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The Patient Protection and Affordable Care Act (PPACA) individual market enrolls sicker individuals but has lower allowed health costs than the large employer market. Small group market enrollees also had lower costs, despite varying health risks.

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Area of Science:

  • Health Economics
  • Public Health Policy
  • Insurance Market Analysis

Background:

  • The Patient Protection and Affordable Care Act (PPACA) enacted significant reforms in 2014 for individual and small group health insurance markets.
  • This study compares the reformed individual and small group markets with the established large employer market.

Purpose of the Study:

  • To analyze and compare health risk and per-member-per-month (PMPM) allowed charges across individual, small group, and large employer health insurance markets.
  • To understand cost implications within PPACA-compliant markets relative to the traditional large employer market.

Main Methods:

  • Utilized claims data from 2017 for all PPACA-compliant individual and small group market enrollees.
  • Included a sample of large employer market enrollees for comparative analysis.
  • Calculated risk scores and PMPM allowed charges, adjusting for demographic and enrollment duration differences.

Main Results:

  • Individual market enrollees exhibited 20% higher health risk than large employer market enrollees.
  • Despite higher risk, PPACA individual market enrollees had 27% lower PMPM allowed charges.
  • PPACA small group market enrollees had 3% lower health risk and 12% lower PMPM allowed charges compared to the large employer market.

Conclusions:

  • The PPACA individual market, while enrolling sicker individuals, demonstrates lower overall allowed charges than the large employer market.
  • Factors such as narrower networks and increased cost-sharing in individual plans likely contribute to reduced allowed charges.
  • Lower-income enrollees in the individual market particularly show reduced allowed charges, suggesting complex interactions between plan design, risk, and cost.