QHP enrollees have also  expressed satisfaction, to varying degrees, with specific aspects of their  plans, including their coverage, their choice of providers, and plan  affordability, according to five national surveys we reviewed. Overall Plan Satisfaction

QHP enrollees who obtained their coverage through the exchanges have  reported overall satisfaction with their plans from 2014 through 2016,  according to national surveys that we reviewed. The overall satisfaction level of QHP enrollees was somewhat lower than  or similar to those who were enrolled in employer-sponsored health  insurance in 2015 and 2016. Concerns Have Been Noted by Stakeholders and in Research about Some Enrollees’ Ability to Afford and Access Care

Although available data show most QHP enrollees were satisfied overall  with their plans, our interviews with stakeholders—including experts,  assisters, state department of insurance and exchange officials—and our  review of literature, also revealed concerns about some QHP enrollees’  ability to afford and access their care, and understand their QHP, among  other things. Specifically, some individuals have reported concerns affording  care, or have been deterred from seeking care, because they found it too  expensive to pay for their out-of-pocket expenses before reaching their  deductibles, according to experts we interviewed. Understanding QHPs

Some QHP enrollees who obtained their coverage through the exchanges  have faced difficulties understanding how to use their plans, according to  our interviews with stakeholders and our review of literature. Other Concerns

To varying degrees, QHP enrollees who obtained their coverage through  the exchanges have also faced a range of other challenges related to  their health insurance plans, according to assisters and state department  of insurance and exchange officials we interviewed and literature we  reviewed. CMS and Selected States Have Monitored Post- Enrollment Experiences by Reviewing Information Reported by Consumers and Assisters

CMS and the five selected states in our review have monitored QHP  enrollees’ post-enrollment experiences by reviewing information reported  by consumers, through call centers and enrollee surveys, as well as by  assisters. Consumer Call Centers

CMS uses information collected from enrollees through its call center to  monitor QHP post-enrollment experiences. QHP enrollees and their  representatives, such as assisters, may call the CMS exchange call  center to request agency assistance in resolving concerns. Officials from all five of the selected states’ departments of  insurance we interviewed reported tracking consumer complaints at the  issuer level and working to resolve reported issues. Specifically, CMS developed a survey, which was administered to a  sample of QHP enrollees nationwide, including those in FFE and SBE  states, about their experiences with their plans in 2015 and 2016. CMS officials told us that they ultimately expect the results of their  2017 and future surveys to, among other things, inform the agency’s  monitoring of enrollee post-enrollment experiences, as well as their  monitoring of issuers beginning in 2017. For example, CMS officials told  us that they expect to use survey results to identify issues in enrollee  overall satisfaction and access to care. Officials from the state’s exchange office told  us that they used the survey results to inform their prioritization of work  related to improving enrollee experiences, such as developing better  methods to educate enrollees on financial literacy and health insurance  information, and to work with issuers to ensure that consumers with  complaints are using the appropriate channels for filing them. Assisters

CMS and states have also monitored enrollee experiences with  information received from assisters. CMS officials told us that they use information they receive from  navigators and other assisters to help them troubleshoot FFE enrollee  problems, clarify policy, and develop additional training or materials for  dissemination. Exchange offices in the two selected states in our study that operated an  SBE, Colorado and Vermont, required their state-funded assisters to  routinely report information about the post-enrollment assistance they  provided, according to officials and assisters, and, officials from the state  exchange offices told us that they use this information to, among other  things, identify and address any problems related to enrollees’  experiences with their QHPs, or identify training needs. Agency Comments

We provided a draft of this report to HHS for comment; HHS provided  technical comments, which we incorporated as appropriate. Appendix I: Methodology Information for Literature Review and Five National Surveys

To examine what is known about the early experiences of enrollees in  qualified health plans (QHP) obtained through the exchanges, we  conducted a structured search of research databases using various  combinations of relevant search terms including, “Affordable Care Act,”  “qualified health plan,” “marketplace,” and “exchange,” to identify any  literature published from January 1, 2014, through April 30, 2016, that  reported on QHPs obtained through the exchanges. In addition, the surveys reported similar results with respect to  enrollee experiences.
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.

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.