The typical Medicare beneficiary this year has 18 private Medicare Advantage plans and 35 stand-alone Part D drug plan options to consider, in addition to traditional Medicare. Medicare encourages seniors to make informed decisions with respect to their health coverage options when they first become eligible for Medicare, and to review these options annually so they select coverage that best meet their needs. Yet research suggests only a small share of Medicare beneficiaries voluntarily switch plans during Medicare’s open enrollment periods. This raises questions about the role of choice in Medicare: How do Medicare beneficiaries choose among coverage options? Are Medicare beneficiaries happy with their coverage or just “sticky” when it comes to plan choice? What motivates some to switch plans and why don’t others do so? What are the implications for Medicare beneficiaries, private plans, health care providers and Medicare’s future?

At 9:30 a.m. ET Tuesday, May 13, the Kaiser Family Foundation will hold a policy briefing to examine how seniors and younger Medicare beneficiaries are negotiating their Medicare Advantage and Part D coverage options and consider the implications for them and for Medicare in the future. Swarthmore College Professor Barry Schwartz, author of The Paradox of Choice and a TED conference speaker, will provide opening remarks on why Americans value choice and the effects of abundant choice for individuals and their decision-making. His remarks will be followed by perspectives from an expert panel that will focus on Medicare, comprising Joe Antos, scholar at the American Enterprise Institute; Gretchen Jacobson, associate director for Medicare policy at the Foundation; Joshua Raskin, managing director at Barclays Capital; and Judith Stein, executive director of the Center for Medicare Advocacy. Foundation Senior Vice President Tricia Neuman will moderate.

WHEN: Tuesday, May 13, 9:30 a.m. to 11:00 a.m. (Registration and breakfast at 9 a.m.)

WHERE: Barbara Jordan Conference Center, Kaiser Family Foundation Offices 1330 G Street, NW, Washington, D.C. (one block west of Metro Center)

View the archived webcast of this briefing.

KFF: for trusted information on the health issues facing the nation and its people. The Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.

New data released by the Centers for Medicare and Medicaid Services (CMS) shows that as of the end of March 2014, Medicaid and CHIP enrollment had increased by over 4.8 million people since open enrollment began for the new Health Insurance Marketplaces in October 2013. These data help provide a better understanding of how the Affordable Care Act (ACA) is impacting Medicaid enrollment, which has been a keen focus and subject of debate among the press, policymakers, and analysts. However, understanding the ACA’s impact on Medicaid enrollment remains complex given that the ACA promotes increased Medicaid enrollment in varied ways, including changes in eligibility, modernization and simplification of enrollment processes, and increased outreach and enrollment efforts. To interpret the data, it is important to understand what they represent, what they show about the impact of the ACA on Medicaid enrollment, and what questions still remain. This brief discusses the data and its interpretation to assess the influence of the ACA on Medicaid enrollment and finds:

• As of March 2014, Medicaid and CHIP enrollment grew by more than 4.8 million people compared to average monthly enrollment in the three months leading up to the start of open enrollment.
• Enrollment growth in states that have expanded Medicaid coverage to low-income adults outpaced the national average, and was significantly higher than growth in non-expanding states (12.9% vs. 2.6%).
• The recent data show very strong enrollment growth relative to historic trends, with the recent growth exceeding reported growth at the height of the most recent economic downturn.
• Overall, the data suggest that the ACA is having a positive impact on Medicaid and CHIP enrollment, particularly in states that have implemented the Medicaid expansion. However, it remains challenging to quantify and separately identify the impacts of the specific ACA policies on enrollment.
• Although enrollment gains are an important indicator of progress, ultimately the key measure of the ACA’s success in achieving its coverage goals will be a reduction in the number of uninsured.

Three main ACA changes lead to Medicaid enrollment gains.

Even though most observers remain focused on the ACA’s Medicaid expansion, the ACA strengthens and improves Medicaid in other key ways that will increase Medicaid enrollment. Overall, there are three main changes the ACA makes to eligibility and enrollment that are expected to contribute to Medicaid enrollment gains (Figure 1):

1. Medicaid expansion to low-income adults. The ACA expands Medicaid eligibility to adults with incomes at or below 138 percent of the poverty line, which is just over $16,000 per year for an individual today. Historically, Medicaid covered low-income children, pregnant women, elderly and disabled individuals, and some parents, but excluded other low-income adults. The expansion, which the Supreme Court effectively made optional for states in 2012, fills this longstanding gap in the program. To date, 27 states, including DC, are implementing the expansion and additional states may expand moving forward.¹ 
2. Modernized, simpler enrollment processes. The ACA makes it easier for people to enroll in and renew Medicaid coverage. Prior to the ACA, states had achieved varied progress in modernizing and simplifying their Medicaid enrollment processes. Under the ACA, all states must offer individuals multiple options to apply (for example, online or by mail or phone), seek to rely on electronic data instead of paper to verify information, and, in as many cases as possible, provide “real time” determinations of eligibility for coverage (Figure 2). These processes are designed to coordinate with the new Marketplaces to create a “no wrong door” enrollment system, so that regardless of whether an individual applies directly to Medicaid or through a Marketplace, he or she is enrolled in the program for which he or she is eligible. All states must implement these changes, regardless of whether a state expands Medicaid.

   

3. Increased outreach and enrollment efforts. The ACA spurred outreach and enrollment efforts to help connect eligible people to coverage. Leading up to and throughout the open enrollment period for the Marketplaces, there was significant outreach to encourage individuals to apply for coverage and an array of assistance was available to help individuals enroll. Moreover, because Medicaid enrollment is not limited to the Marketplace open enrollment period, Medicaid outreach and enrollment efforts continue year-round.

Together, these three key changes are expected to lead to increased Medicaid coverage and a reduction in the number of uninsured. In states that expand Medicaid, there will be enrollment gains among adults made newly eligible by the expansion. But, in all states, the simpler enrollment processes and broad outreach and enrollment efforts will promote increased enrollment among individuals who were already eligible for Medicaid before the ACA, but not enrolled, many of whom are children. Prior to the ACA, these individuals may not have known that coverage was available, did not think they would be eligible, or may have encountered difficulties enrolling.

Previous experience with CHIP shows that the combined effects of increased eligibility, simplified enrollment, and enhanced outreach and enrollment efforts lead to decreases in the uninsured rate for children. CHIP was created in 1997 as a complement to Medicaid. It expanded eligibility to uninsured children who were not eligible for Medicaid, led states to simplify enrollment and renewal processes for children, and spurred broad outreach and enrollment efforts. Together, the combined effects of these changes not only increased enrollment of children in both Medicaid and CHIP, but resulted in a steady decline in the uninsured rate for children. Between 1997 and 2012 the uninsured rate for children was cut in half from 14% to a record low of 7%, even as uninsured rates for adults climbed during the recent economic downturn (Figure 3).

What do CMS Medicaid enrollment data show?

CMS recently began publishing monthly reports as part of an initiative to provide data on a broad set of Medicaid and CHIP eligibility and enrollment performance indicators to inform program management and oversight.²  This type of timely data had never before been reported and is providing some of the fastest insights on national Medicaid enrollment in the program’s history. The initial monthly reports provided data on the number of applications submitted and eligibility determinations made for Medicaid and CHIP. The press and assorted experts focused on trying to tease out what share of these determinations were attributable to the ACA and, in particular, the Medicaid expansion. However, it was difficult to disentangle the impacts of the ACA given the limitations of the data. Beginning in its April 2014 report, CMS also began reporting data on total Medicaid and CHIP enrollment. The addition of this data represents progress toward the agency’s goal of reporting a broader set of performance indicators and allows for greater insight into the ACA’s impact on enrollment. To date, CMS has reported point-in-time total Medicaid enrollment as of February 2014 and March 2014, as well as average monthly enrollment data for a comparison period prior to open enrollment (July through September 2013).  However, the data are new and remain subject to gaps, inconsistencies and limitations.

The CMS data show that between the comparison period prior to open enrollment (July to September 2013) and March 2014, total Medicaid and CHIP enrollment grew by over 4.8 million people (from 58.9 to 63.7 million) among the 47 states reporting data for both periods. Nearly all of this growth occurred among the reporting states implementing the Medicaid expansion. In the states expanding Medicaid that reported data for both periods, enrollment grew by 4.2 million (from 34.1 to 38.3 million). In states that are not expanding Medicaid and that reported data for both periods enrollment grew by just over 643,000 people (from 24.7 to 25.4 million).³  This growth reflects a combination of increased enrollment among newly eligible adults in states that have implemented the Medicaid expansion and increased enrollment among previously eligible individuals in all states due to changes in enrollment processes and stronger outreach and enrollment efforts. In the non-expansion states, it is likely that most enrollment gains have been among children, given that children make up most of the eligible but not enrolled uninsured population due to the higher income eligibility levels for children and limited eligibility for adults in these states. The 4.8 million enrollment increase does not reflect the 950,000 individuals enrolled under early expansions in seven states, since most individuals enrolled in these expansions were already enrolled in Medicaid by the July-September 2013 comparison period before the ACA.⁴ 

There are wide disparities in enrollment growth between states that have already expanded Medicaid and those that have not expanded. Across the 47 states that reported data for both the period prior to open enrollment and March 2014, enrollment grew by an average of 8.2% between summer 2013 and March 2014 (Figure 4). The 22 states that had their Medicaid expansions in effect as of March 2014 and reported data for both periods experienced significantly greater enrollment growth compared to reporting states that are not expanding at this time (12.9% vs. 2.6%). Overall, 16 of the 22 reporting states that had already expanded Medicaid reported enrollment growth that exceeded 10%, including 5 that experienced growth exceeding 30%. Among expansion states, the variation in enrollment changes in part reflects differences in the size of the coverage expansion that is occurring in 2014. For example, states that previously covered many adults may see a smaller increase. Nearly all (22 of 23) states that are not expanding Medicaid and reported data for both periods had enrollment growth of less than 10%, with 7 reporting negative enrollment growth or net declines in enrollment over the period (Appendix Table 1).⁵ 

It is expected that Medicaid and CHIP enrollment will continue to grow. As noted, not all states reported enrollment data for the period and the data that were reported are preliminary and expected to increase as states finalize their data and incorporate retroactive enrollments into their enrollment counts. These enrollment adjustments will likely include some individuals determined eligible for Medicaid or CHIP by the Federally Facilitated Marketplace (FFM) who may not have had their enrollment completed due to delays in the transfers of accounts between the FFM and Medicaid and CHIP agencies. Moreover, because Medicaid and CHIP enrollment is not limited to the open enrollment period for the Marketplaces, new enrollments will continue year-round.

What have we learned from the new enrollment data?

The recent enrollment data from CMS show strong growth relative to previous enrollment trends. Earlier Medicaid and CHIP enrollment data collected and analyzed by the Kaiser Commission on Medicaid and the Uninsured for multiple years show that enrollment growth was slowing prior to the beginning of open enrollment as economic conditions continued to improve, at 1.4 million between June 2011 and 2012 and 1.0 million between June 2012 and 2013 (Figure 5).⁶  The CMS-reported enrollment gain of 4.8 million between summer 2013 and March 2014 is greater than enrollment trends at the height of the most recent economic downturn, which peaked at 3.6 million between June 2008 to 2009 and June 2009 to 2010. Although these earlier data are not directly comparable to the new CMS data because not all states reported to CMS and there are differences in data adjustments, they both similarly report monthly point-in-time enrollment. Comparing the recent enrollment change reported by CMS to earlier trends suggests that the ACA policy changes are having a positive impact on enrollment. However, it is important to recognize that additional factors may also be influencing enrollment, including seasonal fluctuations, changing economic conditions, and overall population growth.

Even with the new enrollment data, it remains challenging to quantify and separately identify the impacts of the specific ACA policies on enrollment. Although, in principle, it should be relatively easy to calculate the number of adults enrolled in the Medicaid expansion in the states that have expanded, the reality has proven challenging. Many state systems are not yet able to track enrollment in this group separately and report in real-time. Only a few states (such as Washington) have reported data on the number of people enrolling in the expansion group, and it is not possible to extrapolate from a few states to estimate the entire expansion population accurately. In addition, the CMS enrollment data are for overall enrollment and do not separately identify expansion enrollees. In the future, data on expansion enrollees will become available when states begin requesting payments for the higher federal matching rate provided for adults made newly eligible by the Medicaid expansion. It also is difficult to identify how many people are enrolling in Medicaid as a result of the new, simpler processes or as a result of the ACA’s broad outreach and enrollment efforts. Unlike the Marketplaces, Medicaid was an existing program with ongoing enrollment at the time the ACA was implemented, so separating usual enrollment changes from ACA-driven changes is complex. In contrast, the Marketplaces are entirely new entities created by the ACA, so any enrollee in the Marketplace is, by definition, new and growth in enrollment over time can be more easily measured and compared across states.

Looking Ahead

The new enrollment data reported by CMS suggest that the ACA is having a strong positive impact on Medicaid enrollment, particularly in states that have implemented the Medicaid expansion. However, ultimately the key measure of the ACA’s success will changes in the number of uninsured. Early survey findings show promising reductions in the uninsured rate to date. However, fully assessing the impact of the ACA will require monitoring changes in coverage over longer periods of time to determine changing patterns in health insurance coverage and access to care and the extent to which individuals are able to maintain continuous coverage. While waiting for these measures is challenging, they ultimately will provide the most meaningful measures of the ACA’s progress in achieving its broader coverage goals. In the meantime, the data released by CMS is expected to continue to improve and expand over time, allowing for greater analysis, and surveys like the Kaiser Survey of Low-income Americans will provide insight into low-income consumers’ experiences to provide greater understanding about the impact of the ACA on the low-income uninsured.⁷ 

1. State Health Facts, “Status of State Action on the Medicaid Expansion Decision, 2014,” Kaiser Family Foundation, http ://kff.org/medicaid/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/. ↩︎
2. See Monthly Medicaid and CHIP reports, Medicaid Moving Forward 2014, Eligibility Data http://medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/medicaid-moving-forward-2014.html#. ↩︎
3. Centers for Medicare and Medicaid Services, “Medicaid & CHIP: March 2014 Monthly Applications, Eligibility Determinations, and Enrollment Report,” May 1, 2014, http://medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/medicaid-moving-forward-2014.html#. ↩︎
4. Seven states (CA, CO, CT, DC, MN, NJ, WA) implemented an “early option” to expand Medicaid coverage to adults between April 1, 2010 and January 1, 2014, using new state plan authority provided by the ACA or a Section 1115 demonstration waiver. Some of these states previously covered some adults enrolled in these early expansions through state- or locally-funded coverage programs.  Overall, nearly 950,000 people are covered under these early expansions. Because most of these individuals were already enrolled in Medicaid by the July-September 2013 comparison period before the ACA, most of these beneficiaries are not counted as part of the 4.8 million enrollment gain. ↩︎
5. Ibid. ↩︎
6. Snyder, L., et al., “Medicaid Enrollment: June 2013 Data Snapshot,” Kaiser Family Foundation, January 29, 2014, https://modern.kff.org/report-section/medicaid-enrollment-june-2013-data-snapshot-total-enrollment/ and Smith, V., et al, “CHIP Enrollment: June 2013 Data Snapshot,” Kaiser Family Foundation, January 29, 2014, https://modern.kff.org/medicaid/issue-brief/chip-enrollment-june-2013-data-snapshot/. ↩︎
7. Garfield, R., Licata, R., and K. Young, “The Uninsured at the Starting Line: Findings from the 2013 Kaiser Survey of Low-Income Americans,” February 6, 2014, https://modern.kff.org/uninsured/report/the-uninsured-at-the-starting-line-findings-from-the-2013-kaiser-survey-of-low-income-americans-and-the-aca/. ↩︎

Despite concerns that payment changes enacted in the Affordable Care Act of 2010 (ACA) would lead to reductions in Medicare Advantage enrollment, the number and share of Medicare beneficiaries enrolling in Medicare  Advantage plans has continued to climb.  Since the enactment of the ACA, Medicare Advantage enrollment has increased by 4.6 million, or by 41 percent.  Reductions in payments enacted in the ACA aimed to reduce historical overpayments to Medicare Advantage plans and to create more equity between Medicare payments made for beneficiaries in the traditional Medicare program and those joining Medicare Advantage plans.  As of March of 2014, almost one in three (30 percent) people on Medicare (15.7 million beneficiaries) were enrolled in a Medicare Advantage plan, a 10 percent increase since March 2013.  During the past year,  Medicare Advantage enrollment has increased in virtually all states.  Most of the enrollment growth since 2013 has been in the individual market, but group enrollment in Medicare Advantage plans accounted for almost one-third (32%) of the enrollment growth in 2014 and has been a major factor in the experience of some firms.

Average monthly premiums (weighted by enrollment) have remained relatively stable since 2012 ($35 per month in 2014).   During this same period, however, average out-of-pocket spending limits have been on the rise, which could expose a subset of enrollees to higher costs – mainly those who have significant medical needs.   Medicare Advantage plans, unlike traditional Medicare, are required to limit out-of-pocket costs for services covered under Parts A and B ($3,400 is recommended; $6,700 is the maximum).   Between 2013 and 2014, the share of Medicare Advantage enrollees in plans with limits above $5,000 almost doubled, from 24 percent in 2013 to 44 percent in 2014. This Data Spotlight reviews national and state-level enrollment trends as of March 2014 and examines variation in enrollment by plan type and firm. It also analyzes the most recent data on premiums, out-of-pocket limits and prescription drug coverage in the Part D “donut hole” for Medicare Advantage enrollees.

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Introduction

Despite concerns that payment changes enacted in the Affordable Care Act of 2010 (ACA) would lead to reductions in Medicare Advantage enrollment, the number and share of Medicare beneficiaries enrolling in Medicare Advantage plans has continued to climb.¹  Since the enactment of the ACA, Medicare Advantage enrollment has increased by 4.6 million, or by 41 percent.[endnote 111939-2] Reductions in payments enacted in the ACA aimed to reduce historical overpayments to Medicare Advantage plans and to create more equity between Medicare payments made for beneficiaries in the traditional Medicare program and those joining Medicare Advantage plans. As of March of 2014, almost one in three (30 percent) people on Medicare (15.7 million beneficiaries) were enrolled in a Medicare Advantage plan, a 10 percent increase since March 2013.During the past year, Medicare Advantage enrollment has increased in virtually all states. Most of the enrollment growth since 2013 has been in the individual market, but group enrollment in Medicare Advantage plans accounted for almost one-third (32%) of the enrollment growth in 2014 and has been a major factor in the experience of some firms.

Average monthly premiums (weighted by enrollment) have remained relatively stable since 2012 ($35 per month in 2014).   During this same period, however, average out-of-pocket spending limits have been on the rise, which could expose a subset of enrollees to higher costs – mainly those who have significant medical needs.   Medicare Advantage plans, unlike traditional Medicare, are required to limit out-of-pocket costs for services covered under Parts A and B ($3,400 is recommended; $6,700 is the maximum).   Between 2013 and 2014, the share of Medicare Advantage enrollees in plans with limits above $5,000 almost doubled, from 24 percent in 2013 to 44 percent in 2014. This Data Spotlight reviews national and state-level enrollment trends as of March 2014 and examines variation in enrollment by plan type and firm. It also analyzes the most recent data on premiums, out-of-pocket limits and prescription drug coverage in the Part D “donut hole” for Medicare Advantage enrollees.

 

Issue Brief: Overall Trends In Enrollment

Nationwide Enrollment. There are 15.7 million beneficiaries – 30 percent of the Medicare population – enrolled in a Medicare Advantage plan in 2014 (Exhibit 1).²  Between 2013 and 2014, total Medicare Advantage enrollment grew by almost 1.4 million, or 9 percent; since 2010, Medicare Advantage enrollment has increased by 4.6 million beneficiaries or 41 percent from 2010 to 2014. This pattern continues the rapid growth in enrollment that occurred concurrently with the introduction of Part D (prescription drug coverage) in 2006 and other changes in the Medicare Advantage program authorized by the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003.  Medicare enrollment has continued to grow despite the fact that the average number of plans available to enrollees nationwide declined from a high of 48 plans in 2009 to 20 plans in 2012 and to 18 in 2014, as firms made changes to plans offered under their Medicare Advantage contracts.³ 

Enrollment by State. Medicare Advantage enrollment continues to vary geographically (Table 1). In 2014, as in at least the prior two years, 6 states (AK, DE, MD, NH, VT and WY) had less than 10 percent of Medicare beneficiaries in Medicare Advantage plans (Exhibit 2). In contrast 18 states (versus 15 in 2013) have 30 percent or more of their beneficiaries enrolled in Medicare Advantage plans, including 3 (MN, OR, and HI) with 40 percent or more enrolled in Medicare Advantage plans.  This variation reflects the urban origins of health maintenance organizations (HMOs) in Medicare Advantage and other factors, such as the history of managed care in the state and the prevalence of employer sponsored insurance for retirees.

Despite such variation, enrollment increased in virtually all states in 2014, with the exception of New Jersey where enrollment declined 2 percent.  Among other states, 13 states experienced a growth in enrollment of 5 percent or less   In 19 states, enrollment grew by 6-10 percent, in 9 states enrollment grew by 11-15 percent and in 7 states enrollment grew by 16 percent or more between 2013 and 2014.  Very high rates of growth (such as 56 percent in Illinois and 45 percent in North Carolina) reflect the influence of the group market, and illustrate how  a single change in coverage for an employment-based retiree group can move relatively large numbers of people within a state. Each of these states added over 100,000 group enrollees to Medicare Advantage between March 2013 and 2014.  In most other states, enrollment in group plans had a far more modest effect on the growth in Medicare Advantage enrollment.

Table 1.  Medicare Advantage Enrollment and Penetration Rate, by State, 2013-2014
State	2013 Total Enrollment	2014 Total Enrollment	Change in Total Enrollment, 2013-2014	Percent Change in Enrollment, 2013-2014	2013 Penetration Rate	2014 Penetration Rate
Total U.S.	14,361,615	15,732,081	1,370,466	10%	28%	30%
Alabama	203,951	220,640	16,689	8%	22%	24%
Alaska	N/A	N/A	N/A	N/A	N/A	N/A
Arizona	384,851	401,626	16,775	4%	38%	38%
Arkansas	98,322	107,713	9,391	10%	17%	19%
California	1,937,350	2,061,617	124,267	6%	37%	38%
Colorado	244,356	263,788	19,432	8%	35%	36%
Connecticut	137,253	146,372	9,119	7%	23%	24%
Delaware	10,941	12,623	1,682	15%	7%	7%
District of Columbia	8,654	9,714	1,060	12%	10%	11%
Florida	1,318,740	1,438,325	119,585	9%	36%	38%
Georgia	350,142	404,628	54,486	16%	25%	28%
Hawaii	103,346	108,143	4,797	5%	46%	46%
Idaho	74,871	81,440	6,569	9%	30%	33%
Illinois	209,200	326,678	117,478	56%	11%	16%
Indiana	224,875	244,970	20,095	9%	21%	22%
Iowa	74,520	77,032	2,512	3%	14%	14%
Kansas	54,329	59,018	4,689	9%	12%	13%
Kentucky	178,945	198,052	19,107	11%	22%	24%
Louisiana	193,638	213,280	19,642	10%	26%	28%
Maine	49,347	58,234	8,887	18%	17%	20%
Maryland	73,239	76,464	3,225	4%	8%	9%
Massachusetts	209,147	229,400	20,253	10%	18%	20%
Michigan	478,923	547,372	68,449	14%	27%	30%
Minnesota	415,638	448,301	32,663	8%	49%	51%
Mississippi	64,000	69,962	5,962	9%	12%	13%
Missouri	257,164	285,066	27,902	11%	24%	26%
Montana	27,229	31,125	3,896	14%	15%	17%
Nebraska	33,228	33,507	279	1%	12%	13%
Nevada	126,441	135,599	9,158	7%	32%	33%
New Hampshire	12,554	15,905	3,351	27%	5%	6%
New Jersey	223,161	219,494	-3,667	-2%	16%	15%
New Mexico	98,198	107,064	8,866	9%	29%	30%
New York	1,062,329	1,151,620	89,291	8%	33%	35%
North Carolina	328,020	475,432	147,412	45%	20%	28%
North Dakota	13,716	15,202	1,486	11%	12%	14%
Ohio	755,580	794,226	38,646	5%	37%	38%
Oklahoma	102,224	106,706	4,482	4%	16%	16%
Oregon	286,306	305,794	19,488	7%	42%	43%
Pennsylvania	939,496	971,144	31,648	3%	39%	39%
Rhode Island	68,306	70,627	2,321	3%	35%	36%
South Carolina	167,292	193,641	26,349	16%	20%	22%
South Dakota	18,781	22,242	3,461	18%	13%	15%
Tennessee	338,124	376,577	38,453	11%	29%	32%
Texas	889,551	990,399	100,848	11%	27%	29%
Utah	101,751	107,139	5,388	5%	33%	34%
Vermont	8,199	8,368	169	2%	7%	7%
Virginia	181,455	196,993	15,538	9%	15%	15%
Washington	305,289	329,087	23,798	8%	28%	29%
West Virginia	83,922	96,604	12,682	15%	21%	24%
Wisconsin	324,912	352,842	27,930	9%	33%	35%
Wyoming	1,940	1,997	57	3%	3%	3%
NOTE: Includes employer-sponsored plans, special needs plans, and other private plans.  N/A indicates too few (less than 50) enrollees to report.  Total U.S. includes Puerto Rico.SOURCE:  MPR/Kaiser Family Foundation analysis of CMS Medicare Advantage enrollment and Landscape files, 2013-2014.

 

Issue Brief: Trends In Enrollment By Plan Type

Nationwide Trends.  HMOs, which were the original form of Medicare Advantage plan, account for almost two-thirds (64 percent) of Medicare Advantage enrollment  in 2014, with 23 percent in local PPOs, 8 percent in regional PPOs, 2 percent in Private fee-for-service (PFFS) plans, and 3 percent in other types of plans (Exhibit 3).  While the HMO market share has remained relatively stable in recent years, PPOs (especially local PPOs) have replaced the PFFS product as the dominant alternative plan attracting enrollees.

• HMOs. In 2014, 10.1 million Medicare beneficiaries were enrolled in HMOs, up from 9.3 million in 2013, an 8.6 percent increase (Exhibit 4).  Nearly two-thirds of all Medicare Advantage enrollees are in an HMO in 2014 (64%), similar to each year since 2007.
• PPOs.  In 2014, nearly one-third (31%) of Medicare Advantage enrollees are in either a local or regional PPO, with significantly higher enrollment in local than regional PPOs. Local PPOs have been authorized since the Balanced Budget Act of 1997 and regional PPOs have been authorized since 2006 under the MMA of 2003. However, enrollment in PPOs of any form has been relatively limited until recent years. Between 2007 and 2014, total PPO enrollment grew from about 500,000 to 4.9 million. A key difference between an HMO and a PPO is that the latter provides enrollees with the flexibility to see providers outside of the plan’s provider network, although cost sharing associated with out-of-network providers typically is substantially higher than for providers in a plan’s network.
  • Local PPOs. Roughly three of four Medicare Advantage PPO enrollees are in a local PPO in 2014 (3.7 of 4.9 million).  Local PPOs, like HMOs, are open to beneficiaries who live in specified counties. Since 2007, enrollment among Medicare beneficiaries in local PPOs has increased from 0.4 million to 3.7 million enrollees, up from 3.1 million in 2013.
  • Regional PPOs. In contrast to the relatively rapid growth of local PPO enrollment, enrollment in regional PPOs has increased more slowly.  In 2014, 1.2 million beneficiaries were enrolled in regional PPOs, up from 1.0 million in 2013 and 0.8 million in 2010. Regional PPOs are required to serve areas defined by one or more states with a uniform benefit package across the service area. The MMA of 2003 authorized the introduction of Regional PPOs to encourage more plans to serve rural areas  Thus far, Regional PPOs have had  limited traction nationwide, although they account for a not insignificant share of the market in a small number of states (Table A1).⁴ 
• PFFS.  Enrollment in PFFS plans continued to decline in 2014, with only around 300,000 enrollees.  This is one-quarter lower than in 2013, and considerably lower than the high of 2.2 million enrolled in 2009. The decline in enrollment in PFFS plans reflects a deliberate policy change included in the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 that required PFFS plans (with some county-specific exceptions) to have networks of providers by 2011. Such provider networks, legislators believed, were critical to creating the value sought from the Medicare Advantage program. The MIPPA requirements led to a dramatic decline in the number of PFFS plans offered, some of which were offered by companies that only offered PFFS plans and may not have thought that it was in their business interest to form networks.⁵   PFFS plans were the primary alternative to HMOs from 2007 through 2009 but their role in the Medicare Advantage market has now been more than eclipsed by that of PPOs.⁶ 

Geographic Variation in Trends by Plan Type.   The distribution of Medicare Advantage enrollees, by plan type, varies across states (Table A1). HMOs  account for 90 percent or more of Medicare Advantage enrollment in three states (AZ, CA, and NV),  but less than  one-third of total enrollment in 14 states (AK, GA, IN, KY, MN, MT, ND, NH, SC, SD, VT, WV, and WY) plus the District of Columbia.   In states where HMOs are less dominant, local PPOs are most common, but in  some  states, beneficiaries tend to gravitate toward regional PPOs (SC, SD, VT),  PFFS plans (WY,ND, SD) or cost plans (MN, DC). In Florida, most enrollees are in HMOs, but the state also has the largest number of regional PPO enrollees in the nation (almost 340,000).  In Minnesota, more than 60 percent of private plan enrollees are in what is called a cost plan; Minnesota’s cost plan enrollees accounts for 58 percent of all cost plan enrollees nationwide.  Policies that affect specific plan types will therefore have a differential effect from market to market, and across states.

 

Issue Brief: Specialized Sectors Of The Market

Group Enrollment.  Most Medicare beneficiaries who enroll in Medicare Advantage plans do so as individuals, but a small share is enrolled through groups. The group market consists largely of employment-sponsored Medicare Advantage plans for retirees.  Employers that offer health benefits to Medicare-eligible retirees have the option to contract with Medicare Advantage plans to provide supplemental benefits.  Under these arrangements, the employer contracts with the Medicare Advantage insurer to provide its retirees  supplemental benefits, and Medicare pays the plan a fixed payment per enrollee to provide Medicare benefits , which is supplemented by an employer plan premium for the additional benefits.⁷ 

In 2014, 3.0 million of the 15.7 million Medicare Advantage enrollees were in a group plan (Exhibit 5 and Table A2). Of this total, 59 percent were enrolled in local PPOs and 37 percent were enrolled in HMOs.  In contrast to the individual market, PPOs account for a larger share of the group market than HMOs. The share of Medicare Advantage enrollees in group plans has never been very large, but the numbers are growing, consistent with trends in the overall Medicare Advantage market. In the recent past, group enrollment in Medicare Advantage has grown proportionately to the growth in the market overall; between 2008 and 2013, the number of group enrollees grew from 1.7 million to 2.5 million, but the relative share in the group market changed little over the time period (17.5% in 2008 versus 17.3% % in 2013).  In the past year, group enrollment increased by 17 percent (0.4 million additional enrollees), rising at a faster rate than the 7.9 percent growth rate in the individual market (0.9million additional enrollees).  Today, group enrollees account for 19 percent of the total Medicare Advantage population.

According to the Medicare Payment Advisory Commission (MedPAC), group Medicare Advantage plans typically receive higher Medicare payments and have higher bids, on average, than plans offered in the individual Medicare Advantage market.⁸   Their analysis shows that the average payment to group Medicare Advantage plans was 109 percent of traditional Medicare spending whereas the average payment to all Medicare Advantage plans was 106 percent of traditional Medicare spending.  MedPAC attributes the differences to incentives for firms in the group market to maximize Medicare revenue to offset employer costs by bidding at the benchmark, whereas firms in the individual Medicare Advantage market have an incentive to bid below the benchmark, in order to receive a rebate (a percent of the difference between the bid and the benchmark) with which they can provide extra benefits to individual plan enrollees. MedPAC has recommended changes in the way payments are made for group plans so that there is greater parity with the individual market.

The influence of employer groups on Medicare Advantage enrollment differs across the country depending on the prevalence of employers offering retiree health benefits, including public and unionized industries.⁹   States where a substantially larger share of Medicare Advantage enrollees are in group plans include West Virginia (57%), Michigan (49%), Kentucky (42%), Illinois (40%), Ohio (38%), District of Columbia (33%), and New Hampshire (33%).  In other states, group enrollment tends to account for less than one-third of total Medicare Advantage enrollment.

Special Needs Plans. Special Needs Plans (SNPs) restrict enrollment to specific types of beneficiaries with significant or relatively specialized care needs, including beneficiaries: (1) dually eligible for Medicare and Medicaid (D-SNPs); (2) requiring a nursing home or institutional level of care (I-SNPs); or (3) with severe chronic or disabling conditions (C-SNPs.)

The most SNP enrollees are in HMOs (87%), with 10 percent enrolled regional PPOs and 3 percent in local PPOs. As a share of the total Medicare Advantage population (Exhibit 6 and Table A3), enrollment in SNPs is relatively low. The 1.9 million enrollees in such plans in 2014 account for about 12 percent of total Medicare Advantage enrollment.

Most SNP enrollees (1.5 million or 82%) are in plans serving those dually eligible for Medicare and Medicaid. Such enrollment varies greatly by state, and enrollment of dually eligible beneficiaries in SNPs is particularly prevalent in four states: Hawaii (62%), Arizona (44%), Utah (35%), and Minnesota (30%).

Separately, several states (including CA, MA, MN, NY, IL, OH, SC, VA, and WA) are undertaking demonstrations with CMS to improve the financial alignment of Medicare and Medicaid for dually eligible beneficiaries.  In many states, SNPs may continue to operate separately from the demonstration, and dually eligible beneficiaries enrolled in these SNPs can remain in them.  It is not clear how the demonstration will affect the growth in D-SNP enrollment over time in these states.

 

Issue Brief: Premiums

Medicare Advantage enrollees are responsible for paying the Part B premium, in addition to any premium charged by the plan. The Medicare Advantage premium paid by enrollees reflects the difference between the plan’s costs of providing Part A and B benefits and any supplemental benefits offered, and the federal payment to the plan for the benefits.  Plans receive a percentage of the difference between their bid and the maximum federal payment (known as a rebate) and are required to use this amount to offset any extra benefits not offered by traditional Medicare, any reduced cost sharing, or the Part B premium. If Part D is part of the plan, as it is for most enrollees, the plan may also use the rebate to reduce the Part D premium.

In this brief, we analyze premiums for Medicare Advantage plans that offer prescription drug benefits (MA-PDs) because the vast majority (88%) of Medicare Advantage enrollees in individual plans is in an MA-PD.

Average Premium Trends. The average enrollee in an MA-PD paid a monthly premium of about $35 in 2014, reflecting little change since 2012, and a reduction in average premiums since 2011 ($38)  and 2010 ($43) (Exhibit 7). It is important to note, however, that the actual premium an enrollee pays varies by plan type and locale, as well as by decisions and preferences of enrollees, such as whether they are willing to pay more for a broader network or more generous benefits. Average premiums and trends in premiums paid by enrollees vary across plan types.  Enrollee premiums in 2014 averaged $27 per month for HMOs, $32 per month for regional PPOs, $59 per month for local PPOs, and $63 per month for PFFS plans.  Compared to 2013, the average HMO premium was unchanged whereas average premiums for local PPOs, regional PPOs, and PFFS plans increased by an average by $1, $3, and $11 per month, respectively.  In 2014, enrollees are generally paying lower premiums in 2014 than in 2010, mainly due to the reduction in average HMO and local PPO premiums over that period and most enrollees are in HMOs and local PPOs in 2014.

In the fall of 2013, we calculated that beneficiaries who were enrolled in Medicare Advantage plans at that time would pay a premium of $39 per month in 2014, compared to $35 per month in 2013, which assumed they remained in the same plan.¹⁰  Among Medicare Advantage enrollees in 2014, the average premium actually paid by enrollees ($35 per month) is similar to that in 2014. The difference in estimates reflects both changes in beneficiaries enrolled in Medicare Advantage from 2013 to 2014 and shifts by enrollees among plans and plan types.

Zero Premium Plans.  As in prior years, most Medicare beneficiaries (84%) had a choice of at least one MA-PD that charged no additional premium for coverage, other than the monthly Part B premium, also known as “zero premium plans”.  Many plans view such products as good ways of attracting enrollees into Medicare Advantage since they often provide more benefits than traditional Medicare and “one stop shopping” that avoids separate decisions about Part D and supplemental coverage through various Medigap options.

In 2014, 56 percent of all Medicare Advantage plan enrollees were in zero premium MA-PDs (Exhibit 8).  A larger than average share of enrollees in HMOs were enrolled in zero-premium plans (66%) while  a much smaller than average share of PFFS enrollees were enrolled in such plans (17%).  A substantially smaller share of local PPO enrollees than regional PPO enrollees were covered by a zero-premium plan (25% versus 54%).   Further analysis is needed to assess the relationship between zero-premium plans and benefit design, and factors that motivate employers to offer zero premium products in some situations and not others.¹¹ 

 

Issue Brief: Benefits

OUT OF POCKET LIMITS AND DONUT HOLE COVERAGE

In addition to analyzing premiums, we examined variations across plans and trends with respect to two types of benefits: the limit on out-of-pocket costs set by the plan and the availability of expanded Part D benefits relating to the coverage gap or “donut” hole.

Out-0f-Pocket Limits.  Although traditional Medicare does not include an annual out of pocket limit on cost sharing for Medicare A and B benefits, CMS began requiring in 2011 that all Medicare Advantage plans have a limit below $6,700 annually and recommended a limit of $3,400 or lower.  Since 2011, the share of beneficiaries in plans with limits below $3,400 has declined from 51 percent in 2011 to 33 percent in 2014 (Exhibit 9).  During this time period, the share of enrollees in plans with limits above $5,000 almost doubled, from 24 percent in 2011 to 44 percent in 2014.

Historically, HMOs have had the lowest average out of pocket limit and regional PPOs have had the highest average out of pocket limit (Exhibit 10). While this remains the case in 2014, limits have risen considerably across plans of all types.  Virtually all regional PPO enrollees (98%), 43 percent of local PPO enrollees, and 38 percent of HMO enrollees are in a plan with a limit over $5,000 annually. While limits define ultimate financial liability rather than the amount an enrollee pays, limits are important and also valuable in communicating to beneficiaries their potential maximum liability, at least for in-network Medicare-covered benefits, in the plan.

Coverage in the Part D Donut Hole.  The standard Medicare Part D benefit in 2013 has a $310 deductible and 25 percent coinsurance up to an initial coverage limit of $2,850 in total drug costs, followed by a coverage gap (the so-called “donut hole”), until their total out of pocket Part D spending reaches $4,550 when the catastrophic limit kicks in and beneficiaries pay 5 percent of specified limits for drugs. The ACA gradually reduces the coverage gap until it is eliminated in 2020. In 2014, enrollees in plans with no additional gap coverage will pay 47.5 percent of the total costs of brands and 72 percent of the total cost of generics in the gap until they reach the catastrophic limit.

Covering a larger share of beneficiaries’ out-of-pocket costs in the “coverage gap” is one way Medicare Advantage plans can enhance benefits. In 2014, about half (49%) of all Medicare Advantage enrollees were in plans that offered no additional coverage in the gap (Exhibit 11). Twenty two percent were in plans with some additional coverage for generics and 27 percent with some additional coverage for both some generics and brand name drugs. A relatively small share of enrollees in regional PPOs had any additional gap coverage (30%) compared to enrollees in HMOs (57%).  Most stand-alone Part D plans provide little or no gap coverage in 2014 beyond what is required under the standard benefit.¹² 

 

Issue Brief: Firms And Market Structure

Enrollment by Firm.  As in prior years, Medicare Advantage enrollment in 2014 tends to be highly concentrated among a small number of firms (Exhibit 12 and Table A4).  In 2014, six firms or affiliates accounted for 72 percent of the market: United Healthcare (20%), Humana (17%), Blue Cross Blue Shield (BCBS) affiliated plans (17%), Kaiser Permanente (8%), Aetna (7%), and Cigna (3%).  Another 6 national firms account for 5 percent of the market, including Wellcare, HealthNet, Universal American, Munich American Holding Corporation, and Wellpoint not affiliated with BCBS.  The remaining enrollees are in plans offered by more locally or regionally focused firms.

Firms differ in how they position themselves in the market, including the plan types they offer. As has been the case historically, almost all of Kaiser Permanente’s enrollees (94%) are in HMOs and the remainder are in similarly structured cost plans (Exhibit 13).  In contrast, United Healthcare’s enrollment is in HMOs, local PPOs, regional PPOs, and PFFS plans, in proportions that are similar with the nationwide enrollment distribution. Compared to United Healthcare, Humana and BCBS affiliated plans have a smaller share of their enrollment in HMOs (45% for each versus 62% for United Healthcare). Humana’s distribution of enrollment across plan types continues the shift from earlier years when a much larger share of Humana’s enrollees were in PFFS plans.

Each of the large national firms in the Medicare Advantage market now has a sizeable share of enrollees from group accounts. Enrollment in group plans now represents 47 percent of enrollment in Aetna, 39 percent of enrollment in Kaiser Permanente, 23 percent of enrollment in BCBS affiliated plans, 17 percent of enrollment in Humana, and 14 percent of enrollment in United Healthcare (Table A4).

Between 2013 and 2014, some firms appear to have grown their group enrollment particularly rapidly, suggesting that they had a change in employers contracting with them.  Growth in the group market accounts for all of the net growth in United Healthcare’s enrollment over the past year.  Wellpoint BCBS’s total Medicare Advantage enrollment would have declined in the absence of a large increase in group enrollment (from roughly 28,000 to 120,000). In contrast, enrollment in Kaiser Permanente’s individual plans grew more rapidly than its group enrollment.¹³   Most of the growth in Medicare Advantage enrollment is in the individual market, but enrollment through group plans increased particularly rapidly in 2014 and has been a major factor in the experience of some firms.

Market Concentration by State.   As is the case nationally, a small number of firms also dominate Medicare Advantage enrollment in most states (Exhibit 14).  In all but one state (NY), the three largest firms or affiliates account for 50 percent or more of enrollment.  In 20 states and the District of Columbia, 90 percent of enrollment or more is in the three largest plans and in 18 states, 75 percent of enrollment is in the three largest plans. Some states with highly concentrated markets (three firms accounting for at least 90 percent of enrollment) have relatively low Medicare Advantage penetration rates (AK, DE, KS, MS, MT, ND, NE, SD, VT, WY), but several other such states do not (LA, NC, NV, RI).

In 15 states and the District of Columbia, one company has more than half of total Medicare Advantage enrollment (Table A5). United Healthcare has the largest share in 19 states and is among the top three firms in an additional 19 states and the District of Columbia. Humana has the largest enrollment in 11 states and is among the top 3 in another 18 states. Plans offered by BCBS affiliates have the most enrollees in 8 states and are among the top firms in another 16 states. Kaiser Permanente’s presence is more geographically focused than other major national firms, with a heavy concentration in California, Colorado, the District of Columbia and Maryland. Kaiser Permanente has more enrollees than any other firm in California, the District of Columbia and Maryland. Locally dominant plans, that is, those with the most Medicare Advantage enrollees in their state include EmblemHealth (CT), Martin’s Point Health are (ME), Tufts Associated HMO (MA), New West (MT), Presbyterian Healthcare Services (NM), and Medica Holding Company (ND and SD).

Enrollment Across Counties with High and Low Traditional Medicare Spending.  Over the years, Congress and various Administrations have made a number of changes to payment and participation rules for private risk-bearing plans that provide Medicare benefits under contract with the federal government, now called Medicare Advantage plans.  Many of these changes have revolved around plan payment levels, seeking to balance having more plans participate with parity in payments between traditional Medicare and Medicare Advantage. The latest of these changes, which is included in the ACA, varies payment policy with the level of traditional Medicare spending in counties, grouped evenly into four quartiles by cost.  Payments to plans now depend on the relationship between their bids and the counties’ traditional Medicare spending and also are increased by any quality based bonus payments the plan may receive.  After being frozen in 2011 at 2010 levels, benchmarks (the maximum Medicare will pay a plan) are being adjusted down so that once payments are fully phased in they will range from 95 percent of traditional Medicare spending for counties in the top quartile of spending (e.g., Miami-Dade, FL) to 115 percent of traditional Medicare spending in the bottom quartile of such spending (e.g., Boise, ID).

Despite the payment changes, enrollment continues to grow across counties in each of the four quartiles of traditional Medicare spending (Table A6). Between 2013 and 2014, enrollment grew at a relatively similar rate in aggregate across in highest quartile counties (8.3%) as in the lowest quartile counties (8.7%), and higher, but not very much differently, in the two quartiles in between (10.7% and 12.3%, respectively).  In 2014, overall penetration also was not very different across quartiles (ranging from 27% to 34%). Thus, enrollment continues to grow across counties that differ in traditional Medicare spending, which is not surprising given that Medicare Advantage penetration rates have historically been high in several low cost counties (e.g., Multnomah, OR and Boise, ID) as well as high cost counties (Miami-Dade, FL and Los Angeles, CA).

 

Discussion

Medicare Advantage enrollment continues to grow despite concerns that payment rate changes incorporated in the ACA will lead to a drop in enrollment, and a significant reduction in benefits.  Enrollment trends suggest that Medicare Advantage remains an attractive option for a growing number of beneficiaries. Despite some turnover in the composition of available plans, beneficiaries continue to have many choices and the share of beneficiaries enrolled in Medicare Advantage continues to grow in virtually all states, suggesting that the market currently has sufficient choice to attract enrollees.  Our analysis also shows that premiums paid by enrollees have remained fairly flat, with the average premium ($35 per month) the same as it was in 2012 and 2013.

Looking to the future, it is not clear if or how plans will modify their offerings, nor what the effect will be for beneficiaries.  Thus far, there hasn’t been much of a change in the Medicare Advantage market, other than the increase in out-of-pocket limits and reports in the media that some insurers have scaled back provider networks.  As payment reductions continue to be phased in, insurers may reduce the extra benefits they now offer, though they will still be required to provide benefits that are at least equivalent to those that are offered under traditional Medicare, in conjunction with a limit on out-of-pocket spending.  Insurers will need to balance their interest in maintaining market share (and remain attractive to beneficiaries) against their ongoing interest in operating as profitably as possible.

Ultimately the form of both the overall Medicare program and Medicare Advantage will be shaped by the policy and fiscal climate. There are very different perspectives on the kinds of protections Medicare needs to provide for seniors and younger enrollees with disabilities, the appropriate level of Medicare spending and how to finance it, and how Medicare benefits should be provided.  This larger context, and its relevance to the long term stability of the Medicare program, warrants explicit consideration as part of the debate on Medicare Advantage payment.

Marsha Gold is a Senior Fellow Emeritus with Mathematica Policy Research;Gretchen Jacobson and Tricia Neuman are with the Kaiser Family Foundation;Anthony Damico is an independent consultant.

Endnotes

1. G. Jacobson, T. Neuman, and J. Huang, “Projecting Medicare Advantage Enrollment: Expect the Unexpected?” Kaiser Family Foundation, June 2013.  Also see Alliance for Health Reform briefing, “The Future of Medicare Advantage: Are We on the Right Path?” June 2013; available at https://modern.kff.org/medicare/event/june-10-briefing-the-future-of-medicare-advantage-are-we-on-the-right-path/ ↩︎
2. Statistics include cost and demonstration plans even though they are organized under separate authority from Medicare Advantage. Enrollment includes those in Special Needs Plans, as well as regular Medicare Advantage plans and includes those enrolled individual plans and group plans. The analysis is based on publicly available CMS data from the contract/plan/state/county enrollment file. This file excludes enrollment in counties with fewer than 11 people in a plan in a county. County-plan records without a valid FIPS county identifier were also excluded from the analysis. These small exclusions add up to about 242,640 beneficiaries or 1.5 percent of total Medicare Advantage enrollment in March 2014. ↩︎
3. M. Gold, G. Jacobson, A. Damico, and T. Neuman. u201cMedicare Advantage 2014 Data Spotlight: Plan Availability and Premiums,u201d Washington DC: Henry J. Kaiser Family Foundation, December 2013. ↩︎
4. M. Gold u201cMedicareu2019s Private Plans: A Report Card on Medicare Advantage,u201d Health Affairs Web Exclusive, November 24, 2008. ↩︎
5. u00a0 For more information on PFFS plans, see M. Gold, G. Jacobson, A. Damico, and T. Neuman. u201cMedicare Advantage 2011 Data Spotlight: Plan Availability and Premiums,u201d Washington DC: Henry J. Kaiser Family Foundation, October 2010.u00a0 J. Blum, R. Brown and M. Frieder u201cAn Examination of Medicare Private Fee For Service Plans, Washington DC: Kaiser Family Foundation, March 2007. ↩︎
6. M. Gold, u201cMedicare Advantage in 2008.u201d (Table 1: PFFS Contracts by Firm and Number of Counties Covered by the Contract, 2006-2008), Kaiser Family Foundation, June 2008. ↩︎
7. F. McArdle, T. Neuman and J. Huang.u00a0 u201cRetiree Health Benefits at the Crossroadsu201d.u00a0 Washington DC:u00a0 Henry J. Kaiser Family Foundation, April 2014. ↩︎
8. u00a0 Medicare Payment Advisory Commission u201cChapter 13. The Medicare Advantage Program: Status Reportu201d in Report to Congress: Medicare Payment Policy, Washington DC, March 2014. pp 323-349. ↩︎
9. Kaiser Family Foundation and Health Research and Education Trust, u201cSection 11. Retiree Health Benefits.u201d Employer Health Benefits: 2013 Annual Survey. Washington, DC: Kaiser Family Foundation, 2013, pp. 191-199; and P. Fronstein and N. Adams. u201cEmployment Based Retiree Health Benefits: Trends in Access and Coverage: 1997-2010.u201d EBRI Education and Research Institute, 2012. ↩︎
10. M. Gold, G. Jacobson, A. Damico, and T. Neuman. u201cMedicare Advantage 2014 Data Spotlight: Plan Availability and Premiumsu201d Washington DC: Henry J. Kaiser Family Foundation, December 2013. ↩︎
11. M. Gold and M. Hudson (2013, op site) and M. Gold, M. Hudson, G. Jacobson and T. Neuman u201c2010 Data Spotlight: Benefits and Cost Sharingu201d Washington DC: Henry J. Kaiser Family Foundation, February 2010. ↩︎
12. Kaiser Family Foundation. u201cThe Medicare Part D Prescription Drug Benefitu201d Fact Sheet. Washington DC, November 2013. ↩︎
13. M. Gold, u201cMedicare Advantage in 2008.u201d Kaiser Family Foundation, June 2008. ↩︎

A new brief from the Kaiser Family Foundation documents the continuing climb in Medicare Advantage plan enrollment, even at a time when payments to such plans are being reduced under the Affordable Care Act. Despite spending reductions enacted in the ACA to reduce historical overpayments to Medicare Advantage plans, from March 2013 to March 2014 enrollment in Medicare Advantage plans grew by 9 percent, or 1.4 million people, to reach a total of 15.7 million Medicare beneficiaries. The Medicare Advantage 2014 Spotlight: Enrollment Market Update highlights that 30 percent of the Medicare population is now enrolled in such plans, up from 24 percent in 2010, and analyzes trends in Medicare Advantage enrollment, premiums, out of pocket limits, prescription drug coverage and related topics. Other key findings include:

• Medicare Advantage enrollment continues to vary geographically. Eighteen states had more than 30 percent of Medicare beneficiaries in Medicare Advantage plans, while six states (AK, DE, MD, NH, VT and WY) had fewer than 10 percent of Medicare beneficiaries in Medicare Advantage plans;

• Since 2013, most of the enrollment growth in Medicare Advantage plans has been in the individual market, but enrollment for retirees in the group (employment-based) market increased relatively rapidly in 2014 and accounts for almost one-third of total Medicare Advantage enrollment growth in the past year;

• Premiums in Medicare Advantage plans averaged $35 per month in 2014, reflecting little change since 2012 and remaining below average premium levels in 2011 ($39) and 2010 ($44);

• Out-of-pocket spending limits have been on the rise in recent years, with the share of Medicare Advantage enrollees in plans with limits above $5,000 almost doubling from 24 percent in 2011 to 44 percent in 2014.  Medicare Advantage plans, unlike traditional Medicare, are required to limit out-of-pocket costs for services covered under Parts A and B ($3,400 is recommended; $6,700 is the maximum).

The full analysis is available online, as are the Foundation’s updated Medicare Advantage fact sheet and our latest spotlight on Medicare Advantage plan availability and premiums.

Also available is the Foundation’s newly updated interactive Medicare Health and Prescription Drug Plan Tracker, where users can monitor trends in enrollment, market penetration and other topics for Medicare Advantage plans since 1999 and stand-alone Medicare drug plans since 2006 by state, county and other sub-state geographies.

# # #

KFF: for trusted information on the health issues facing the nation and its people. The Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.

“Through Love of Self, Family and Community, Empowering Black Women to End AIDS”

Friday, July 4^th at the Ernest N. Morial Convention Center, New Orleans

MENLO PARK, CA, May 1, 2014 – Fifteen time Grammy Award-winning artist and HIV advocate Alicia Keys will join with Greater Than AIDS and ESSENCE to headline a special ESSENCE Empowerment Experience panel on Friday, July 4^th (specific time to be announced) in New Orleans on “Through Love of Self, Family and Community, Empowering Black Women to End AIDS.” 

The hour-long program will open with a one-on-one with Ms. Keys about her passion for ending AIDS to be followed by an engaging and inspiring conversation with women whose lives have been touched by HIV and how they responded.  Among those joining Ms. Keys on the stage in conversation:  Kym, a young professional who found out she was positive when her new husband became sick and died as a result of HIV/AIDS, and Teresa, a mother whose unconditional love of her HIV positive son has helped him to maintain his treatment and thrive in the face of this disease.  At the close of the program the panel will respond to questions from the audience.

The ESSENCE Empowerment Experience is part of the hugely popular ESSENCE Festival, one of the largest and most powerful gatherings in the nation. Prominent cultural icons, celebrities and community leaders convene for thought provoking conversations on health, education, politics, love and relationships, to offer solutions for the audience’s day-to-day lives. The Empowerment Experience is free to Festival attendees and the New Orleans community.

Of the more than 1.1 million people living with HIV in the United States today, one in four is a woman.  Women of color have been especially hard hit, accounting for the majority of new infections occurring among women in this country.  If current trends continue, it is estimated that one in 32 Black women will contract HIV in her lifetime.

The program is presented as part the Empowered campaign, launched in 2013 by Greater Than AIDS and featuring Ms. Keys  to reach women about HIV/AIDS and the role we all play in helping to end the epidemic. Through targeted media messages, community outreach and special promotions, the campaign promotes specific ways women are empowered in the face of HIV/AIDS, including:

•   EMPOWERED to know the facts about HIV/AIDS, including the impact of HIV on women
•   EMPOWERED to speak openly about HIV/AIDS with family, friends and others in our lives
•   EMPOWERED to protect ourselves and our loved ones
•   EMPOWERED to ask to be tested and to know doing so is an act of pride, not shame
•   EMPOWERED to live full and healthy lives and help prevent spread of disease if positive by staying on treatment

The program is organized by ESSENCE together with Greater Than AIDS co-founders, the Kaiser Family Foundation and Black AIDS Institute, and Alicia Keys Worldwide.  Gilead Sciences, Inc. contributed financial resources to support the program.

Over the three days of the ESSENCE Festival, July 4-6, in the Convention Center, Greater Than AIDS together with the Louisiana Office of Public Health and the Black AIDS Institute will provide free daily on-site HIV testing as well as a photo / video booth and other activations to bring attention to the impact of HIV.  (Greater Than AIDS Booth #1800 in Hall D.)

For more information about Greater Than AIDS and the Empowered campaign, including for more details about Alicia Keys’ appearance at the 2014 ESSENCE Empowerment Experience, visit:  www.greaterthan.org/empowered.

About the ESSENCE Festival and ESSENCE Empowerment Experience

The ESSENCE Festival has become one of the most powerful African-American gatherings as it represents not only our brightest stars but provides inspiration, purpose and enlightenment through its empowerment programming. The ESSENCE Empowerment Experience features engaging content that brings “the pages of ESSENCE to the stage” with our most prominent cultural icons, celebrities and community leaders who provide various modes of thought and solutions for our audience within our daily, themed discussion.  The free Experience has become the daytime destination of the ESSENCE Festival that has made history by having Bill Cosby, Iyanla Vanzant, Tyler Perry, Steve Harvey, Bishop TD Jakes, Soledad O’Brien, Jada Pinkett Smith, Hill Harper, Valerie Jarret, former Secretary of State Hillary Rodham Clinton, Marc Morial, and many others share the stage.

Last year, with a record-breaking audience of more than 545,000 Festival-goers, attendance at thedaily Empowerment series reached maximum capacity  for thought-provoking conversations on love and relationships, health, education, politics and our all-star inspirational Sunday Gospel tribute.  Our media partner MSNBC engaged many of our Empowerment speakers in interviews as they broadcast live from the ESSENCE Festival convention center floor throughout the weekend.

About Greater Than AIDS

Greater Than AIDS is a leading national public information response focused on the U.S. domestic epidemic. Launched in 2009 by the Kaiser Family Foundation and Black AIDS Institute, Greater Than AIDS is supported by a broad coalition of public and private sector partners.  Through targeted media messages and community outreach, Greater Than AIDS and its partners work to increase knowledge, reduce stigma and promote actions to stem the spread of the disease.  While national in scope, Greater Than AIDS focuses on communities most affected.  www.greaterthanaids.org

About Alicia Keys

Alicia Keys is a 15 time Grammy Award^® winning singer/songwriter/producer, actress, New York Times best-selling author, entrepreneur and humanitarian. Since releasing her debut album, songs in A minor, Keys has built an unparalleled repertoire of hits with over 30 million albums sold worldwide. As a philanthropist, Keys co-founded Keep a Child Alive (KCA) which provides AIDS treatment, support, nutrition and love to children and families affected by HIV/AIDS in Africa and India.

The first open enrollment period under the Affordable Care Act (ACA) has come to an end, and many are looking for ways to assess the law and its implementation thus far. Of particular interest is how many people who were previously uninsured took up new coverage options, but questions about whether people with insurance changed their type of coverage also are receiving attention. Changes in employer-based insurance are particularly important because so many people get their coverage in this way.

The ACA provides significant new coverage options for people, particularly for those with lower incomes or problems with their health. The scope of the reforms, and the intense political controversy surrounding their approach and implementation, has fueled an intense demand for data about their effectiveness. Unfortunately, the information needed to adequately understand enrollment changes across private and public coverage sources will not be available for many months.

Most of what we know about who has health insurance and what type of coverage they have comes from large federal surveys, which provide estimates of the number of people enrolled in different types of coverage, including those with no coverage, along with information about their household demographics and incomes. These surveys can be used to track changes in coverage for different types of people over time. The main advantages of these surveys are their large size and their sophisticated sampling and interviewing techniques, which allow detailed analysis of coverage and coverage changes for people in different demographic and income groups. Further, many federal surveys enable analysis at the state level for at least some states, which is important because ACA implementation (e.g., the availability of expanded Medicaid coverage or the existence of a state-operated Marketplace) will vary greatly across states. Their main disadvantage is that they do not provide rapid turnaround. The data needed to evaluate the coverage changes between 2013 and 2014 will not become available until 2015.

In the interim, people will need to look to other sources of information. One is administrative data, such as the number of people who have enrolled through new health insurance marketplaces or the number of people who have enrolled in Medicaid. A problem with this type of information is that we do not know the enrollees’ coverage status prior to enrollment: did they have insurance before and, if so, what type? It also is difficult to distinguish new enrollment from coverage changes that would have occurred in the absence of the law, since people’s job status and income change throughout the year. Also, there is currently no administrative data that covers the individual market outside of the marketplaces or any data that captures the entire employer market, so there is no information to help us understand how things are changing in the market that covers the majority of nonelderly people. And most importantly, because people without insurance are not enrolled in anything, they cannot be counted in administrative data. Administrative data can provide clues about where to look for changes, but we do not have administrative systems that provide information about changes across types of coverage or changes in the number of people without insurance.

The second interim source of information about health coverage is surveys by private entities, which ask about health insurance by type of coverage and track changes over time (or at least between a few points in time). This means that they provide some opportunity to look at changes across type of coverage as well as changes in the number of people who have any coverage. The main advantage of these surveys is their rapid turn around: indeed, several private surveys already have released findings and show that the number of people without health insurance has fallen between late 2013 and early 2014. Differences in approach and sampling mean that these surveys have different strengths and weaknesses and that their results may not be consistent or comparable.

Below we discuss the details and timing of some of the private and federal surveys that will be used to look at how coverage has changed due to the ACA. Different surveys offer different information and insight into coverage under the ACA, and we discuss the contribution and challenges in each type of effort (see Textbox 1).

1. Pascale, Joanne. “Findings from a Pretest of a New Approach to Measuring Health Insurance in the Current Population Survey.” Statistical Research Division, U.S. Census Bureau, Nov. 16, 2009. http://www.census.gov/srd/papers/pdf/rsm2009-07.pdf#page=10. ↩︎
2. Brault, Matthew; Medalia Carla; O’Hara, Brett; Rodean, Jonathan; and Steinweg, Amy. “Changing the CPS Health Insurance Questions And The Implications On The Uninsured Rate: Redesign and Production Estimates.” U.S. Census Bureau, Feb. 3, 2014. http://www.census.gov/hhes/www/hlthins/publications/sehsd_wp_2014-16.pdf. ↩︎
3. Claxton, Gary; Levitt, Larry; Damico, Anthony; and Rae, Matthew. “Data Note: How Many People Have Nongroup Health Insurance?” Kaiser Family Foundation, Jan. 3, 2014. http://modern.kff.org/private-insurance/issue-brief/how-many-people-have-nongroup-health-insurance/. ↩︎
4. “Data Note: Attempting to Measure Early Impact of the ACA through National Public Opinion Polls- A Note of Caution and What to Watch For”. Kaiser Family Foundation, Nov. 22, 2013. https://modern.kff.org/health-reform/poll-finding/data-note-measuring-aca-early-impact-through-national-polls/. ↩︎
5. Levy, Jenna. “In U.S., Uninsured Rate Lowest Since 2008.” Gallup, Inc, Apr. 7, 2014. http://www.gallup.com/poll/168248/uninsured-rate-lowest-2008.aspx. Witters, Dan. “Uninsured Rate Drops More in States Embracing Health Law.” Gallup, Inc, Apr. 16, 2014. http://www.gallup.com/poll/168539/uninsured-rates-drop-states-embracing-health-law.aspx.   Carman, Katherine and Eibner, Christine. “Survey Estimates Net Gain of 9.3 Million American Adults with Health Insurance.” The Rand Blog, Rand Corporation, Apr. 8, 2014. http://www.rand.org/blog/2014/04/survey-estimates-net-gain-of-9-3-million-american-adults.html.   Long, Sharon; Kenney, Genevieve; Zuckerman, Stephen; et al. “QuickTake: Number of Uninsured Adults Falls by 5.4 Million since 2013.” Health Reform Monitoring Survey, Urban Institute. http://hrms.urban.org/quicktakes/changeInUninsurance.html.   ↩︎
6. Levy, Jenna. “In U.S., Uninsured Rate Lowest Since 2008.” Gallup, Inc, Apr. 7, 2014. http://www.gallup.com/poll/168248/uninsured-rate-lowest-2008.aspx. ↩︎
7. For more information on HRMS and the methodology behind it, see: http://hrms.urban.org/faq.html. ↩︎
8. For more information on the RAND ALP Panel, see: https://mmicdata.rand.org/alp/index.php?page=panel. ↩︎
9. Gallup reported reductions in the percentage of adults without insurance between 4th quarter of 2013 and 1st quarter of 2014 of 1.8 percentage points (18-24, 25-34 age groups) and 1.9 percentage points (35-64 age group). See: http://www.gallup.com/poll/168248/uninsured-rate-lowest-2008.aspx. The HRMS showed a reduction in the percent of adults without health insurance between the 4th quarter of 2013 and 1st quarter of 2014 of 2.3 percentage points. See: http://hrms.urban.org/quicktakes/changeInUninsurance.html. ↩︎
10. Gallup finds that 17.1 percent of all adults, including the elderly, lacked health insurance in the 4th quarter of 2013. If there were about 240 million adults, including the elderly in 2013, the number of uninsured adults would be just over 41 million (17.1% * 240 million). Two percent of the elderly were uninsured (2% * 45 million), or 900,000, leaving about 40.1 million uninsured nonelderly adults, or about 20.6 percent of nonelderly adults. ↩︎
11. Long, Sharon; Kenney, Genevieve; Zuckerman, Stephen; et al. “QuickTake: Number of Uninsured Adults Falls by 5.4 Million since 2013.” Health Reform Monitoring Survey, Urban Institute. http://hrms.urban.org/quicktakes/changeInUninsurance.html. ↩︎
12. Levy, Jenna. “In U.S., Uninsured Rate Lowest Since 2008.” Gallup, Inc, Apr. 7, 2014. http://www.gallup.com/poll/168248/uninsured-rate-lowest-2008.aspx. ↩︎
13. Rand found an increase in the percent of adults with employer-based insurance of 8.2 percentage points between September, 2013 and March, 2014. See page 3, http://www.rand.org/content/dam/rand/pubs/research_reports/RR600/RR656/RAND_RR656.pdf.   Gallup found that the percent of adults with insurance who received their insurance through a current or former employer fell by about 2 percentage points between the 4th quarter of 2013 and the end of February, 2014. However, because the percentage of people with insurance increased over that period, the change is fairly small. See: http://www.gallup.com/poll/167798/uninsured-rate-continues-fall.aspx.   ↩︎
14. For more information on NHIS data collection procedures, see: http://www.cdc.gov/nchs/nhis/about_nhis.htm#procedures. ↩︎
15. For more information, see: http://www.cdc.gov/nchs/data/nhis/earlyrelease/microdata201403.pdf#page=8 ↩︎
16. See http://www.cdc.gov/chronicdisease/resources/publications/AAG/brfss.htm. ↩︎
17. In fact, the main health insurance question – Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare, or Indian Health Service? – does not even distinguish public from private insurance. ↩︎
18. DeNavas-Walt, Carmen; Proctor, Bernadette and Smith, Jessica. “Income, Poverty, and Health Insurance Coverage in the United States: 2012.” Current Population Reports, Sept. 2013. http://www.census.gov/prod/2013pubs/p60-245.pdf. See Table 7. ↩︎
19. DeNavas-Walt, Carmen; Proctor, Bernadette and Smith, Jessica. “Income, Poverty, and Health Insurance Coverage in the United States: 2012.” Current Population Reports, Sept. 2013. http://www.census.gov/prod/2013pubs/p60-245.pdf. ↩︎
20. The September 2014 release of the CPS will comprise a 5/8ths file using an income collection methodology consistent with prior definitions. At a later date, the remaining 3/8ths file (using a new methodology, expected to be comparable and trendable) will be released. More detail about this change can be found at: http://www.copafs.org/UserFiles/file/fcsm/H3_Semega_2013FCSM.pdf. ↩︎

On Thursday, May 15 at 9:30 a.m. ET, the Kaiser Family Foundation will host a public briefing to release a new report based on the Foundation’s most recent comprehensive survey on women’s health.  This report provides new findings that will be critical to understanding women’s early experiences with the coverage changes that are part of the Affordable Care Act, including the latest information on:

•  Private and public insurance coverage rates for women
•  Use of preventive services for women covered as a result of the ACA
•  Coverage and use of contraceptives and other reproductive health services for women
•  The impact of out of pocket costs, medical bills, and other barriers on women’s access to care

The key findings from the new survey will be presented by Usha Ranji, the Foundation’s Associate Director for Women’s Health Policy, which will be followed by a panel discussion on the ACA and challenges in improving women’s health and access to care that will be moderated by Alina Salganicoff, Ph.D, Kaiser Family Foundation Vice President and Director of Women’s Health Policy.

Discussants include:

Amy Allina, Deputy Director, National Women’s Health Network and Co-Founder, Raising Women’s VoicesVanessa Cullins, MD, MPH, MBA, Vice President, External Medical Affairs, Planned Parenthood Federation of AmericaFrancisco Garcia, MD, MPH, Director and Chief Medical Officer, Pima County Health Department, Arizona.Cara James, Ph.D, Director, Office of Minority Health, Centers for Medicare and Medicaid Services

When:

Thursday, May 15, 20149:30 a.m. -11:00 a.m. ET

 (Registration and breakfast begins at 9 a.m. ET)

Where:

Barbara Jordan Conference CenterKaiser Family Foundation Offices1330 G Street, NWWashington, D.C.(one block west of Metro Center)

View the archived webcast of this briefing

KFF: for trusted information on the health issues facing the nation and its people. The Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.

Most Common Reason for Remaining Uninsured is Not Being Able to Find an Affordable Plan; Just 7 Percent Would Rather Pay a Fine than Pay for Coverage

As the Supreme Court Considers Challenge, a Majority Supports the Law’s Requirements for Contraceptive Coverage, Including for Employers with Religious Objections

Despite the news that 8 million people have signed up for health insurance through the ACA’s new marketplace, the April Kaiser Health Tracking Poll finds no change over the past month in the public’s view of the law, with 46 percent of the public saying they have an unfavorable view and 38 percent a favorable view.

At the same time, nearly six in ten (58%) say they want their representative in Congress to work to improve the law, compared to just over a third (35%) who want them to work on repealing it and replacing it with something else.  While there are clear partisan divisions on this question, about three in ten Republicans agree with the majority, preferring that Congress work to improve the law.

In spite of the late surge that pushed marketplace enrollment above the Congressional Budget Office’s initial projections, nearly six in ten people (57%)  say that the number of people signing up for coverage fell short of the government’s expectations.  The same share (57%) also says “there have been so many problems since the law’s rollout that it’s clear the law is not working as planned.”  As expected, Republicans are far more likely to say the law is still not working than Democrats, with independents in the middle.  Among Democrats, though, about a third believes the law is still not working.

The poll also asked people who remain uninsured to choose the main reason they haven’t gotten coverage this year after being told or reminded of the law’s requirement for individuals to get coverage or pay a fine.  More than a third (36%) say they tried to get coverage but it was too expensive. Smaller shares say they don’t think the requirement applies to them personally (14%), they didn’t know about the law’s requirement to get coverage (13%), and they tried to get coverage but were unable (12%). Few (7%) say they would rather pay the fine than buy insurance.

With the Supreme Court weighing challenges to the ACA’s requirement that private health plans cover prescription birth control without cost-sharing, the latest Kaiser Health Tracking Poll finds that, in general, the public supports the requirement by a nearly 2-to-1 margin (61% support, 32% oppose). Women, younger adults, Democrats and independents are the groups most likely to support the requirement, while seniors are split and a majority of Republicans are opposed.

Asked more specifically about for-profit companies whose owners have religious objections to birth control, a majority (55%) feels these companies should still be required to cover birth control.  This includes nearly three quarters of Democrats, a majority of independents and a third of Republicans.

This month’s Kaiser Health Policy News Index finds that just over half the public (53%) says they closely followed news coverage of the ACA enrollment numbers, and more than four in ten (44%) report closely following the Supreme Court contraceptive coverage case.

The survey was designed and analyzed by public opinion researchers at the Kaiser Family Foundation and was conducted from April 15-21 among a nationally representative random digit dial telephone sample of 1,504 adults ages 18 and older. Telephone interviews conducted by landline (750) and cell phone (754) were carried out in English and Spanish. The margin of sampling error for the full sample is plus or minus 3 percentage points. For results based on subgroups, the margin of sampling error may be higher.

A new Kaiser Family Foundation brief explores the U.S. government’s efforts to address the health and human rights of lesbian, gay, bisexual and transgender (LGBT) individuals around the world. LGBT individuals continue to face stigma, discrimination, and violence, both within and outside of the health sector, and in many countries — including those in which the U.S. provides global health assistance — these barriers include discriminatory laws and policies. Recent actions by several countries to further criminalize LGBT individuals have raised the stakes in the conversation and introduced a greater sense of urgency, yet many questions and challenges remain about the best way forward.

The U.S. Government and Global LGBT Health: Opportunities and Challenges in the Current Era summarizes two roundtable discussions convened by the Foundation, which identified opportunities, challenges, and potential next steps for the U.S. government to consider on LGBT health.  It also provides an overview of global LGBT health issues, and reviews U.S. government efforts to address global LGBT health to date.

Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.