Amid the discussions of number of people who enrolled or didn’t enroll during the first open enrollment period, I remained curious about why some people enrolled and others did not. Helpfully, the organization Enroll America (EA), did a study on that http://www.enrollamerica.org/resources/public-education/why-did-some-people-enroll-and-not-others/
Some of EA’s findings seem obvious:
“There was a high demand for health insurance during the Affordable Care Act’s first open enrollment period. Those who enrolled were willing to put time and effort into the process.”
“Those who enrolled had more information. For example, the newly enrolled were more than twice as likely to know about the availability of financial help to low and moderate-income people as those who did not enroll (56% vs. 26%).”
Others are instructive. For example: “As many as 40% indicate they might not have enrolled without the mandate… Young adults were more motivated by the fine than others.” Many have suggested the mandate is not really important relative to the basic desire for insurance. I think this indicates that people generally agree with the mandate and want to support it.
Still other findings of the EA study are encouraging:
“Three-quarters (74%) of the newly enrolled feel confident they can afford their premiums.”
“Healthy people enrolled. The self-reported health status of those who enrolled and those who did not was similar.”
“Most of those who did not enroll (61%) wanted coverage.”
“The top reason why some people did not even look for coverage was the perception that they could not afford insurance.”
Health insurance premiums—though higher than any of us think they should be— turned out to be affordable for the people who did sign up. In some cases, the affordability included program subsidies. But people are getting insured. And that, after all, is the primary goal of the Affordable Care Act.
One of the major features of the Affordable Care Act (ACA) was the requirement that all insurance plans must offer the ten Essential Health Benefits (EHBs). But, what are those benefits and how do they differ from benefits before the law was passed.
I use a mnemonic to help remember what the 10 EHBs are: “PROM HELD on WEB”
|R||Rehab||rehabilitative and habilitative services and devices|
|O||Outpatient||ambulatory patient services;|
|M||Mental||mental health and substance use disorder services, including behavioral health treatment|
|D||Dental for kids||pediatric services, including oral and vision care|
|W||Wellness||preventive and wellness services and chronic disease management|
|B||Babies||maternity and newborn care|
Since passage of the Affordable Care Act (ACA), insurance companies have worked diligently to retool and tweak their offerings to accommodate the requirements and demands of the law. Some of these changes have made it more difficult to accurately compare insurance plans and benefits. One area of change health insurance consumers must be aware of is the use of “new networks.”
A provision of the ACA has the effect of limiting insurance companies spending on overhead by requiring the companies to spend at least 80% of premium revenue on “medical care and efforts to improve the quality of care.” When matched with the requirement to provide all 10 Essential Health Benefits[link] in each plan, the insurance companies look for ways to control spending.
One way to do this is by creating new provider networks that limit the doctors and hospitals included as “in-network” providers. Typically, these networks rely on providers that offer the best discounts to that insurance company. The result is a provider network that stands beside the insurer’s traditional network. Another is to make the plan an HMO design[link], to make the less-expensive network required for exclusive use by policyholders.
Given what we have, how should a consumer think about all this in choosing health insurance? Here are some ideas:
- If you are a new consumer of health insurance, none of this may matter to you. Pick a doctor from the new network and have coverage if you need an emergency room or generate big medical bills.
- If you’re facing the double-whammy of high premiums and low use of the plan (that is, you never get sick), you may be willing to give up any out-of-network doctors in exchange for lower premiums.
- If you have significant, ongoing medical costs, specialized doctors/facilities, or travel a lot, you may require the traditional type of health insurance. Happily, there are still PPOs[link] with national networks to serve these needs as well.
What’s right for you? CHB is always available to provide quotes and help with making decisions among the various plans and companies.