Eibner Christine, Girosi Federico, Miller Amalia, Cordova Amado, McGlynn Elizabeth A, Pace Nicholas M, Price Carter C, Vardavas Raffaele, Gresenz Carole Roan
Rand Health Q. 2011 Jun 1;1(2):7. eCollection 2011 Summer.
The Patient Protection and Affordable Care Act as amended by the Health Care and Education Reconciliation Act of 2010 (ACA) changes the regulatory environment within which health insurance policies on the small-group market are bought and sold. New regulations include rate bands that limit premium price variation, risk-adjustment policies that will transfer funds from low-actuarial-risk to high-actuarial-risk plans, and requirements that plans include "essential health benefits." While the new regulations will be applied to all non-grandfathered fully insured policies purchased by businesses with 100 or fewer workers, self-insured plans are exempt from these regulations. As a result, some firms may have a stronger incentive to offer self-insured plans after the ACA takes full effect. In this article we identify factors that influence employers' decisions to self-insure and estimate how the ACA will influence self-insurance rates. We also consider the implications of higher self-insurance rates for adverse selection in the non-self-insured small-group market and whether enrollees in self-insured plans receive different benefits than enrollees in fully-insured plans. Results are based on data analysis, literature review, findings from discussions with stakeholders, and microsimulation analysis using the COMPARE model. Overall, we find little evidence that self-insured plans differ systematically from fully insured plans in terms of benefit generosity, price, or claims denial rates. Stakeholders expressed significant concern about adverse selection in the health insurance exchanges due to regulatory exemptions for self-insured plans. However, our microsimulation analysis predicts a sizable increase in self-insurance only if comprehensive stop-loss policies become widely available after the ACA takes full effect and the expected cost of self-insuring with stop-loss is comparable to the cost of being fully insured in a market without rating regulations.
经《2010年医疗保健与教育协调法案》修订的《患者保护与平价医疗法案》（ACA）改变了小团体市场医疗保险政策的买卖监管环境。新规定包括限制保费价格变动的费率区间、将资金从低精算风险计划转移至高精算风险计划的风险调整政策，以及要求计划包含“基本健康福利”。虽然新规定将适用于由100名或更少员工的企业购买的所有非祖父条款完全承保保单，但自保计划可豁免这些规定。因此，在ACA全面生效后，一些公司可能更有动力提供自保计划。在本文中，我们确定影响雇主选择自保的因素，并估计ACA将如何影响自保率。我们还考虑了自保率上升对非自保小团体市场逆向选择的影响，以及自保计划的参保者与完全承保计划的参保者是否获得不同福利。结果基于数据分析、文献综述、与利益相关者讨论的结果以及使用COMPARE模型的微观模拟分析。总体而言，我们几乎没有发现证据表明自保计划在福利慷慨程度、价格或理赔拒绝率方面与完全承保计划存在系统性差异。利益相关者对自保计划的监管豁免导致医疗保险交易所出现逆向选择表达了重大担忧。然而，我们的微观模拟分析预测，只有在ACA全面生效后综合止损政策广泛可用，且有止损措施的自保预期成本与无费率监管市场中完全承保的成本相当的情况下，自保才会大幅增加。
