As I mentioned above, PPACA also changed, as of 2014, how insurers  determine health insurance premiums and how consumers shop for  health insurance plans. As part of this, PPACA required that health plans  be marketed based on information that helps consumers compare the  relative value of each plan. Specifically, plans must be marketed by  specific categories—including four “metal” tiers of coverage (bronze,  silver, gold, and platinum)—that reflect out-of-pocket costs that may be  incurred by an enrollee. These changes occurred at the same time that  PPACA required the establishment of health insurance exchanges for  each state, through which consumers could compare and select from  among QHPs. Health-Insurance Markets Remained Concentrated in Most States in 2014, While Issuer Participation Generally Decreased from the Prior Year

In 2016, we examined enrollment in private health-insurance plans in the  years leading up to and through 2014, the first year of the exchanges  established by PPACA, and found that in each year, markets were  concentrated among a small number of issuers in most states. Enrollment through the exchanges was  generally more concentrated among a few issuers than was true for the  individual and small group markets overall in 2014. Consumers in the Individual Market Had Access to More Plans in 2015 than 2014, with Varying Premiums in Both Years

In 2015, we reported that individual market consumers generally had  access to more health plans in 2015—a year after the initial  implementation of key PPACA provisions—than in 2014. Consumers in  most of the counties analyzed in the 28 states for which we had  sufficiently reliable data for plans offered either on or off an exchange had  six or more plans from which to choose in three of the four health plan  metal tiers (bronze, silver, and gold) in both 2014 and 2015. In our 2015 report, we also found that premiums varied among states and  counties, the lowest cost plans were typically available on an exchange,  and in most states premiums increased from 2014 to 2015. Specifically,  we found that:
The range of premiums available to consumers in 2014 and 2015  varied among the states and counties we analyzed. In most states, the costs for the minimum and median premiums for  silver plans increased from 2014 to 2015. While our 2015 report examining the numbers of health plans and ranges  of health plan premiums available to individuals in 2014 and 2015 was  our most recent examination of these two issues, HHS has examined  more recent data. Available Data Show That Most Early QHP Enrollees Expressed Satisfaction with Their Plans in 2014 through 2016, Despite Some Concerns

In 2016, we reported that most enrollees who obtained their coverage  through the health insurance exchanges were satisfied overall with their  QHP during the first few years that exchanges operated, according to  national surveys of QHP enrollees. For example, 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 that asked this question. 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 with plan  affordability. We also interviewed stakeholders—including experts, state departments  of insurance, and others—and reviewed literature for our 2016 report. These interviews and the literature revealed some concerns about QHP  enrollee experiences that were similar to longstanding concerns in the  private health insurance market.
Why GAO Did This Study

PPACA contained provisions, many of which took effect in 2014, that could affect how issuers determine health insurance coverage and premiums and how they market their plans. For example, PPACA prohibits issuers from denying coverage or varying premiums based on consumer health status or gender. PPACA also requires health plans to generally be marketed based on metal tiers (bronze, silver, gold, and platinum), which allows consumers to compare the relative value of each plan. It also required the establishment of health insurance exchanges in each state, through which consumers can compare and select from among participating health plans.
This testimony describes (1) private health-insurance market concentration and issuer participation from 2011 through 2014, the year by which key PPACA provisions took effect, (2) health plans and premiums available to individuals in 2014 and 2015, and (3) the experience of enrollees that obtained coverage through the exchanges from 2014 through 2016. It is based on three GAO reports issued in 2015 and 2016. For these reports, GAO examined data from the Centers for Medicare & Medicaid Services (CMS); reviewed published research; and interviewed stakeholders, including experts and officials from CMS and five states—Colorado, Indiana, Montana, North Carolina, and Vermont—that varied in geography and whether the state or CMS offered the exchange.

What GAO Found

GAO issued three reports in 2015 and 2016 on the early impact of the Patient Protection and Affordable Care Act (PPACA) on private health insurance markets.
Market Concentration
In a 2016 report, GAO examined enrollment in private health-insurance plans in the years leading up to and through 2014, the first year of the exchanges established by PPACA, and found that in all years analyzed, markets were concentrated among a small number of issuers in most states.
Beginning in 2014, enrollment in PPACA exchange plans was generally more concentrated among a few issuers than was true for the overall markets.
Plan Availability and Premiums
In a 2015 report, GAO examined the availability of health plans for individual market consumers and found that they generally had access to more health plans in 2015 than in 2014.
In both years, most consumers in 28 states for which GAO had sufficiently reliable data had 6 or more plans from which to choose in three of the four health plan metal tiers (bronze, silver, and gold).
The range of premiums available to consumers varied considerably by state, and in most states the costs for the minimum and median premiums for silver plans increased from 2014 to 2015. In both years, the lowest cost plans were typically available on an exchange.
More recent analyses by the Department of Health and Human Services found that in 2017 all consumers continued to have multiple plan options, and that premiums for exchange plans increased more in 2017 compared to the annual increases for these plans since 2014.
Enrollee Experiences
In a 2016 report, GAO examined national survey data to examine satisfaction of exchange enrollees. GAO found that, from 2014 through 2016, most enrollees who obtained their coverage through an exchange reported being satisfied overall with their plans.
In 2015 and 2016, the satisfaction that exchange enrollees reported with their plans was either somewhat lower than or similar to that of enrollees in employer-sponsored plans.
Exchange enrollees reported varying degrees of satisfaction with specific aspects of their plans, including coverage and plan affordability.
Stakeholders GAO interviewed and literature GAO reviewed revealed some concerns about exchange enrollee experiences that were generally consistent with longstanding concerns in the private health insurance market—including concerns about affordability of out-of-pocket expenses and difficulties understanding coverage terminology.