In particular, PPACA standardized health  insurance plans into four “metal” tiers of coverage—bronze, silver, gold,  and platinum—which reflect out-of-pocket costs that may be incurred by  an enrollee. Premium variation based on health status or gender was  effectively prohibited. Individual Market Consumers Generally Had Access to More Plans in 2015 Compared to 2014, and the Lowest-Cost Plans Were Available through Exchanges in Most Counties in Both Years

Individual market consumers in every county in our analysis had access  to a variety of plan options each year, and the number of plans available  to consumers generally increased from 2014 to 2015. For example, in   28 states for which we had reliable data for all plans (offered either on or  off exchanges), the percentage of counties for which six or more plan  options were available to consumers increased from 2014 to 2015 for  three of the metal tiers—bronze, silver, and gold—and in 2015 consumers  in every county in these states had access to six or more plans in each of  these three metal tiers. Not all  consumers had access to platinum plans, however, the availability of  platinum plans generally also increased from 2014 to 2015. We also found that the lowest-cost plan options available in a county  were available on an exchange in a majority of the counties included in  our analysis. For example, among the 1,886 counties in the 28 states for  which we had sufficiently reliable data for plans both on and off an  exchange, we found that the lowest-cost silver plan option for a 30-year  old was available on an exchange in 63 percent of the counties in 2014  and in 81 percent of the counties in 2015—an increase of 18 percentage  points. The Range of Premiums Available to Consumers Varied among the States and Counties in Our Analysis in Both 2014 and 2015 Premiums Varied Widely among the States in Our Analysis, and from 2014 to 2015 Premiums Were More Likely to Increase than Decrease

The premiums for the lowest-cost plan options available in each state  included in our analysis varied significantly from state to state. By contrast, in Maine (a state for which the lowest-cost  premiums were among the highest in the country) the lowest-cost silver  plan options for a 30-year-old were $252 in 2014 and $237 in 2015 for  plans both on and off an exchange. For example, in both years  Hawaii had among the lowest median premium costs for silver plans  offered to a 30-year-old either on or off the exchange—$217 per month in  2014 and $180 per month in 2015. For example, in the 28 states  included in our analysis, from 2014 to 2015 the minimum premium values  for silver plans available to a 30-year-old increased in 18 states,  decreased in 9 states, and remained unchanged in 1 state. For  example, our analysis of the minimum premiums for silver plans in states  where we analyzed data on plans offered either on or off exchanges  found that premiums for a 30-year-old increased by 5 percent or more   in 51 percent of the counties. In Rhode Island, 2014 premiums for plans ranged from a   low of $241 per month to a high of $266 per month, a difference of   10 percent, and in 2015 ranged from a low of $217 per month to a high   of $285 per month, a difference of 32 percent. By contrast, in Arizona,  2014 premiums for these plans ranged from a low of $147 per month to a  high of $508 per month, a difference of 244 percent, and in 2015 ranged   from a low of $147 per month to a high of $545 per month, a difference of  270 percent. For example, among the  1,886 counties in the 28 states for which we had sufficiently reliable data  on all plans offered on or off an exchange, we found that the range in  silver plan premiums for a 30-year-old in 2015 was wider in 79 percent   of the counties compared to 2014. In the interactive graphic linked to below, we provide files showing the  range of health insurance premiums, by county, that were available to  selected categories of consumers for exchange plans and all plans  (whether or not they were available on an exchange)—for both 2014 and  2015. Agency Comments

We received technical comments on a draft of this report from the  Department of Health and Human Services and incorporated them as  appropriate. In  addition, the report is available at no charge on the GAO website at  http://www.gao.gov.
Why GAO Did This Study

PPACA, as of 2014, changed how insurers determine health insurance premiums and how consumers shop for individual market health insurance plans. For example, PPACA prohibited insurers from denying coverage or varying premiums based on consumer health status or gender. At the same time, PPACA required health plans to be marketed based on their metal tiers (bronze, silver, gold, and platinum), which helps consumers 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.
GAO was asked to examine variation in the health plan options and premiums available to individuals under PPACA, and how the options available in 2014 compared to those in 2015. GAO examined: (1) the numbers of health plans available to individuals and how they changed from 2014 to 2015, and (2) the range of health insurance premiums in 2014 and 2015, and how they changed for individuals in each state and county for selected consumers. GAO analyzed data from the Centers for Medicare & Medicaid Services (CMS); reviewed applicable statutes, regulations, guidance, and other documentation; and interviewed officials from CMS. Comparisons across years were conducted for states that had sufficiently reliable data in both years—including comparisons of plans offered either on or off an exchange in 28 states (1,886 counties) and comparisons of plans offered only on an exchange for 38 states (2,613 counties) although GAO is reporting some data on 49 states.

What GAO Found

As of 2014, key provisions of the Patient Protection and Affordable Care Act (PPACA) resulted in the establishment of health insurance exchanges in each state and changed how insurers determined health insurance premiums. Individual market consumers generally had access to more health plans in 2015 compared to 2014, and in both years the lowest-cost plans were available through exchanges in most of the 1,886 counties GAO analyzed in the 28 states for which it had sufficiently reliable data for plans offered either on or off an exchange. In addition, consumers in most of the counties analyzed had six or more plans to choose from in three of the four health plan metal tiers (bronze, silver, and gold) in both 2014 and 2015, and the percentage of counties with six or more plans in those metal tiers increased from 2014 to 2015. Consumers had fewer options regarding platinum plans, although the availability of platinum plans generally also increased from 2014 to 2015. The lowest-cost plan available in a county was available on an exchange in most counties. For example, among the 1,886 counties analyzed, GAO found that the lowest-cost silver plan for a 30-year-old was available on an exchange in 63 percent of these counties in 2014 and in 81 percent of these counties in 2015—an increase of 18 percentage points.
The range of premiums available to consumers in 2014 and 2015 varied among the states and counties GAO analyzed. For example, in Arizona the lowest-cost silver plan option for a 30-year-old was $147 per month in both years, but in Maine, the lowest-cost silver plan options for a 30-year-old were $252 in 2014 and $237 in 2015. In the 28 states included in GAO’s analysis, from 2014 to 2015 the minimum premiums for silver plans available to a 30-year-old increased in 18 states, decreased in 9 states, and remained unchanged in 1 state. At the county level, GAO found that premiums for the lowest-cost silver option available for a 30-year-old increased by 5 percent or more in 51 percent of the counties in the 28 states. GAO also found that the range of premiums—from the lowest to highest cost—differed considerably by state. For example, in Rhode Island, 2014 premiums for silver plans available to a 30-year-old either on or off an exchange ranged from a low of $241 per month to a high of $266 per month, a difference of 10 percent, and in 2015 ranged from a low of $217 per month to a high of $285 per month, a difference of 32 percent. By contrast, in Arizona, 2014 premiums for these plans ranged from a low of $147 per month to a high of $508 per month, a difference of 244 percent, and in 2015 ranged from a low of $147 per month to a high of $545 per month, a difference of 270 percent.
An interactive graphic reporting by state and county the minimum, median, and maximum premium values for all individual market plans (either on or off the exchange) and for exchange-only plans, is available at http://www.gao.gov/products/GAO-15-687 . It includes either data for both years, or partial data (e.g., data for one of the two years) for 49 states.
GAO received technical comments on a draft of this report from the Department of Health and Human Services and incorporated them as appropriate.