New ACA enrollees are sicker than the previously insured, analysis finds

New enrollees twice as likely to have diabetes

Enrollees in Blue Cross Blue Shield (BCBS) plans sold through the Affordable Care Act's (ACA) exchanges tended to be sicker and costlier than BCBS members with employer-sponsored coverage, according to a BlueCross BlueShield Association (BCBSA) analysis released Wednesday.

Analysis details

The analysis was based on medical claims data from 21 BCBS insurers. The analysis did not include claims from Anthem, which is BCBSA's largest insurer.

The analysis included data on about 4.7 million people enrolled in BCBS individual health plans. About one-third of those people had been continuously enrolled in the plans since 2013. The remaining consumers enrolled in BCBS exchange plans in 2014 and 2015. The analysis also included data on about 25 million individuals enrolled in BCBS employer-sponsored health plans.

Findings

The analysis found that individuals enrolled in BCBS health plans sold through the ACA's exchanges had higher rates of certain diseases and medical conditions than those enrolled in individual health plans and employer-sponsored health plans. Those ailments included:

  • Coronary artery disease;
  • Diabetes;
  • Depression;
  • Hepatitis C;
  • High blood pressure; and
  • HIV.

According to the analysis, individuals enrolled in BCBS exchange plans when compared with individuals who were enrolled in BCBS coverage prior to the ACA:

  • Were more than three times as likely to have HIV;
  • Were more than twice as likely to have Hepatitis C; and
  • Were almost twice as likely to have diabetes.

How hospitals are finding—and treating—high-risk patients

Individuals enrolled in BCBS exchange plans also used more medical services, according to the analysis. For example, the analysis found that among BCBS exchange plan enrollees:

  • Inpatient hospital admission rates were 84 percent higher when compared with individuals who had BCBS individual health plans, and 38 percent higher than those enrolled in employer-sponsored BCBS plans; and
  • Visits to outpatient centers were 48 percent higher when compared with those enrolled in BCBS individual health plans, and 10 percent higher than those enrolled in BCBS employer-sponsored health plans.

Further, the analysis found that average monthly spending per BCBS exchange plan enrollee increased by 12 percent from 2014 to 2015, from $501 to $559. In comparison, monthly spending on individuals enrolled in BCBS employer-sponsored coverage increased by 8 percent during that period, from $422 to $457.

Implications

According to the New York Times, the analysis helps explain why BCBS plans have sought significant premium rate increases for its exchange plans across the United States, as well as why insurance commissioners have approved the hikes.

ACA sign-ups: How CBO's projections have changed for the exchanges, Medicaid

Larry Levitt, a senior vice president at the Kaiser Family Foundation, says the analysis likely will inform insurers' decisions on premium increases for 2017. Insurers must submit projected premium rates in May.

Comments

An HHS spokesperson says it isn't surprising that ACA enrollees who have newly gained coverage need more health care, noting that "after years of being discriminated against, Americans with pre-existing conditions are no longer locked out of coverage because of a health condition like asthma or diabetes."

Sam Glick, a partner at Oliver Wyman, says the analysis is "making it clear the populations [BCBS insurers] are serving may be higher cost, and trying to lay some of the groundwork for rate increases and defending their tax-exempt status" (Sun, "To Your Health," Washington Post, 3/30; Wilde Mathews, Wall Street Journal, 3/30; Pear, New York Times, 3/30; Herman, Modern Healthcare, 3/30).


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