Geographic Variation in Plan Uptake in the Federally Facilitated Marketplace
Background
One of the central and most visible components of the Affordable Care Act is the Health Insurance Marketplace (known as the Federally Facilitated Marketplace when administered by the federal government), which provides consumers a method to enroll in non-group health insurance coverage. It is the only enrollment method where qualifying individuals can get premium- and cost-sharing subsidies. Previous research has suggested that although rural populations are more likely to be eligible for the Marketplace tax credits and cost-sharing subsidies,1 outreach and enrollment in rural areas may face barriers.2 For example, identifying potential eligibles in urban areas may be easier due to higher population density. To help monitor enrollment and inform best practices, the National Advisory Committee on Rural Health and Human Services recommended that “the Secretary evaluate the geographic efforts of year one enrollment and use that information to drive subsequent outreach, education, and enrollment efforts”.2 On September 18, 2014, the Assistant Secretary for Planning and Evaluation (ASPE) of the U.S. Department of Health and Human Services (HHS) released data showing that nearly five and a half million individuals had selected an insurance plan in the 36 states where the Federally Facilitated Marketplace was operating.3 [It is important to note that the data report plan selection counts, not enrollment, which requires an individual to pay their premium. Payment confirmation data are not available in the newly released data. For simplicity, in this brief we refer to these plan selectors as enrollees.] The data provide ZIP code-level estimates of uptake between October 1, 2013 and April 19, 2014. Data for ZIP codes with 50 or fewer enrollees are suppressed. This suppression accounts for only 4% of total enrollees (17,674 ZIP codes representing 208,384 individuals of the 5.45 million selections). Although the plan selection counts—i.e., the “numerator”—are important to understanding the impact of the program, the percent of eligible individuals that chose a plan is also important. Understanding the percent of eligible individuals who actually chose a plan—among the uninsured and those in the non-group market—can help states and communities target limited outreach and enrollment resources to the communities most in need of assistance during the next open enrollment period.