Gender Differences and the ACA

Aspects of the Health Care Outlook by Gender

From the availability of over-the-counter drugs to protections for pregnant women, concerns about improving access to affordable health care for women have played an important role in recent health reform efforts. The Affordable Care Act attempts to alleviate insurance barriers by requiring insurers to provide maternity coverage, and reimburse the full cost of contraception, among other reforms. In this report, the Center for Health and Economy (H&E) examines the ten-year outlook of insurance coverage for the male and female population under 65 years old.

Note on the Implementation of the Affordable Care Act

The predictions detailed in this report are sensitive to the implementation of the Affordable Care Act. H&E does not make projections about the success of the Health Insurance Marketplace rollout and the rate at which members of the individual market will shift into the state-based exchanges. The model currently employed by H&E assumes perfect implementation and full enrollment of eligible, individual market consumers in the state-based exchanges in 2014. Because federal programs take time to fully penetrate a given population, this assumption is not likely to be valid until 2016 or later. H&E is in the process of revising the projections for the Under-65 health insurance market to reflect the completion of the first open enrollment period.

Key Findings

• The uninsured rate among women is projected to fall from 21 percent to 13 percent in 2014 and from 21 percent to 12 percent among men. 
• Premium spending for Silver plan enrollees is projected to decrease by up to 76 percent for both men and women—accounting for subsidies—compared with the premiums for similar plans sold in 2013. The total premium price of Silver plans—without offsetting subsidies—is projected to increase up to 16 percent for women and up to 19 percent for men. Insurance premiums for both genders are expected to steadily rise throughout the analysis period by 2 – 11 percent per year.
• In 2014, H&E estimates that subsidized women will receive an average premium and cost-sharing subsidy of $9,000 and subsidized men will receive an average of $8,250.
• With a Medical Productivity Index (MPI) of 3.0, medical productivity is highest among men in the individual market, followed by an MPI of 2.9 for women in the individual market. Average productivity is projected to increase annually by roughly 1 percent for both genders.
• Over the next decade, provider access is expected to decline by 8 percent for women and 10 percent for men.

Insurance Coverage

H&E estimates for non-elderly insurance coverage over the next ten years are shown in Table 1. In 2013, the uninsured rate for both male and female individuals is estimated to be 21 percent. The distribution of insurance type across non-elderly men and women is similar: roughly two thirds of insured men and women receive insurance coverage through an employer. More insured women obtain coverage through Medicaid, and the opposite is true in the individual market. H&E estimates that Medicaid and other federal health programs cover 21 percent of insured women, compared to 14 percent of insured men, whereas 13 percent of insured women and 20 percent of insured men obtain coverage through the individual market.

In 2014, after the implementation of the ACA, the uninsured rate for women is expected to fall to 13 percent. The uninsured rate for men is expected to similarly decline to 12 percent. In both gender groups, nearly half of the estimated gain in insured individuals is through increased enrollment in the individual market—47 percent for women and 51 percent for men. Roughly a third of newly insured women are expected to gain coverage through Medicaid, and 20 percent of newly insured women are predicted to gain coverage through their employer. H&E predicts similar trends for men. Approximately 26 percent of men will gain coverage through Medicaid, and 23 percent will gain coverage through employer sponsored insurance.

After initial gains in insured persons, the uninsured rates in both gender groups are projected to rise throughout the remainder of the analysis period. Roughly 17 percent of both men and women are expected to be uninsured by 2022, due to increasing premium prices unmitigated by federal cost-sharing or premium subsidies. The estimated increase in uninsured persons is largely due to decreasing enrollment in the individual market and stagnation of the employer sponsored insurance market in response to rising premiums.

Insurance Premiums and Subsidies

Table 2 displays H&E estimates for the average annual cost of a Silver plan in the individual market. In 2013, before federal subsidies were available, the average estimated annual cost for a woman’s single coverage Silver plan is $100 greater than that of a man’s. And the average estimated annual cost for a woman’s family premium is $400 greater than that of a man’s.[1] The disparities in price for men and women are a result of higher medical costs for female specific services, such as maternity care. After the implementation of the ACA, insurance companies are no longer permitted to differentiate insurance products based on gender. In 2014, the total estimated cost of Silver plans for women increases by 16 percent for single coverage and 9 percent for family coverage. The total estimated cost of Silver plans for men increases by 19 percent for single coverage and 7 percent for family coverage. The increase in cost is a result of more community rating regulations that prevent insurance companies from pricing applicants according to health status. Over the remainder of the ten-year analysis period, the total cost of Silver plans purchased by men and women is projected to increase between 2 and 11 percent per year.

Despite a higher average total cost for Silver plans, both gender groups are projected to spend much less on premiums after taking into account cost-sharing and premium subsidies: $2,420 and $3,460 for female single and family coverage and $2,480 and $3,420 for male single and family coverage in 2014. The ACA restricts insurance companies from differentiating insurance products based on gender, leading to very similar premiums for both men and women. In comparison to 2013, this reflects approximately a 50 percent drop in the average price of single coverage under a Silver Plan and roughly a 76 percent drop in the average price of family coverage.

The average premium and cost-sharing subsidy in 2014 received by women is projected to be $9,000—ranging from $12,800 for those earning between 100 and 133 percent of the federal poverty level (FPL) to $7,230 for households earning between 300 and 400 percent of FPL. H&E estimates that the subsidies for men are slightly less, averaging $8,250 and ranging from $13,160 for those earning between 100 and 133 percent of FPL to $5,620 for households earning between 300 and 400 percent of FPL. By 2022, average subsidies are projected to increase to $10,410 for women and $9,800 for men. 

Table 3: Average Cost-Sharing and Premium Subsidy, by Gender and Income
	Household Income (percent of Federal Poverty Level)	2014	2015	2016	2017	2018	2019	2020	2021	2022
Female	100% – 133%	12,800	13,170	13,610	14,100	14,500	14,800	14,890	14,840	14,700
	133% – 150%	10,770	11,150	11,560	12,020	12,510	12,970	13,420	13,760	13,860
	150% – 200%	9,490	9,640	9,830	10,080	10,330	10,490	10,670	10,860	11,060
	200% – 250%	8,500	8,720	8,970	9,260	9,540	9,720	9,870	10,020	10,140
	250% – 300%	7,260	7,340	7,550	7,910	8,290	8,590	8,830	9,000	9,160
	300% – 400%	7,230	7,330	7,520	7,790	8,060	8,100	8,100	8,060	8,020
	Average Subsidy	9,000	9,140	9,360	9,650	9,940	10,120	10,240	10,330	10,410
Male	100% – 133%	13,160	13,600	14,090	14,580	14,980	15,230	15,350	15,390	15,390
	133% – 150%	9,410	9,700	10,060	10,550	11,120	11,720	12,230	12,450	12,380
	150% – 200%	9,300	9,440	9,660	9,970	10,260	10,460	10,650	10,840	11,070
	200% – 250%	8,290	8,510	8,770	9,080	9,400	9,620	9,810	9,990	10,150
	250% – 300%	5,840	5,920	6,090	6,380	6,710	6,980	7,190	7,340	7,430
	300% – 400%	5,620	5,640	5,760	5,980	6,220	6,270	6,270	6,200	6,110
	Average Subsidy	8,250	8,350	8,550	8,850	9,150	9,370	9,560	9,690	9,800

Medical Productivity and Provider Access

Table 4: Medical Productivity Index, by Gender and Category
		2013	2014	2015	2016	2017	2018	2019	2020	2021	2022
Female	Individual	2.9	2.8	2.9	2.9	2.9	3.0	3.0	3.0	3.0	3.1
	Employer Sponsored	2.3	2.3	2.3	2.4	2.4	2.4	2.4	2.4	2.4	2.5
	Medicaid	1.5	1.5	1.5	1.5	1.5	1.5	1.5	1.5	1.5	1.5
	Total Insured	2.2	2.2	2.2	2.2	2.2	2.3	2.3	2.3	2.3	2.3
Male	Individual	3.0	2.9	3.0	3.0	3.0	3.1	3.1	3.1	3.2	3.2
	Employer Sponsored	2.3	2.3	2.3	2.4	2.4	2.4	2.4	2.4	2.5	2.5
	Medicaid	1.5	1.5	1.5	1.5	1.5	1.5	1.5	1.5	1.5	1.5
	Total Insured	2.3	2.3	2.3	2.4	2.4	2.4	2.4	2.4	2.4	2.4

H&E is able to measure the medical productivity of the health insurance market using the Medical Productivity Index (MPI), designed by H&E to describe the relative incentive for providers to give efficient care to plan beneficiaries. Table 3 shows that the MPI for men is projected to be slightly higher than that of women in the individual market and equal in the employer sponsored insurance market. Higher enrollment in Medicaid, low-productivity insurance, among women also contributes to a lesser aggregate MPI than men. However, the differences are not large, which reflect similar plan choices between men and women.

Table 5: Provider Access Index, by Gender and Category
		2013	2014	2015	2016	2017	2018	2019	2020	2021	2022
Female	Individual	3.0	2.8	2.7	2.6	2.5	2.4	2.4	2.3	2.2	2.2
	Employer Sponsored	3.9	3.8	3.8	3.8	3.8	3.8	3.8	3.9	3.9	3.9
	Medicaid	1.0	1.0	1.0	1.0	1.0	1.0	1.0	1.0	1.0	1.0
	Total Insured	3.2	3.1	3.1	3.0	3.0	3.0	3.0	2.9	2.9	2.9
Male	Individual	3.1	3.0	2.8	2.7	2.6	2.5	2.5	2.4	2.4	2.4
	Employer Sponsored	3.8	3.8	3.7	3.7	3.7	3.7	3.7	3.7	3.7	3.7
	Medicaid	1.0	1.0	1.0	1.0	1.0	1.0	1.0	1.0	1.0	1.0
	Total Insured	3.3	3.2	3.1	3.1	3.1	3.0	3.0	3.0	3.0	3.0

Similar to productivity and cost control, provider choice is an important aspect of national health reform, and H&E predicts the ten-year outlook using the Provider Access Index (PAI). Table 4 shows that men have a greater PAI in the individual market than women, but a lesser PAI than women in the employer sponsored insurance market. The aggregate PAI is greater for men than it is for women, largely because of higher enrollment in Medicaid and other public insurance programs among insured women. The PAI for both men and women falls throughout the analysis period, as increasing health insurance premiums lead individuals to choose less costly plans with narrow networks. Over the next decade, the PAI is projected to fall by 8 percent for women and by 10 percent for men.

Uncertainty in H&E Projections

As with all economic forecasting, H&E estimates are associated with substantial uncertainty. While our estimates provide good indication on the nation’s health care outlook, there are a wide range of possible scenarios that can result from individual behavior and policy changes, and the current policy environment is unlikely to remain unchanged throughout our entire ten-year analysis period. For instance, the uncertainty surrounding the implementation of the Affordable Care Act and similar obstacles facing the implementation of new health care overhauls affect the accuracy of short-term coverage estimates. Importantly, we do not believe that the uncertainty in our estimates creates biased results. H&E predictions are not more likely to overestimate rather than underestimate certain aspects of the health care outlook. We attempt to project the most likely scenarios, but actual events may differ significantly from our predictions.

 

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