketplace understand that they have a choice each year and providing them with the information, tools, and resources to fully understand their options are critical to the ACA's success moving forward.


Laurie T. Martin is a senior policy researcher at the nonprofit, nonpartisan RAND Corporation.

This commentary originally appeared on The Health Care Blog on February 11, 2015. Commentary gives RAND researchers a platform to convey insights based on their professional expertise and often on their peer-reviewed research and analysis.