Studies: Exchange Enrollees Sicker Than Those With Employer Plans

Individuals who enrolled in coverage through the Affordable Care Act's exchanges were sicker on average and more likely to be treated for serious illnesses than individuals with employer-sponsored coverage, according to two studies, the New York Times reports.

For one study -- conducted by pharmacy-benefit manager Express Scripts -- researchers analyzed data from a national sample of five million prescription drug claims filed by individuals enrolled in exchange coverage between January and July.

For the second study -- conducted by pharmacy-benefit manager Prime Therapeutics -- researchers analyzed data from prescription drug claims filed by exchange plan enrollees between January and June.

Study Findings

Both studies found that, exchange plan enrollees filled prescriptions at similar rates as those with employer-sponsored plans.

However, Express Scripts found exchange plan enrollees were age 43.6 on average, compared with 36.7 for people with employer-sponsored coverage.

Meanwhile, Prime Therapeutics found that prescription drug treatments for HIV and hepatitis C comprised about 18.5% of total drug costs for exchange plan enrollees, with spending on the drugs 228% and 160% higher, respectively, compared with individuals with employer-sponsored coverage. Express Scripts found that HIV medications were the most costly prescription drug treatment among exchange enrollees, at 11.3% of drug spending, but were not in the 10 most costly drug treatments for those with employer-sponsored plans.

In addition, Express Scripts found that spending on specialty drugs accounted for 38% of total prescription drug spending for exchange plan enrollees, compared with 28% for people with employer-sponsored coverage. Despite exchange enrollees spending more on such drugs, Express Scripts found that insurers spent about 10% less -- $59.83 a month versus $66.80 a month -- on average for exchange enrollees' prescription drugs compared with those with employer-sponsored coverage because of exchange enrollees' higher out-of-pocket costs.

In addition, Express Scripts found that near-deadline exchange plan enrollees were on average healthier than earlier enrollees, with 13.3% of early enrollees receiving prescription drugs for high cholesterol, compared with about 6.5% of near-deadline enrollees (Thomas, New York Times, 10/7).