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ACA Individual Market Share by Metal Level
The ACA standardized an approach to quantifying plans’ benefit value by placing plan designs into actuarial value (AV) metal levels, with bronze plans having the lowest AV (60 percent), followed by silver (70 percent), gold (80 percent), and platinum (90 percent). A plan’s AV is the expected average percentage of claims that will be covered by a plan and is largely a function of its cost-sharing parameters (generally, deductible, coinsurance, and copayments). As demonstrated by the figure, enrollees who do not receive cost-sharing reduction (CSR) assistance have shifted enrollment to bronze plans over time.
CSR enrollees were removed from this comparison as they overwhelmingly choose silver plans in order to receive CSR benefits, which significantly reduce plan deductibles, cost-sharing amounts, and out-of-pocket limits. Generally, non-CSR enrollees are those in households with income above twice the poverty level.
After 2017, bronze plans have been by far the most common plan chosen by these enrollees. The percentage of silver plan enrollees has decreased dramatically as insurers significantly increased silver plan premiums after CSR defunding—which is discussed in It’s Not Just the Prices. Gold plans are also relatively more affordable than silver plans after silver loading, which is why the percentage of enrollees with gold plans has increased since 2017 as well, now exceeding the number of non-CSR enrollees in silver plans. Platinum coverage was relatively low in 2014 but has all but disappeared.
As comparison, in the employer market, 84 percent of employees have single-coverage deductibles that are less than $3,000, while 54 percent of non-CSR enrollees in the individual market are enrolled in bronze plans, which typically have single-coverage deductibles higher than $6,000.
ACA Individual Market Share by Network Type
The generosity of health insurance networks can be measured in terms of type and breadth. The type of network ranges from a health maintenance organization (HMO), which is generally more restrictive in terms of which providers are covered, to a preferred provider organization (PPO), which allows access to all providers but incentivizes using in-network providers. The breadth of network is usually differentiated between the number of physicians or medical groups that are in-network and by the included facilities.
This week’s Paragon Pic, from a forthcoming Paragon research paper, maps the market share by type of network from 2014 to 2023, illustrating that individual market enrollment has shifted toward plans that include fewer providers and facilities in their networks. In 2014, 50 percent of individual market consumers were in PPO and point-of-service (POS) plans. By 2023, that percentage had declined to 17 percent. In 2023, 83 percent of enrollees were in the more restrictive HMOs or exclusive provider organizations (EPOs).Show More
SOURCE: Paragon
