Consumer Cost-Sharing in Marketplace vs. Employer Health Insurance Plans, 2015

Area of Science:

• Health Economics
• Public Health Policy
• Insurance Markets

Background:

• The Patient Protection and Affordable Care Act established state and federal health insurance exchanges (marketplaces).
• Understanding cost-sharing structures is crucial for evaluating plan affordability and accessibility for individuals and families.
• Changes in cost-sharing can significantly impact out-of-pocket expenses for health insurance enrollees.

Purpose of the Study:

• To analyze changes in cost-sharing for individual and family health plans offered through U.S. health insurance marketplaces between 2014 and 2015.
• To compare cost-sharing levels in marketplace plans with those in employer-based insurance plans.
• To assess the prevalence and impact of cost-sharing reductions (CSRs) for marketplace enrollees.

Main Methods:

• Analysis of cost-sharing data from 49 states and Washington, D.C., for marketplace plans (2014-2015).
• Examination of eight cost-sharing components: deductibles, copayments, coinsurance, and out-of-pocket maximums.
• Comparative analysis against cost-sharing metrics of employer-sponsored health insurance plans.

Main Results:

• Cost-sharing for marketplace plans remained largely stable from 2014 to 2015.
• In 2015, 56% of marketplace enrollees qualified for and received cost-sharing reductions.
• Enrollees without CSRs faced significantly higher average copayments, deductibles, and out-of-pocket limits in catastrophic, bronze, and silver plans compared to employer-based plans.
• Gold-tier marketplace plans exhibited cost-sharing comparable to employer-based plans.
• Marketplace plans were substantially more likely than employer plans to require deductibles for prescription drug coverage.

Conclusions:

• Marketplace cost-sharing remained stable between 2014 and 2015, with stable premiums not indicating increased enrollee costs.
• Cost-sharing reductions significantly benefited a majority of marketplace enrollees, mitigating higher out-of-pocket expenses.
• Individuals without CSRs, particularly those in lower-tier plans, faced greater financial burdens compared to those with employer-sponsored insurance, highlighting potential affordability gaps.