What GAO Found
Available survey data show that most enrollees who obtained their coverage through the health insurance exchanges were satisfied overall with their qualified health plans (QHP) during the first few years that exchanges operated, according to five national surveys of QHP enrollees that GAO identified through its literature review. Specifically, most QHP enrollees who obtained their coverage through the exchanges reported overall satisfaction with their plans in 2014 through 2016, according to three national surveys. The surveys reported that QHP enrollees' satisfaction with their plans was either somewhat lower than or was similar to that of those enrolled in employer-sponsored health insurance in 2015 and 2016. To varying degrees, QHP enrollees expressed satisfaction with specific aspects of their plan, including their coverage and choice of providers, and plan affordability. Stakeholders—including experts, state departments of insurance, and others GAO interviewed—and literature GAO reviewed also revealed some concerns about QHP enrollee experiences. Some enrollees found it too expensive to pay for their out-of-pocket expenses before reaching their deductibles and have reported concerns about affording care or have been deterred from seeking care, according to experts. Some enrollees have faced difficulties understanding their QHP's coverage terminology and others have faced problems accessing care after enrollment, according to stakeholders and literature reviewed. These issues have also been identified in literature as longstanding concerns of the private health insurance market.
The Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS), and selected states GAO reviewed have monitored enrollees' post-enrollment experiences by reviewing information reported by consumers and consumer assisters. For example, CMS uses information collected from enrollees through its Marketplace Call Center—where exchange enrollees may call to request agency assistance in resolving concerns. CMS officials said that they use this information to identify trends in enrollees' post-enrollment experiences and ensure that enrollee concerns are resolved in a timely manner. They began using it in 2016 to identify issuers for compliance reviews. Similarly, officials from the five selected states' departments of insurance reported tracking consumer complaints by issuer and working to resolve all reported issues. CMS developed a survey that was administered to a sample of QHP enrollees nationwide in 2015 and 2016, to gather information about their experiences with their plans. According to CMS officials, the agency expects to use results of its 2017 and future surveys to inform its monitoring of issuers. In addition, QHP enrollees in Vermont were surveyed with respect to their satisfaction in 2015; state officials reported using the results to inform their prioritization of work. CMS and selected states also reported monitoring enrollee experiences with information received from consumer assisters—including navigators—who interact directly with QHP enrollees. CMS officials told GAO that they have used information received from federally funded navigators to troubleshoot enrollee problems, clarify policies, or develop additional training or materials for dissemination.
HHS provided technical comments on a draft of this report, which were incorporated as appropriate.
Why GAO Did This Study
The Patient Protection and Affordable Care Act (PPACA), enacted in 2010, included provisions that were intended to make health insurance more available and affordable for individuals seeking coverage, including the establishment of health insurance exchanges. Health insurance was made available to individuals through the exchanges beginning in 2014. While PPACA contributed to an overall expansion in health insurance coverage, experts and consumer advocates have raised concerns about enrollees' experiences with QHPs, including access to providers and affordability of care.
PPACA includes a provision for GAO to conduct an examination of exchange activities and QHP enrollees. This report describes (1) what is known about enrollee experiences with QHPs obtained through the exchanges during the first years of exchange operation, and (2) how CMS and selected states have monitored the post-enrollment experiences of those who obtained their QHPs through the exchanges. GAO examined federal and state laws, regulations, and reports, and conducted a literature review to identify original research on enrollees' experiences with QHPs obtained through the exchanges. GAO interviewed officials from CMS and five selected states—Colorado, Indiana, Montana, North Carolina, and Vermont—that varied in geography and whether the state or CMS operated the exchange on which QHPs were offered, as well as officials from stakeholder groups and consumer assisters.
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