In this month’s Health Affairs, the Covered California team published some new research on how likely people who were automatically moved from strictly dominated plans to superior options were likely to stay in their new, better option:
Before the start of the 2022 renewal period, in September 2021, we queried the Covered California database and identified 4,911 households with incomes of 138–150 percent of poverty enrolled in bronze plans but eligible for zero-premium CSR silver 94 plans with their current health insurers and provider networks. In the first week of October 2021, through an automated batch process, these households were crosswalked to zero-premium CSR silver 94 plans with the same insurers and provider networks….
On average, 93.11 percent of households with incomes of 138–150 percent of poverty, and thus in the crosswalk, were enrolled in CSR silver plans at the end of open enrollment, compared with an average of 10.06 percent of households with incomes of 150–160 percent of poverty, who were in the control group. It is possible that this difference, which rounds to 83.1 percentage points, was upwardly biased as a result of some of the underlying differences between the households in the treatment and control groups in the crosswalk intervention.
This is INTERESTING!
First about 7% of enrollees opted out of the CSR-94 plan. We can’t assess if they went to a strictly dominated plan or moved to a different insurer and perhaps metal level because they preferred network over cost-sharing or premium. If that is the case, this is a reasonable trade-off in some situations.
More interestingly, the paper also examined a nudge intervention. The nudge target was slightly different so it is not apples to apples but the outcome was the same — what percentage of folks chose a CSR plan.
At the end of the 2022 open enrollment period, 8.8 percent of the control group in the nudge intervention had switched to CSR silver plans. This low rate of plan switching is consistent with prior research that documents inertia in the ACA Marketplaces.8,9 Assignment to the letter and email treatment group caused a statistically significant 2.3-percentage-point increase in CSR silver 94 plan enrollment
The nudge had statitistically signficant results. About 26% higher CSR-94 uptake than the folks who never got new information. Nudges are soft, they are subtle, and they are effective but limited. The automatic re-enrollment experiment had an 800% change in behavior relative to a non-randomized but plausible control on the other side of the CSR richness discontinuity.
In the first experiment, California took on the burden of moving people out of objectively bad choices. Once they did that, very few people took an action that went against the new default. The state had the ability to identify the likely target population. They had the ability to identify strict domination. They had the ability to make a switch. And they made it easy. And people took easy.
In the nudge, the state had the ability to identify likely better targets and switches. They provided information to individuals. But the individuals had to do something (sign-in and change plans) which made the nudge effective but only modest in its effects. The state did not take on the administrative burden.
I’ve been leery of nudges as they always seem effective small ball when cross-checking state data bases and taking on the burden of complexity can create new and better defaults in at least the most obvious cases. I think this article reinforces this prior.
gvg
Which doctors are on which plans? I can’t switch just for cost, if I can possibly afford it. Many doctors don’t take certain plans so its pointless to be on that insurance in my area even though the plan looks good. I also care which hospitals are covered by my plan. Around here, we basically have too big hospitals and the plans usually only go to one, at least for reasonable costs. It took effort to get in with a doctor that listened. He is popular and has a wait list.
It also matters about the drug plans. They want us to do mail order but allow local pharmacy at the grocery store which I find far better for me, especially when I am really sick or feeling bad.
gvg
Oh yes, and if my employer had still kept the insurer who covered me during cancer I would have stayed with them and paid higher because they were reliable and proved IMO. Well they got 20 years of premiums out of me.
trollhattan
Speaking of California, PERS has published their preliminary 2024 premiums and the rate hikes are substantial, for the second year in a row. 19% for my current PPO plan, or 11% if they phase in over two years. Whee!
Martin
So, I really like what CA is doing here. It has its challenges, but they are worthwhile challenges to accept.
A related policy, not a nudge, is the blending of MediCal with exchange plans. It’s the same application for both, and the state looks to have exchange policyholders automatically fall down to MediCal if their income drops, or to fall up to the exchange if they become ineligible for MediCal.
The state has applied to remove asset maximums for MediCal, so it will only be income based. My problem, being retired now, having the house paid off, no car in favor of my bike, etc. that even though I live in the most expensive housing market in the US, last year we *barely* stayed above the MediCal eligibility line, and the state is telling me ‘you know, if you don’t earn enough money, we’re going to move you down’. I don’t want to go down – I like my HMO. It’s the same coverage as I had as a state employee. The state has made it too easy to cross those lines. And my income is based on investments until my pension kicks in so taking $x to pay bills doesn’t necessarily mean taking $x in income. So in a few minutes I have a meeting with my financial person to explain that I need them to generate more taxable income. It’s not a problem I want the state to fix, because boo fucking hoo on me that I have to do a bit of extra work, but I really do like what they’re trying to achieve here.
Juju
I have a question about re-enrollment for those of us who had Friday Health Plans. I’ve tried to re-enroll in my market place account, but the system won’t let me and tells me I am not eligible because I am already enrolled. Should I wait a few more days and try again since I have until the end of August, or call market place or or NCDOI? I appreciate any advice, especially since your advice got me to a place where I could manage to get health insurance.