When the new health insurance exchanges opened for business one year ago, whether they would succeed was a matter of fervent debate. Who would sign up? Would they know how to use their insurance? And would a flood of seriously ill patients overwhelm insurers, sending premiums skyrocketing and dooming the new law?
Two new studies are beginning to answer some of these questions by looking at prescription drugs, one of the most common ways that people use their health insurance.
Among the main findings of both studies: Those who signed up for coverage through the exchanges were more likely to be treated for serious conditions like H.I.V. and hepatitis C compared with people who were insured through their employers. They tended to be older, although one of the studies, by the pharmacy-benefits manager Express Scripts, found that larger numbers of young and healthy people signed up as the March 31 enrollment deadline approached. More broadly, those who signed up through the exchanges filled prescriptions at about the same rate as people who had employer coverage.
Both studies show the new members of the exchange plans are eagerly using their coverage. “They are getting out there and they are accessing it — they are going to their doctor and they are filling medications,” said Julie Huppert, vice president for health care reform at Express Scripts, which examined a national sample of five million drug claims made by exchange-plan members between January and July of this year. Express Scripts, which administers the prescription-drug benefit for about 30 percent of exchange plan members, plans to release its findings on Wednesday. “That is great news for patients, as well as for the insurance carriers.”
Insurers, policy experts and others are intensely interested in the health of those who are insured through the exchanges because it may help predict whether the new system will prosper or fail. If people who sign up for insurance under the Affordable Care Act are sicker than expected — as many feared they would be — their expensive medical bills could lead to higher premiums and ultimately doom the law.
Some of the studies’ findings show that many of those who signed up did, indeed, have serious medical conditions. “We originally suggested this may be a sicker population,” said Michael Showalter, chief marketing officer at Prime Therapeutics, another pharmacy-benefits manager, which has about 17 percent of the exchange market and recently conducted a similar analysis of drug claims. “What I can tell you officially today is that this really is a sicker population.”
But while the Express Scripts study also found that exchange enrollees tended to be sicker, insurers are not spending more on them for drug coverage. Because patients in these plans are being asked to pay more out-of-pocket, insurers are actually spending 10 percent less on drugs for members enrolled through the exchanges, or an average of $59.83 a month, than for members they cover through employer plans. Insurers pay an average of $66.80 a month for those members.
Clare Krusing, a spokeswoman for America’s Health Insurance Plans, the industry trade group, said comparing exchange plans to employer plans was problematic and noted that people signing up for plans on the exchanges had a variety of coverage options, ranging from basic to generous.
“You can’t look at just averages,” she said. “You have to compare what the individual patient experience is, and you have to look at what they were enrolled in pre-Affordable Care Act, versus now.”
Prime’s study, carried out from January to June, found that drugs to treat H.I.V. and hepatitis C made up about 18.5 percent of total drug spending for members with exchange plans, and that spending on H.I.V. was 228 percent higher than those with employer plans. Spending on hepatitis C drugs, which includes the expensive new treatment Solvadi, was 160 percent higher than in employer plans.
Express Scripts reached similar conclusions. H.I.V. medications were the most costly treatment category in the exchange plans, accounting for 11.3 percent of total spending. But H.I.V. drugs did not even appear in the top 10 costliest treatment categories for employer plans.
Total spending on specialty drugs — expensive medications that typically treat serious conditions like cancer — was far higher among exchange plans, accounting for 38 percent of total drug spending, compared with 28 percent of spending in employer plans, Express Scripts found.
Several observers said the high enrollment of people with H.I.V. and other serious conditions demonstrated that by preventing insurance carriers from denying coverage to people with existing medical conditions, the health care law was meeting its goal of encouraging widespread coverage. “It just showed that the H.I.V. patients were really locked out of health insurance,” said Carl Schmid, deputy executive director of the AIDS Institute, an advocacy group. “It did not work for them.”
Sabrina Corlette, a policy expert at Georgetown University’s Center on Health Insurance Reforms, said it was too early to know whether the overall health of the newly enrolled would lead to higher premiums. “It’s still early days,” she said. “I probably would not try to draw any strong conclusions or say this is indicative of long-term trends.”
She noted that many insurers expected the first year of new enrollees to be sicker, as a whole, both because many had been unable to get health insurance and because the new exchanges accepted thousands of people who had previously been enrolled in insurance pools specially designed for people with existing medical conditions. “Health insurance companies did price on the expectation that they would be getting a lot of high-needs people,” she said.
Both studies found that people enrolling through the exchanges tended to be older than those with coverage in employer plans. Express Scripts found that the average age of someone with exchange coverage was 43.6, in contrast to 36.7 for those with employer-provided insurance.
But while Prime’s study found that the average age of exchange members remained about the same as the enrollment deadline approached, at about 42, Express Scripts said the average age of its sample dropped about four years as time grew short. This population was also generally healthier, Express Scripts found: 13.3 percent of early enrollees filled a prescription for high cholesterol, for example, compared with about 6.5 percent of late sign-ups.
Ms. Huppert, of Express Scripts, said she expected the health status of people in the exchange plans to level out over time as pent-up demand for coverage eased. She said those with health insurance in the exchanges were likely to be people who did not have full-time jobs, with benefits, and yet did not qualify for Medicaid. “They will likely remain in these plans for some time,” she said.