ACA enrollees are sicker, cost more in care, according to insurer

The newest healthcare policy holders, those who purchased insurance under the Affordable Care Act, are sicker and had higher medical costs than those who already had healthcare policies, a study released Wednesday reported.

Newly Enrolled Members in the Individual Health Insurance Market After Health Care Reform,released by the Blue Cross and Blue Shield Association, showed that those who enrolled under the ACA in 2015, many who were too sick to be insured prior to the passage of the law, cost its member companies an average of 22 percent more to insure than those with employer-based coverage.

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The report noted that people newly enrolled in plans in 2014 and 2015 had higher rates of diabetes, high blood pressure, coronary artery disease, HIV and hepatitis C when compared to those in group coverage. In addition, monthly medical spending per member averaged $559 for individual enrollees, while those who are part of group coverage cost the company an average of  $457 a month.

The report drew the connection between the cost of insuring people who are sicker and recent requests for increases in premiums. The Association, which includes 36 companies, insures 105 million Americans.

The Affordable Care Act, signed into law in 2010, requires most Americans to have health care insurance either on their own or through their employer. Individuals can purchase policies through state-based health care exchanges. Employers with more than 50 employees must cover employees under a plan.

One reason the cost of covering the new insurees is higher, is that the policies must now cover all medical costs – something not required prior  to the bill’s passage six years ago.

“The findings underscore the need for all of us in the health care system, and newly insured consumers, to work together to make sure that people get the right health care service in the right care setting and at the right time,” said Alissa Fox, senior vice president of the office of policy and representation for BCBSA. “Better communication and coordination is needed so that everyone understands how to avoid unnecessary emergency room visits, make full use of primary care and preventive services and learn how to properly adhere to their medications.”

The  report also noted:

  •  Consumers who newly enrolled in BCBS individual health plans in 2014 and 2015 received significantly more medical services in their first year of coverage, on average, than those with BCBS individual plans prior to 2014.
  • The new enrollees used more medical services across all sites of care—including inpatient hospital admissions, outpatient visits, medical professional services, prescriptions filled and emergency room visits.
  • Inpatient admissions were higher by 84 percent; outpatient visits by 48 percent and medical professional services by 26 percent. New enrollees also used more medical services compared to members who received their coverage through an employer, with inpatient admissions higher by 38 percent; outpatient visits by 10 percent and medical professional services by 10 percent.
  • New enrollees filled 35 percent more prescriptions in 2015 compared to enrollees who first purchased their coverage prior to 2014 and six percent more prescriptions compared to those who received their coverage through an employer

The Blue Cross and Blue Shield Association,  which prepared the report, is made up of 36 different health insurance plans. It has  coverage in 89 percent of counties in the United States. 

The study looked at medical claims from 4.7 million individual members and 25 million employer-based group members enrolled in BCBS plans. The ages of those used in the study ranged from 21 to 64 and excluded Medicare and Medicade.

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