Report: Early ACA Enrollees Were Sicker Than Average

Beyond the enrollment numbers, enrollee health status has been one of the highest points of interest in regard to who has signed up on the Affordable Care Act’s  marketplaces. After all, the makeup of the insurance pools will have a heavy impact on the cost of premiums. A new report shows that those who signed up in ACA plans early in the six-month enrollment period were sicker-than-average.

Express Scripts, a pharmacy benefit management service, reports that use of specialty medications was higher among exchange enrollees versus patients enrolled in commercial health plans. Six of the top 10 costliest medications that were used by ACA enrollees were specialty drugs, compared to four in 10 of the costliest medications used by patients on commercial health plans.

Health-status is key to keeping costs low for insurance companies, and in return, consumers. If only older and sicker people were to sign up, analysts say an adverse risk “death spiral” would occur, meaning young and healthy enrollees wouldn’t be there to offset the costs of insuring older and less healthy people. This would cause premiums to spike in years to come, although insurers and experts are reporting double-digit hikes are likely to occur in 2015 due to the reform and inflation.

Express Scripts also found approximately 43% of exchange enrollees had a plan with Express Scripts in 2013, meaning 57% were uninsured or had a plan that did not provide pharmacy coverage. The proportion of pain medication was 35% higher in exchange plans versus commercial plans, while the proportion of anti-seizure medications was 27% higher in each respective plan.

Antidepressant prescription proportions were 14% higher in exchange plans than commercial plans, but the proportion of contraceptives was 31% lower in exchange plans. More than 6 in every 1,000 prescriptions in exchange plans were for HIV medications, which is four times higher than figures from commercial health plans, Express Scripts reports.

The survey looked at 650,000 de-identified pharmacy claims from January 1 through February 28 for patients enrolled in public health exchange plans under the law, versus those on commercial plans during the same period.

The ACA mandates that every insurance plan must cover 10 essential health benefits, including prescription drug costs, mental health care and ambulatory services. Customers with pre-existing conditions can no longer be discriminated against by insurers under the law. Ratios for charging older and sicker people versus younger and healthier people also dropped to three-to-one from five-to-one under the 2010 law.

The White House has reported 7.1 million Americans selected plans on both federal and state exchanges, but health-status and age have yet to be specified. The ACA mandates every individual in the country have insurance by the end of open enrollment period, which ended on March 31, or they will face a fine of $95 a year or 1% of their annual income for failing to comply.

Those who have not been able to complete enrollment have until April 15 to finish the process on Healthcare.gov.

The survey confirms what many believed about early enrollees, says Julie Huppert, Express Scripts vice president of health-care reform.

“The hypothesis was that sicker and older people would be the first in line to get coverage,” Huppert says. “Those with chronic and complex conditions would want coverage, so we aren’t surprised that the early enrollment demo skewed older.”

It still remains to be seen if younger and healthier enrollees signed up toward the second half of the enrollment period, she says. The last demographic breakdown was in mid-March, when 4.2 million enrollees were announced, and 25% were between the ages of 18 and 34, according to HHS.

But it’s important to remember that being young doesn’t necessarily mean an enrollee is healthy.

“It’s important that you hook the two together—young and healthy—but you will have some young people with chronic conditions,” Huppert says. “But way of generality, you see the assumption is always made that if you are young, you are healthy.”