Small Increases To Employer Premiums Could Shift Millions Of People To The Exchanges And Add Billions To Federal Outlays

Transcription

1 By Daniel R. Austin, Anna Luan, Louise L. Wang, and Jay Bhattacharya Small Increases To Employer Premiums Could Shift Millions Of People To The Exchanges And Add Billions To Federal Outlays The Exchange Health Insurance Provision The Affordable Care Act extends insurance coverage to the currently uninsured through two main mechanisms: expanding Medicaid eligibility to people with incomes of up to 133 percent of the federal poverty level, 1,2 and subsidized private insurance through newly created health indoi: /hlthaff HEALTH AFFAIRS 32, NO. 9 (2013): Project HOPE The People-to-People Health Foundation, Inc. ABSTRACT The Affordable Care Act will expand insurance coverage to more than twenty-five million Americans, partly through subsidized private insurance available from newly created health insurance exchanges for people with incomes of percent of the federal poverty level. The act will alter the financial incentive structure for employers and influence their decisions on whether or not to offer their employees coverage. These decisions, in turn, will affect federal outlays and revenues through several mechanisms. We model the sensitivity of federal costs for the insurance exchange coverage provision of the Affordable Care Act using the nationally representative Medical Expenditure Panel Survey data set. We assess revenues and subsidy outlays for premiums and cost sharing for individuals purchasing private insurance through exchanges. Our findings show that changing theoretical premium contribution levels by just $100 could induce 2.25 million individuals to transition to exchanges and increase federal outlays by $6.7 billion. Policy makers and analysts should pay especially careful attention to participation rates as the act s implementation continues. Daniel R. Austin is a medical studentatstanford University, in California. Anna Luan is a medical studentatstanford University. Louise L. Wang is a medical studentatstanford University. Jay Bhattacharya (jay@ stanford.edu) is an associate professor at the School of Medicine, Stanford University. When the Affordable Care Act is fully implemented in 2014, it will expand insurance coverage to more than twenty-five million people who would otherwise not have insurance. However, the act will also have a fundamental effect on the incentives for employers to offer insurance to their employees, and decisions in response to these incentives will affect federal revenues and outlays. Currently, when an employer decides not to offer health insurance coverage, federal revenues often increase as a result, because employer-provided insurance is tax-deductible. After the Affordable Care Act is fully implemented, the calculus will reverse itself, as workers who do not receive health insurance through their employers will be eligible for federally subsidized insurance through insurance exchanges. Although this logic is well known, little attention has been paid to how sensitive federal government obligations are to decisions by employers about offering insurance to their workers. Our goal in this article is to model the sensitivity of federal government outlays for insurance subsidies through the exchange. September :9 Health Affairs 1531

2 Exhibit 1 surance exchanges (or marketplaces) for people with incomes of percent of poverty. 3 Although there is much to say about the expansion of Medicaid and its financing, our focus here is on subsidized private insurance. Health insurance exchanges are marketplaces where private insurers will present vetted plans to individuals and small businesses interested in purchasing coverage. To make exchange plans affordable for lower-income households, the government will subsidize a portion of the premium cost to people with annual incomes of percent of poverty 4 and will require these participants to contribute percent of their annual incomes to premium costs. The government will provide a premium credit that covers the remainder of the premium cost, based on the price of the region s second-least-expensive silver-level plan. 5 Exhibit 1 shows the schedule of subsidies for individuals and a family of four with sample income levels. People with incomes of percent of poverty who choose a silver-tier plan will receive a cost-sharing subsidy, in addition to the premium subsidy described above, that will increase the actuarial value (the average total percentage of benefit costs covered by a health plan) beyond what the insurer covers. Silver plans will cover an average of 70 percent of costs to covered people, while participants will be responsible for paying, on average, 30 percent of covered medical costs. The cost-sharing subsidy would lower expected contributions further by an amount based on the person s relation to the federal poverty level. According to the Congressional Budget Office (CBO), 6 about twenty-five million people will be Characteristics, Coverage Subsidies, And Coverage Costs For Nonfamily And Family Households Under The Affordable Care Act Number in family Characteristic One Four Household income ($) 27,757 56,604 Percent of federal poverty level Annual medical expenditures ($) 5,091 13,168 Silver-tier insurance premium ($) 5,003 13,836 Expected premium contribution ($) 2,234 4,589 Costs to federal government Premium subsidy ($) 2,769 9,247 Cost-sharing subsidy ($) Revenues to federal government Taxes ($) 641 2,955 Social Security ($) 529 1,465 Medicare ($) SOURCE Authors calculations, generated using model results, based on the Affordable Care Act and data from the 2010 Medical Expenditure Panel Survey. covered under newly created health insurance exchanges by 2017 the year that the exchanges are expected to be fully operational. Approximately twenty million new enrollees those with incomes below 400 percent of poverty will qualify for federal income-adjusted subsidies to purchase insurance on an exchange. Without these subsidies, insurance on the exchange would be unaffordable for lower-income families. Impact On Employer-Based Health Insurance All forecasts of the Affordable Care Act s exchange subsidies are based on the insight that employer-provided health insurance and exchange insurance are substitutes for each other. Low-income workers who receive adequate, affordable coverage through an employer do not qualify for federal subsidies for insurance purchased through the exchange. The extent to which employers will provide insurance to lower-income workers, instead of having them acquire coverage via exchanges, is a vital input into any forecast of the act s cost to the federal government. However, there is considerable controversy about how employers will react to the act s implementation. On the one hand, the act includes penalties to incentivize businesses to provide health insurance to employees. Larger companies will be charged a penalty of $2,000 $3,000 per full-time employee if they do not offer insurance or if the coverage offered either is too expensive for employees or does not provide coverage deemed adequate according to the provisions in the essential health benefit package specified in the legislation. In addition, the employer s pretax contribution to health care coverage provides a strong impetus for employers to continue providing coverage. Based in part on the penalty and pretax incentives, the CBO estimates that a net seven million people will forgo employer-based insurance once the Affordable Care Act reaches its equilibrium. 6 On the other hand, some analysts expect more employers to transition away from employerbased health insurance. For example, Douglas Holtz-Eakin and Cameron Smith 7 estimate how much employers can save by not providing insurance to their workers. Since providing insurance coverage is expensive the average annual premium for employer-based health insurance was $15,745 to cover a family of four in employers may find it financially advantageous to not provide insurance at all, even after accounting for the Affordable Care Act s penalty. 7 In some cases at income levels of per Health Affairs September :9

3 cent of poverty they estimate that workers would be financially better off if their employers were to drop their insurance coverage in exchange for increased wages, because the act s subsidy is so large. At income levels of percent of poverty, employers that dropped coverage would have to raise workers pay to keep them financially indifferent. But even with that taken into account, Holtz-Eakin and Smith argue that employers would be better off dropping coverage. 7 This sort of evidence from financial contributions is buttressed by national surveys of employers intentions following the act s implementation in A 2013 survey from Mercer 9 found that nearly 20 percent of surveyed employers expect costs to rise more than 5 percent as a result of premium costs for newly eligible people, with 7 percent of large employers planning to terminate coverage and shift employees onto public exchanges. The consulting firm Oliver Wyman 10 reported in 2012 that 8 percent of employers would likely drop coverage, while a 2011 survey by McKinsey and Company 11 reported that 30 percent of employers would likely do so. Although these estimates are probably too high (and do not reflect the share of the workforce affected), if they are even approximately right, subsidized exchange participation and federal budget outlays and revenues will be quite different from current forecasts. A March 2012 CBO report 12 modeled four new scenarios to evaluate the costs associated with possible changes in employer-based insurance coverage. The study found that overall costs to the federal government could increase by an additional $45 billion over ten years (if highly responsive employers with predominantly lower-income employees eliminated insurance coverage). Other scenarios resulted in a net reduction in cost of up to $82 billion as increased tax revenues on new wages (see below) and employer penalties outweighed federal subsidies. When an employer drops coverage, employees will collect a portion of the previous premium contributions (less any penalty incurred by the employer) in the form of newfound income. Thus, an offsetting benefit to the federal government is that income, Medicare, and Social Security taxes may rise as a result of new wages. Our overall aim in this article is to examine the balance between exchange subsidy costs and revenues from employer penalties and newfound wages to the federal government by adjusting participation in exchange-based health insurance. Many reports have attempted to predict how the Affordable Care Act will affect federal health care spending. Given the numerous components of the reform and lack of precedent for many decisions that will affect federal outlays, projections vary greatly. 13 The CBO projects that in 2014, exchange subsidies will cost the federal government $26 billion, and these expenditures are forecast to rise to $129 billion by Higher estimates total $899 billion between 2014 and 2019 and consider net expenditures once the legislation has been fully implemented with more robust participation. 14 Although the CBO and other reports provide fixed estimates, we believe, given the challenge of predicting many outcomes of the legislation, 12,15 that it is more informative to measure the sensitivity of projected federal obligations to potential variations in key assumptions. In particular, there is strong public policy interest in whether forecast federal expenditures are sensitive to employers decisions about insurance coverage. If federal expenditures are sensitive to participation, then actual federal outlays could vary substantially from the projected level as a result of relatively small changes in factors that influence exchange participation. With this objective in mind, we assessed the sensitivity of government cost estimates for the insurance coverage provisions of the Affordable Care Act by modeling variations in exchange participation using data from a nationally representative data set. Study Data And Methods Data We used data from the Medical Expenditure Panel Survey Household Component (MEPS-HC) to construct our model. MEPS-HC is a nationally representative survey of health care use, health insurance status, health care expenses, and overall health status, along with relevant demographic and socioeconomic information. 16 We weighted the results to represent the civilian noninstitutionalized US population and adjusted for inflation to 2014 dollars. 17 Eligibility To estimate federal costs of exchange subsidies, we considered both currently uninsured people and those with public and employer-based insurance with incomes of percent of poverty. Our model assumed that uninsured people with incomes in this range would rather purchase insurance through exchanges than incur an individual penalty. In the discussion, we address how violations of this assumption would affect our results. For employees to be eligible to switch to exchange-based coverage from employer-based coverage, their current premium payment contribution must exceed 9.5 percent of their income.we assumed that all employer-based insurance plans had an actuarial value of at least September :9 Health Affairs 1533

4 60 percent (the basic exchange plan coverage), so that the eligibility requirements for exchange participation depended only on federal poverty level and premium as a fraction of current income. When the income requirement and the 9.5 percent premium payment contribution are met, the federal government incurs costs in the form of the insurance subsidy and gains revenue from taxes on additional income and the penalty to employers. In addition, for individuals whose family incomes are less than 250 percent of poverty, the federal government incurs costs in the form of cost-sharing assistance. The overall design of our decision model is presented schematically in the online Appendix. 18 One issue that is still outstanding relates to how the government will determine the affordability of employer-based insurance and associated penalties (whose enforcement is being delayed until 2015). The Internal Revenue Service (IRS) is considering a test for eligibility for an exchange subsidy (for an otherwise eligible worker with dependents) based on the affordability of single, not family, insurance coverage. 19 In a sensitivity analysis, we explored the effects of this perverse eligibility test. We also conducted a sensitivity analysis in which the government ignored the 9.5 percent affordability requirement altogether. Exchange Subsidy Model Briefly, the study incrementally increased contributions to current insurance premiums. In each round, as premiums rose, eligible individuals decided whether to switch to the exchange or keep their current insurance, based on the costs of each premium. Once it became financially favorable to switch, all relevant revenues and penalties were totaled, based on the type of insurance currently held, taxes, and health expenses. Decision To Switch To Exchange Coverage In our model, people who met the eligibility criteria would switch to exchange-based coverage if the premium amount that they would pay in the exchange was less than their direct contribution to their current insurance, less income tax. 7 Eligible uninsured individuals would opt into the exchange instead of incurring an individual penalty. In this calculation, we counterfactually varied insurance premium contributions by $300 increments between $101 and $10,101, and then we plotted how resulting changes in exchange participation would influence federal outlays. Subsidy Estimates: Costs For Premiums And Cost Sharing We estimated premium costs for exchange insurance plans based on family size, applying the CBO s most recent premium cost estimate and MEPS Insurance Component (MEPS-IC) data. 12 We generated expected contributions toward premium costs using a sliding scale based on annual family income. The percentage of total income to be contributed toward premium costs was fixed to the federal poverty level. Thus, the premium subsidy cost to the federal government was the difference between the average silver plan cost and a household s expected contribution. Our estimates were not adjusted for age, region, and tobacco use. However, they accurately measured the average and aggregate premium subsidy costs over the national population assuming full participation in the exchanges by those eligible. We determined eligibility for cost-sharing subsidies based on income level at the actuarial values specified in the Affordable Care Act. Cost subsidies depend on health care use, so these calculations were estimated using a family s health care costs in 2010.We generated the highest possible cost-sharing subsidies by assuming that all exchange participants obtained the second-cheapest silver plan, and thus enrollees with incomes of percent of poverty received cost-sharing subsidies. Revenue: Income, Medicare, Social Security Tax, And Employer Penalty Within a competitive labor market, employers that drop insurance coverage must reimburse employees for the decrease in total compensation. In calculating revenues, we assumed that once a household switched to exchange-based insurance, the previously untaxed premium contribution for employer-based coverage would become taxable income and be taxed at the household s current marginal tax rate (in addition to Medicare and Social Security deductions on eligible income). Therefore, those who switched to the exchanges from employer-based insurance would effectively earn a taxable wage increase and generate an employer penalty of $3,000 per person who switched. In such cases, we assumed that employers would deduct the penalty cost from workers adjusted wage increases. Using a sensitivity analysis, we also explored a version of our model in which we assumed that if an employer cut insurance coverage for an employee, instead of increasing the employee s wages, the employer s operating costs declined. In this alternative scenario, we assumed that the additional revenues to the government, generated by dropping insurance, would be taxed at the corporate tax rate of 35 percent. Study Results We estimated a simple model in which eligible people switch to the exchange when it is finan Health Affairs September :9

5 cially beneficial to them to do so. At the average US national premium contribution rate of $2,450 (adjusted by family size), our model shows that roughly thirty-seven million eligible people would benefit financially from participating in exchanges. At that baseline level, annual federal outlays for exchange subsidies would be $132 billion (in 2014 dollars). Exhibit 2 presents our baseline results. The exhibit shows how changes in household premium contributions for employer-based insurance lead to changes both in participation in the exchange and in net federal outlays. As household premium contributions rise, people are increasingly eligible and motivated to participate in the exchange, because they will receive a federal premium subsidy and an effective wage increase (to compensate for leaving employer-provided insurance). At the lowest premium contribution levels, only subsidy costs (premiums and cost sharing) are incurred for currently uninsured people with incomes of percent of poverty. At higher contribution levels that is, at increasing levels of exchange participation federal government obligations start to equal revenues from taxes and employer penalties. At levels straddling the adjusted national average contribution of $2,450, our results show that outlays (incurred through federal subsidies to premiums and cost sharing) greatly outpace revenues from increased income taxes and penalties on those switching from employer-based insurance. Importantly, our findings show that changing theoretical premium contribution levels by just $100 could induce 2.25 million people to transition to exchanges and increase federal outlays by $6.7 billion. In addition to Exhibit 2 s baseline scenario, we conducted three additional sensitivity analyses. In the first analysis we altered our assumption that an employer pays higher wages to compensate for dropping insurance coverage. Instead, we assumed that the employer s profits rise. The results in this alternative scenario are virtually identical to those of our baseline scenario. This is because tax revenues generated by reduced claims of the tax exemption for employer-provided insurance are less than 10 percent of the federal obligation for exchange subsidies. As in the baseline scenario, the net federal revenue effect of the Affordable Care Act is sensitive to employers decisions about coverage. In a second sensitivity analysis we estimated our model assuming that eligibility for an exchange subsidy for a worker with dependents was based on the affordability of single insurance coverage, rather than on family insurance coverage. This is the current interpretation of the IRS eligibility rules for the Affordable Care Act. 19 Unsurprisingly, we found that such an interpre- Exhibit 2 Net Cost And Exchange Participation As A Function Of Premium Contributions To Current Insurance Coverage SOURCE Authors calculations of data from the 2010 Medical Expenditure Panel Survey. NOTESThe red graphing line (net federal obligations) relates to the left-hand y axis. The blue graphing line (exchange participation) relates to the right-hand y axis. Dollar figures shown are 2014 dollars. September :9 Health Affairs 1535

6 tation would greatly reduce exchange participation by families who can afford their employer s individual coverage, but not their employer s family coverage. Under this scenario there would be little switching from employer-based insurance to exchange insurance. Finally, we altered our assumption that eligibility for an exchange subsidy is conditional on whether an employer offers affordable insurance. Instead, we assumed that low-income employees would be eligible for exchange subsidies regardless of whether they were offered insurance by their employers. This scenario is plausible given the federal government s recent decision to delay the implementation of the employer mandate and the difficulty that the IRS will consequently have in verifying that workers do not have insurance available through their employers. In this scenario exchange participation increases sharply, as do federal government outlays up to $170 billion from the baseline of $132 billion but there is no qualitative change in the sensitivity of net federal spending to employees participation in employer-based plans. Discussion Our analysis examined costs to the federal government for the insurance exchange subsidies provided under the Affordable Care Act. We found that federal outlays and revenues for health exchanges were quite sensitive to changes in current household contributions to insurance. Because the extent of employers dropping coverage is uncertain, our results imply that federal obligations will vary greatly based on the health care decisions of individuals, employers, insurers, and the government. We assumed that everyone who was eligible for federal subsidies to purchase insurance on the exchange would opt to buy insurance instead of paying an individual penalty (or tax). To the extent that people in these categories actually decide to opt out of coverage, we overestimated the effect of the insurance mandate on federal budget outlays. However, the fraction of the eligible exchange population who pay the penalty is likely to be low, as 50 percent of the uninsured or individually insured population have incomes within percent of poverty and are eligible for substantial subsidies. 20 Those who are most likely to pay the penalty (with incomes greater than 400 percent of poverty) are ineligible for the exchange subsidies and would not increase net costs. This caveat does not bias our estimate of how sensitive federal obligations are to employers decisions not to provide insurance. A household s decision to switch from its current insurance to exchange-based insurance will involve factors beyond cost. One consideration is how extensive exchange coverage is relative to current health insurance. The CBO estimates 21 that current employer-based plans have an average actuarial value of 88 percent in other words, plans cover 88 percent of incurred medical care costs, on average. This is much greater than the 70 percent requirement of the silver plan. Households with known health risks may chose an insurance plan with a higher premium that offers more complete coverage. Other characteristics, such as loading fees (markups above the cost of expected claims) and available physician networks, may also influence individuals decisions about whether to switch from employer-based insurance to an exchange. The Department of Health and Human Services has outlined the benefit coverage in the exchange health plans. 22 However, given the challenges of incorporating the multitude of factors that influence health insurance decisions at the individual level, we were limited to modeling the decision exclusively on financial circumstances. Cost estimates rely upon premium pricing of plans in exchanges, which will also influence premium subsidies and nonexchange premium pricing. These dynamics will all affect exchange participation. Variations in exchange premium costs and the composition of the insured population would shift premium subsidies, which are the greatest determinant of outlays, and greatly alter Affordable Care Act costs. Some states have begun releasing premium rates for the individual and small-group markets, where prices have been an average of 18 percent lower than those predicted by CBO estimates. 23 Nevertheless, although these premiums levels remain uncertain, they will have a substantial effect on federal obligations for exchange subsidies. Conclusion The Affordable Care Act is an intricate and vast reform whose components are expected to have an enormous impact on the delivery and funding of health care in the United States. Our findings show that exchange participation, and therefore net costs, rest on a very steep curve. This suggests that minor changes in current premium costs could greatly alter US federal government outlays. Although policy makers may hope for an alternate scenario, they should plan for the possibility that the exchange subsidies may end up costing the federal government much more than currently projected Health Affairs September :9

7 The authors thank Tom Deleire, Steven Haider, and Tom MaCurdy for their comments and help. All authors contributed equally to the production of this article. The authors are responsible foralloftheopinionsexpressedinthe article as well as for any errors. NOTES 1 An income disregard of 5 percent raises the effective cutoff of Medicaid eligibility to 138 percent. 2 The federal government will incur 100 percent of costs during , 95 percent in 2017, 94 percent in 2018, 93 percent in 2019, and 90 percent in 2020 and all subsequent years. 3 Congressional Budget Office. Estimates for the insurance coverage provisions of the Affordable Care Act updated for the recent Supreme Court decision [Internet]. Washington (DC): CBO; 2012 Jul [cited 2013 Jul 31]. Available from: files/cbofiles/attachments/ coverageestimates.pdf 4 People with incomes below 133 percent of the federal poverty level who are ineligible for Medicaid can purchase insurance in the exchange market, with subsidized premiums. 5 Health care plans are divided into four tiers on the exchange (bronze, silver, gold, and platinum), based upon the actuarial value of the insurance plan. 6 Congressional Budget Office. CBO s estimate of the net budgetary impact of the Affordable Care Act s health insurance coverage provisions has not changed much over time [Internet]. Washington (DC): CBO; 2013 [cited 2013 Jul 31]. Available from: publication/ Holtz-Eakin D, Smith C. Labor markets and health care reform: new results. Washington (DC): American Action Forum; Kaiser Family Foundation, Health Research and Educational Trust. Employer health benefits: 2012 summary of findings [Internet]. Menlo Park (CA): KFF; 2012 Sep [cited 2013 Jul 31]. Available from: employer-health-benefits-annual- survey-summary-of-findings pdf 9 Mercer [Internet]. New York (NY): Mercer; c2013. Press release, Employer plans for dealing with health care reform evolving as 2014 draws closer new Mercer survey; 2013 Jun 12 [cited 2013 Jul 31]. Available from: 10 Kairey M, Rudoy J. Employersponsored healthcare: what happens now? [Internet]. New York (NY): Oliver Wyman; 2012 [cited 2013 Jul 31]. Available from: OW_EN_HLS_PUBL_2012_ Employer_Sponsored_Healthcare_ What_Happens_Now.pdf 11 Singhal S, Stueland J, Ungerman D. How US health care reform will affect employee benefits [Internet]. New York (NY): McKinsey and Company; 2011 [cited 2013 Aug 9]. Available from: systems_and_services/how_us_ health_care_reform_will_affect_ employee_benefits 12 Congressional Budget Office. CBO and JCT s estimates of the effects of the Affordable Care Act on the number of people obtaining employment-based health insurance [Internet]. Washington (DC): CBO; 2012 Mar [cited 2013 Jul 31]. Available from: attachments/03-15-aca_and_ Insurance_2.pdf 13 Foster RS. Estimated financial effects of the Patient Protection and Affordable Care Act, as amended [Internet]. Baltimore (MD): Centers for Medicare and Medicaid Services, Office of the Actuary; 2010 Apr 22 [cited 2013 Jul 31]. Available from: Statistics-Data-and-Systems/ Research/ActuarialStudies/ downloads/ppaca_ pdf 14 Ringel JS, Girosi F, Cordova A, Price C, McGlynn EA. Analysis of the Patient Protection and Affordable Care Act (H.R. 3590). Santa Monica (CA): RAND Corporation; Holtz-Eakin D, Parente S, Ramlet M. Congressional Budget Office revision to the Affordable Care Act Baseline. Washington (DC): American Action Forum; Cohen J. Design and methods of the Medical Expenditure Panel Survey Household Component. Rockville (MD): Agency for Healthcare Research and Quality; (MEPS Methodology Report No. 1). 17 Machlin SR, Chowdhury SR, Ezzati- Rice T, DiGaetano R, Goksel H, Wun L-M, et al. Estimation procedures for the Medical Expenditure Panel Survey Household Component. Rockville (MD): Agency for Healthcare Research and Quality; (MEPS Methodology Report No. 24). 18 To access the Appendix, click on the Appendix link in the box to the right of the article online. 19 Government Accountability Office. Children s health insurance: opportunities exist for improved access to affordable insurance. Washington (DC): GAO; Houchens PR. Measuring the strength of the individual mandate [Internet]. Indianapolis (IN): Milliman; 2012 [cited 2013 Aug 9]. (Milliman Research Report). Available from: 21 Congressional Budget Office. An analysis of premiums under the Chairman s Mark of the America s Healthy Future Act: letter to the Honorable Max Baucus [Internet]. Washington (DC): CBO; 2009 Sep 22 [cited 2013 Jul 31]. Available from: default/files/cbofiles/ftpdocs/ 106xx/doc10618/09-22-analysis_ of_premiums.pdf 22 CMS.gov. Essential health benefits, actuarial value, and accreditation standards: ensuring meaningful, affordable coverage [Internet]. Baltimore (MD): Centers for Medicare and Medicaid Services, Center for Consumer Information and Insurance Oversight; [cited 2013 Jul 31]. Available from: Fact-Sheets-and-FAQs/ehb html 23 Skopec L, Kronick R. Market competition works: proposed silver premiums in the 2014 individual and small group markets are nearly 20% lower than expected [Internet]. Washington (DC): Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation; 2013 Jul [cited 2013 Jul 31]. (ASPE Issue Brief). Available from: aspe.hhs.gov/health/reports/2013/ MarketCompetitionPremiums/rb_ premiums.pdf September :9 Health Affairs 1537