Little wins to improve outcomes

Yesterday, the Centers for Medicare and Medicaid Services(CMS) released the annual Healthcare.gov Public Use Files (PUFs).  I use these PUFs all the time for my research and will be processing them over the next week or so.  I want to highlight one of the PUFs as it had three new columns this year.  The Plan ID Crosswalk PUF tells us how CMS moves current 2023 enrollees to 2024 plans.  Traditionally, the schematic is that CMS will move folks to their identical plan first and then to plans that look as much like the 2023 plan as possible if there is no exact match.  It does not incorporate any consideration for an individual being placed in a dominated or likely to be dominated plan.  Even with these movements, people are totally and fully free to pick another plan or to stop coverage entirely!

You should actively choose plans each year!!!!

However, this year, there are three new fields in the PUF.

Those three fields are designed to improve the quality of plan choice. CMS changed the algorithm.  Individuals who purchased a Bronze plan but are eligible for a Silver plan with Cost Sharing Reduction from the same insurer and network for the same or lower premium will be moved to the Silver plan.

CMS finalizes changes to allow Marketplaces to modify their automatic re-enrollment hierarchies such that enrollees who are eligible for cost-sharing reductions (CSRs) and are currently enrolled in a bronze level QHP, and who would otherwise be automatically re-enrolled in a bronze-level QHP, are instead automatically re-enrolled in a silver-level QHP (with CSRs) in the same product with the same provider network and with a premium after the application of APTC that is lower or equivalent to the premium of the bronze level QHP into which the enrollee would have otherwise been re-enrolled

This is a big deal.

And this is a fast policy change.

In January 2021 as the outlines of  the American Rescue Plan Act (ARPA) were being put together, I was chatting with my frequent co-authors Drs. Coleman Drake and Petra Rasmussen.  Petra and I were working on a dominated plan choice paper where we found automatic re-enrollment placed a lot of people into strictly dominated plans in California.  Coleman and I were part of a team looking at how zero premium plan proliferation changes enrollment and choice behavior in Colorado.  A big chunk of ARPA was to increase premium subsidies for the ACA at all income levels.  We quickly realized two things.  First, a tremendous number of people would be newly exposed to zero premium plans.  Secondly, a lot of people were facing a policy shock, that if nothing happened, would lead them to be automatically re-enrolled into dominated plans.

So we wrote!  We wrote an analysis in JAMA Health Forums using  California enrollment data to simulate automatic re-enrollment policies. We defined strict domination as the situation when someone’s current plan has both more cost-sharing and the same or higher premiums than another option from the same insurer with the same plan type (HMO vs PPO etc) on the same network ID.  We found that this was about half Bronze to Silver CSR plans and half other:

CMS is taking action on the Bronze to CSR.  We estimated in California that 2.5% of all enrollees would benefit from this switch.  And this switch is substantial as the premiums would be the same but deductibles would decrease from $6,300 for a single individual with a Bronze plan to $0 for a CSR 94 or CSR 87 (<200 FPL) Silver plan in 2024.  This is real money.  Actual savings for individuals would be less as most people don’t use a ton of services that this would substantially reduce a cost based barrier to care for lower income enrollees.

This policy change came into play within 2.5 years after CMS was aware that their automatic re-enrollment system was systemically placing some people into a massively dominated and expensive mistake.  I’m celebrating three new fields in a public use file as a win.