Newly Enrolled BCBS Members Under the ACA Needed More Care

People who enrolled in a Blue Cross Blue Shield (BCBS) health plan after enactment of the Affordable Care Act (ACA) have higher rates of disease and received significantly more medical care, on average, than those who enrolled in BCBS individual plans before 2014, according to a new study by BCBS Association.

Nationwide, BCBS companies have participated in the new ACA marketplaces more broadly than any other insurance carrier, according to BCBSA; thus, the millions of new BCBS members provide the largest single group of individuals whose health status and use of medical services can be examined to see the medical needs and costs associated with providing care.

The report, “Newly Enrolled Members in the Individual Health Insurance Market After Health Care Reform: The Experience from 2014 through 2015,” provides an in-depth look at actual medical claims among those enrolled in individual coverage before the ACA went into effect. This group of enrollees was compared with those who receive insurance through their employers, and includes adults ages 21 through 64 who purchased coverage through state-based and federally facilitated marketplaces, as well as individual, ACA-compliant policies sold outside the marketplaces (no Medicare or Medicaid recipients were included).

The major findings of the study include:

• Newly enrolled members in BCBS individual health plans in 2014 and 2015 have higher rates of diseases such as hypertension, diabetes, depression, coronary artery disease, HIV, and hepatitis C than people who had BCBS individual coverage prior to ACA enactment.
• Newly enrolled members in BCBS individual health plans in 2014 and 2015 received significantly more medical care, on average, than those with BCBS individual plans prior to 2014 who maintained BCBS individual health coverage into 2015, as well as those with BCBS employer-based group health insurance.
• New enrollees used more medical services across all sites of care, including inpatient care (higher by 84%), outpatient care (higher by 48%), services of medical professionals (higher by 26%), than enrollees who first purchased coverage before 2014. New enrollees filled 35% more prescriptions in 2015 compared with enrollees who first purchased coverage before 2014 and 6% more prescriptions than those who received coverage through an employer.
• Emergency department (ED) use among the newly enrolled population was 79% higher than that of those who enrolled during the first nine months of 2015 and slightly higher than those who receive coverage through employers.
• Medical costs of care for the new enrollees in individual markets were, on average, 19% higher than employer-based group members in 2014 and 22% higher in 2015. The average monthly medical spending per member was $559 for individual enrollees versus $457 for group members in 2015.

The findings underscore the need for healthcare providers, insurers, and newly insured people to work together to make sure that consumers get the right health care services in the right setting at the right time, said Alissa Fox, BCBSA senior vice president of the office of policy and representation.

However, given that individuals gaining access to healthcare coverage under the Affordable Care Act may be gaining coverage for the first time, it’s unsurprising they need the most care, Ben Wakana, a spokesman for the Department of Health and Human Services, told The New York Times.

In addition, the article noted, new insurance policies are often more comprehensive than individual policies sold before the ACA went into effect; for example, new policies must cover maternity care and mental health and substance abuse services. Researchers and health policy experts had predicted that people with higher medical costs would enter the market in the first few years of the public insurance exchanges, and the ACA provided special payments to insurers with unexpectedly high costs.