Thursday, October 29, 2020

A narrow look at the broad middle of the ACA marketplace

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 This is a rather unilluminating post.  Are you still here?

I have been expecting to see more discounts in gold plans this year than in prior years, given CMS's report showing that lowest-cost gold plan premiums in 20201 are down an average of 6% from the year prior, while lowest-cost bronze and silver plans are down just 1%.  Yesterday's sampling of premiums in the 10 counties with the highest enrollment nationally offered some evidence in favor, albeit with really cheaply gold concentrated mostly in Texas' largest markets, Harris County (Houston) and Dallas.

As a followup, I took a look at middling markets -- literally: zip codes where enrollment was at the median for all 27,365 zip codes in the U.S. That is, 13 zip codes that each had 239 on-exchange enrollees. These markets are scattered through the country's broad middle (four were in Tennessee, but the plan offerings varied considerably among them). Population ranged from 3800 to 11,300.

The one consistent pattern was an increase in participating insurers -- often resulting in higher premiums for lowest-cost plans. Market watchers know that new competition is more likely to weaken discounts for subsidized enrollees than to improve them, and that's the case here (though new entrants may provide important new options where provider networks are concerned).  On average, lowest-cost bronze and silver premiums for subsidized enrollees in these markets rose from 2020 to 2021. Lowest-cost gold was all over the map, but also rose a bit.

Lowest-Cost Plans at 3 metal levels in median-enrollment counties, 2020 vs. 2021
Single 40 year-old with annual income of $24,000 (192% FPL in 2020; 188% FPL in 2021)
Benchmark (second cheapest) silver plan is $119 at this income/age in 2021

Source: Healthsherpa

The worst damage to discounts was done where monopolies or near-monopolies ended. In Dover, TN, Ambetter rode in to undercut BCBS Tennessee (United Healthcare joined in at the high end), and a monopolist's deep discount in silver (produced by a wide spread between the lowest-cost and benchmark silver premiums) disappeared, along with a steep gold discount. In Tulsa and Osage Counties in Oklahoma, too (zip code 74073 straddles both), BCBS had an effective monopoly in 2020, way underpricing Medica, and using it to create discount-generating spreads in all metal levels. New entry CommUnityCare and Medica took the low price points in 2021, reducing the discounts.

The averages are weighted, since every zip code had 239 enrollees. For 74073, I averaged the premiums in the two counties and used that composite in the overall average calculation.

As I noted in my last post, FPL rises annually with inflation, so an income of $24,518 in 2021 would be the same FPL as $24,000 in 2020. Adding that income in 2021 would increase premiums by about $6/month for a 40 year-old.  For that reason, I consider premiums drops of less than about $10/month in 2021 insignificant. 

This is a small sampling. It may not mean much. It indicates a relatively stable market, with competition increased and discounts accordingly reduced. Accent here is on "relatively": the ACA marketplace is designed to create wild swings in available discounts. That's only okay if benchmark coverage is truly affordable. For too many prospective enrollees, it's not.

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