Health Policy Journal Articles

Journal Article
Kong, Edward, Mark Shepard, and Adrianna McIntyre. 2022. “Turnover in Zero-Premium Status Among Health Insurance Marketplace Plans Available to Low-Income Enrollees”. JAMA Health Forum 3 (4) : e220674-e220674. Publisher's VersionAbstract

Importance  Recent subsidy enhancements in Affordable Care Act (ACA) Marketplaces made many low-income enrolles (below 150% of the federal poverty level [FPL]) eligible for 2 free silver-tier plans. eligible for 2 free silver-tier plans. However, an unintended consequence of this structure is that the identity of which silver plans are free will often “turn over” between years, requiring that enrollees actively initiate premium payment (or lose coverage). The prevalence of this free-plan turnover is not known.

Objective  To measure the prevalence of free-plan turnover in ACA Marketplaces and to estimate how many enrollees below 150% of FPL are likely to be affected.

Design, Setting, and Participants  This observational cross-sectional study used data on plan offerings and premiums in 33 state ACA Marketplaces using in 2021 and 2022, along with estimates of county-level enrollee characteristics and plan selection patterns. The enrollment-weighted share of county markets affected by free-plan turnover was quantified, along with the association of turnover with enrollee and market characteristics. Estimates of the number of affected low-income enrollees were calculated using the data plus statistics reported in past research. Data were analyzed from November 21, 2021, to February 28, 2022.

Results  This study found that turnover of zero-premium plans was quite common, with 93% of counties (weighted by enrollment) experiencing at least 1 zero-premium plan in 2021 turning over to nonfree in 2022; 84% of counties experienced turnover of all $0 silver plans from 2021 to 2022. This turnover affected an estimated 1.36 million people with incomes below 150% of FPL. Turnover was more common in counties with a higher share of non-White enrollees, in Medicaid nonexpansion states, in counties with more carriers, and in counties with changes in the number of offered plans.

Conclusions and Relevance  The findings of this cross-sectional study suggest that owing to the prevalence of zero-premium plan turnover, many low-income ACA enrollees faced elevated risk of disenrollment at the start of 2022. Outreach to affected enrollees and other actions to encourage coverage retention and midyear reenrollment could help mitigate coverage losses.

Paper (PDF)
McIntyre, Adrianna, and Mark Shepard. 2022. “Automatic Insurance Policies — Important Tools for Preventing Coverage Loss”. New England Journal of Medicine 386 (5) : 408-411. Publisher's Version
Sommers, Benjamin D., Mark Shepard, and Katherine Hempstead. 2018. “Why Did Employer Coverage Fall In Massachusetts After The ACA? Potential Consequences Of A Changing Employer Mandate”. Health Affairs 37 (7) : 1144-52. Publisher's Version Paper
Baicker, Katherine, Mark Shepard, and Jonathan Skinner. 2013. “Public Financing Of The Medicare Program Will Make Its Uniform Structure Increasingly Costly To Sustain”. Health Affairs 32 (5) : 882-890.Abstract

The US Medicare program consumes an ever-rising share of the federal budget. Although this public spending can produce health and social benefits, raising taxes to finance it comes at the cost of slower economic growth. In this article we describe a model incorporating the benefits of public programs and the cost of tax financing. The model implies that the “one-size-fits-all” Medicare program, with everyone covered by the same insurance policy, will be increasingly difficult to sustain. We show that a Medicare program with guaranteed basic benefits and the option to purchase additional coverage could lead to more unequal health spending but slower growth in taxation, greater overall well-being, and more rapid growth of gross domestic product. Our framework highlights the key trade-offs between Medicare spending and economic prosperity.

Niall Brennan,, and Mark Shepard. 2010. “Comparing Quality of Care in the Medicare Program”. The American Journal of Managed Care 16 (11) : 841-848. Publisher's Version PDF