Insurance Exchanges

Approximately 14.1 million previously uninsured Americans gained health insurance between the beginning of open enrollment in October 2013 and March 4, 2015. Some of the greatest declines in uninsured rates were for lower- and middle-income consumers, including those eligible for tax credits to help pay their premiums for plans in the health insurance marketplaces. But simply having health insurance is no guarantee that consumers can afford to pay for health care. Unfortunately, this study shows that, for many Americans with non-group coverage, deductibles and other out-of-pocket costs are prohibitively high, and are associated with many of these insured consumers forgoing needed health care.

The ACA created the Small Business Health Options Program (SHOP) Marketplaces to help small businesses provide health insurance to their employees. This study compares the numbers of carriers and plans and premium levels in 2014 for plans offered through SHOP Marketplaces with those of plans offered only outside of the Marketplaces. An average of 4.3 carriers participated in each state’s Marketplace, offering a total of forty-seven plans. Premiums for plans offered through SHOP Marketplaces were, on average, 7 percent less than those in the same metal tier offered only outside of the Marketplaces. Lower premiums and the participation of multiple carriers in most states are a source of optimism for future enrollment growth in SHOP Marketplaces. Lack of broker buy-in in many states and burdensome enrollment processes are major impediments to success.

To develop this dataset, researchers collecting data simulated a typical shopping experience on healthcare.gov. The dataset captures 25 design aspects of the marketplace websites, which include, but are not limited to, whether websites ask for pregnancy and disability status and whether consumers can view quality ratings for certain plans. This dataset is featured in the data brief entitled, "Window Shopping on Healthcare.gov and the State-Based Marketplaces: More Consumer Support is Needed."

People may purchase subsidized health insurance through the ACA exchanges with premiums based on projected future income. However, if actual income is higher than estimated, they may be required to repay part or all of the subsidy when they file tax returns. This "reconciliation" process could raise taxes substantially for many ACA participants. However, analysis of income tax return data suggests that for most lower-income filers, the reconciliation will reduce the refund they receive rather than require them to remit additional tax because their refunds exceed the reconciliation amount. This paper also includes a discussion of ways in which the reconciliation process could be improved.