Drake Coleman, Nagy Dylan, Avina Sarah, Ludwinski Daniel, Anderson David M
Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, Pennsylvania.
Department of Economics, Oxford College of Emory University, Oxford, Georgia.
JAMA Health Forum. 2025 May 2;6(5):e251424. doi: 10.1001/jamahealthforum.2025.1424.
Millions of lower-income Health Insurance Marketplace enrollees were defaulted from zero-premium to positive-premium health plans in 2022, 2023, and 2024. This turnover in zero-premium plans may cause coverage losses by creating administrative burdens that complicate enrollees' ability to maintain coverage.
To determine how turnover affected Marketplace reenrollment.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used log-linear fixed-effects models including counties in 29 states that used the HealthCare.gov platform from 2022 through 2024.
HealthCare.gov enrollees living in a county that experienced turnover that year.
County-year-level counts of overall reenrollment, automatic and active enrollment, and active reenrollment split by whether enrollees stayed with or switched from their previous plan. We controlled for premium affordability, insurer competition, other county characteristics, and state-by-year policy changes.
The sample consisted of 2159 counties representing roughly 10 million HealthCare.gov enrollees annually in 29 states that used the HealthCare.gov platform from 2022 through 2024. The share of enrollees living in counties exposed to turnover increased from 10.3% to 93.9% from 2021 to 2022 as the American Rescue Plan Act subsidies were implemented. These increases have persisted into 2024. Turnover across insurers was associated with a 7.0% (95% CI, -12.7 to -1.3) decrease in automatic reenrollment. Any turnover was not associated with changes in active enrollment, though it was associated with a 13.4% decrease (95% CI, -17.7 to -9.1) in enrollees choosing to stay with their previous, default plan and a roughly equivalent 15.0% increase (95% CI, 11.5-18.5) in enrollees choosing to switch plans.
Turnover affects coverage losses by decreasing automatic, passive reenrollment among lower-income enrollees that may not realize they need to start paying premiums to retain coverage that previously did not have a premium. Turnover also nudges returning enrollees to select new plans rather than selecting their previous plans. This likely increases insurer price competition but also may create hassles for enrollees. These findings suggest that coverage losses from turnover in 2026 among lower-income Marketplace enrollees may be particularly large if enhanced subsidies from the Inflation Reduction Act expire.
在2022年、2023年和2024年，数以百万计的低收入医保市场参保者从零保费医保计划被默认转为正保费医保计划。零保费计划的这种更替可能会造成行政负担，使参保者维持保险覆盖的能力复杂化，从而导致保险覆盖损失。
确定更替如何影响医保市场重新参保情况。
设计、背景和参与者：这项横断面研究使用对数线性固定效应模型，纳入了2022年至2024年使用医保.gov平台的29个州的县。
当年经历了计划更替的医保.gov参保者所在的县。
按参保者是否继续选择之前的计划或更换计划划分的县年度总体重新参保、自动和主动参保以及主动重新参保的计数。我们控制了保费可承受性、保险公司竞争、其他县的特征以及逐年的州政策变化。
样本包括2159个县，代表2022年至2024年每年使用医保.gov平台的29个州中约1000万医保.gov参保者。随着《美国救援计划法案》补贴的实施，2021年至2022年，经历计划更替的县中参保者的比例从10.3%增至93.9%。这些增长一直持续到2024年。保险公司之间的更替与自动重新参保率下降7.0%（95%置信区间，-12.7至-1.3）相关。任何更替与主动参保的变化无关，不过它与选择继续使用之前默认计划的参保者减少13.4%（95%置信区间，-17.7至-9.1）以及选择更换计划的参保者增加约15.0%（95%置信区间，11.5-18.5）相关。
更替通过降低低收入参保者的自动、被动重新参保率来影响保险覆盖损失，这些参保者可能没有意识到他们需要开始支付保费以保留之前无需付费的保险覆盖。更替还促使重新参保的人选择新计划而非之前的计划。这可能会增加保险公司之间的价格竞争，但也可能给参保者带来麻烦。这些发现表明，如果《降低通胀法案》的强化补贴到期，2026年低收入医保市场参保者因计划更替导致的保险覆盖损失可能会特别大。
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