More About Sarah Lueck

Sarah Lueck

Lueck joined the Center in November 2008 as a Senior Policy Analyst.

Full bio and recent public appearances | Research archive at

Fewer People Having Trouble Paying Medical Bills

January 20, 2015 at 3:55 pm

Fewer people skipped needed health care due to its cost or reported trouble paying medical bills in 2014, a new survey finds.  These improvements, the first since the Commonwealth Fund began asking these questions roughly a decade ago, came as health reform’s major coverage expansions took effect in 2014.

Among the survey’s findings:

  • The number of people ages 19-64 without health insurance showed a statistically significant drop for the first time in the history of the biennial survey, from 36 million in 2012 to 29 million in 2014. The share of the population without insurance fell from 19 to 16 percent.
  • The share of people who failed to get needed health care because of cost fell from 43 percent in 2012 to 36 percent in 2014. This means fewer people said they skipped a recommended test, didn’t fill a prescription, avoided visiting a doctor or clinic when having a health problem, or failed to see a specialist for needed follow-up care.
  • The number of adults who reported problems with medical debt (such as difficulty paying bills) fell from an estimated 75 million in 2012 to 64 million in 2014.  The share of the population reporting these problems fell from 41 to 35 percent.
  • Critics of health reform suggested it would harm young adults, but the opposite appears to be the case. People ages 19-34 made the biggest coverage gains of any age group between 2012 and 2014, with those with incomes below about $47,000 for a family of four seeing the greatest improvement.

As the survey report notes, the gains in health coverage—and the related reductions in people’s financial problems — may partly reflect an improving economy.  However, the coverage gains were far greater in the recovery from the 2007-09 recession, just as health reform took effect, than in the recovery from the previous (2001) recession, our analysis of Centers for Disease Control and Prevention data shows — a sign that health reform’s coverage expansions also played an important role.

Health reform enabled millions of people to obtain more affordable coverage in 2014, through both the Medicaid expansion in many states and the creation of insurance marketplaces that provide federal subsidies to reduce people’s premiums and cost-sharing charges.  Health reform also improved access to coverage by barring health insurers in the individual market from denying coverage or charging higher premiums to people with health problems, and it limited how much insurers could charge older people compared to younger people.

Even before 2014, the law began improving access to coverage, including by requiring most insurance plans to cover adult dependents up to age 26 beginning in 2010.

Millions of Americans still have trouble affording health care, and we need to do more to address that problem.  But, in part due to health reform, the situation is looking up.

Another Health Reform Attack Falls Flat

October 2, 2014 at 3:00 pm

Many health reform opponents warned that people buying health insurance in the individual market would face a sharp, pervasive spike in premiums.  The Manhattan Institute predicted that “Obamacare” would bring double-digit premium increases, while the Heritage Foundation wrote, “individuals in most states will end up spending more on the exchanges” (or marketplaces) than they previously paid.  Not only did those dire predictions fail to come true, but there’s good news to report about premiums as open enrollment under the Affordable Care Act (ACA) approaches.

To be sure, some people buying coverage in the pre-health reform individual market saw their premiums rise, partly due to more robust benefits and market reforms under the ACA that barred insurers from charging higher premiums to people with health conditions.  But for many others, health reform’s consumer protections and premium subsidies to buy marketplace coverage brought lower premiums or the ability to buy coverage for the first time.  Now, as the November 15 start of the ACA’s second open enrollment season draws closer, the outlook for 2015 premiums in the individual market is even more encouraging.

Unsubsidized premiums for the silver-level “benchmark” plans in 16 cities around the country are falling by an average of 0.8 percent compared with 2014, according to a recent report by the Kaiser Family Foundation.  The cheapest bronze-level plan (a basic plan under health reform) in those same areas is rising by an average of just 3.3 percent in 2015.

Those rate changes mark an improvement over the pre-ACA market.  Individual-market health insurance premiums rose an average of 10 percent each year in 2008 through 2010, according to a Commonwealth Fund study.  For 2014 to 2015, the consulting firm PricewaterhouseCoopers estimates a 7 percent average increase in premiums (across all plan tiers and without accounting for subsidies) in the individual markets of those states for which it has data.  Premiums for the cheapest silver plans will rise an average of 8.4 percent in select states that the McKinsey Center for U.S. Health System Reform reviewed.

Of course, preliminary 2015 premiums vary significantly from state to state and insurer to insurer.  This variation means some consumers could see a higher price tag in 2015 for the plans they have now.  But many will be able to find coverage for the same or a lower price — provided they’re willing to shop around during open enrollment.

The bottom line: widespread rate shock isn’t happening.  Yet another attack on health reform is falling flat.

Big Issue for Insurance Marketplaces Is Enrollees’ Health, Not Age

February 14, 2014 at 1:02 pm

Despite what you may have heard, the share of enrollees in the new insurance marketplaces who are young isn’t the most critical factor in determining whether the marketplaces’ risk pool will be well balanced and whether their premiums may have to increase next year.  Instead, the health status of enrollees is far more important.  That’s the conclusion of a recent Commonwealth Fund-organized gathering of insurers, actuaries, researchers, and federal officials.

The misplaced idea that success hinges on whether enough young people sign up — since young people are generally healthier and thus less costly to cover — has gained undeserved traction in recent months.  And the release of the latest federal data on marketplace enrollment, including a breakdown by age, will likely bring renewed attention to the number of young enrollees.  But, as a Commonwealth report summarizing the meeting concludes, “there is no single right percentage for young adult participation.”

We made the same point a few weeks ago, explaining that the health status of enrollees at all ages is far more important in producing a balanced risk pool and ensuring that the marketplaces will have stable and affordable premiums over time.  Also important is how well each insurer predicted who would sign up for coverage this year.  If an insurer’s enrollees cost far more than it anticipated in setting its 2014 premiums, it might raise premiums in 2015 to better reflect its expected costs.

The Commonwealth Fund report also highlights some factors that could limit any losses that insurers may experience this year, which in turn could tamp down any 2015 premium increases.

For example, health reform’s risk corridors (along with its other risk-mitigation programs) limit insurers’ potential losses as the law’s major reforms take effect in the individual market and the new marketplaces become fully established.  And two health reform requirements — that insurers justify premium increases of 10 percent or more and spend a set percentage of their premiums on medical care rather than administration and profits — are expected to help hold down any rate increases in 2015.

It’s Too Soon to Go Negative on Health Reform’s Marketplaces

February 3, 2014 at 3:46 pm

Moody’s recently changed its outlook for health insurers from stable to negative, based in part on concerns about whether enough young, healthy people are enrolling in plans through the new health insurance marketplaces (also known as exchanges) under health reform.

This announcement by the well-known credit rating agency stoked another round of fretting about the marketplaces’ viability.  But it’s far too early to draw conclusions about the marketplaces.

Moody’s based its industry outlook in part on the mix of the insurance risk pool:  whether enough people with lower health costs will join, balancing out the higher costs of those with greater health needs.  But the data that will answer this question is still being generated, as we have explained — and it’s far more individualized per company than the rating agency’s sweeping, industry-wide generalization.

And although Moody’s cited a concern that that enrollment of younger people is lagging, the health status of enrollees is far more important to the risk pool’s balance than their age.

Risk pooling occurs within each state and on an insurer-by-insurer basis.  How any given insurance company that offers marketplace plans will fare depends substantially on how accurately it predicted who would enroll in its plans and the costs they would incur.  (WellPoint, one of the major Blue Cross and Blue Shield insurers, has highlighted this, saying that its preliminary analysis of who is enrolling in its plans is tracking with its assumptions when it set its marketplace premiums.)

Moody’s said several issues contributed to its negative outlook for the insurance industry.  For example, it said the Obama Administration’s recent decisions to allow people more time to enroll for 2014 and to keep policies that don’t comply with all the 2014 standards may add more risk than it previously expected for insurers this year.  But another factor that Moody’s raised is older news:  the coming announcement of reduced Medicare Advantage payments for 2015, which merely involves implementation of scheduled cuts enacted under health reform.  Moody’s assessment of the health insurance industry should have already factored in those cuts.

Amid the speculation about the impact that health reform will have on private insurance markets, it will take time to understand what is happening in this first year of implementation.  It’s far too early to declare that the news is bad.

Don’t Panic Over Early Health Reform Enrollment Data

January 15, 2014 at 1:57 pm

New federal data show that enrollees in health reform’s new health insurance marketplaces are somewhat older than some expected, spurring talk that premiums could rise and even that the law itself is at risk.

But it’s no time to panic, for several reasons.

  • First, it’s early.  People have until March 31 to enroll in marketplace coverage, and enrollment will likely grow substantially by then.  The new data show a swell of enrollment among younger people in December, and federal officials said they expect that to continue.
  • Enrollees’ health status matters more than their age in determining whether the marketplace has a balanced, stable risk pool.  A 20-year-old with significant health needs costs an insurer more to cover than an older person who doesn’t use many medical services, and insurers need healthy people of all ages to balance out the pool.  (As the Kaiser Family Foundation’s Larry Levitt tweeted:  “Will we get the 60-year-old gym rats?”)  We aren’t likely to know the relative health of marketplace enrollees for some time — until enrollees start using health services and insurers examine their claims data.
  • Whether the pool is balanced is a state- and insurer-specific question.  The new data show national and state-specific enrollment in the insurance marketplaces.  But 2014 risk-pooling occurs within each state and on an insurer-by-insurer basis; it also includes enrollees in the individual market outside of the marketplaces as well as marketplace enrollees.  When thinking about how the 2014 risk pool could affect what premiums insurers charge in 2015, what really counts is how accurately a particular insurer predicted the mix of people it would enroll in its plans in a given state when it set its 2014 premiums (and what it expects for 2015).  If an insurer’s enrollees are in poorer health, on average, than the insurer predicted for 2014 and the insurer expects the trend to continue in 2015, it could raise premiums for 2015.  But if actual enrollment was in line with expectations, there should be no effect on premiums.
  • Even a sicker-than-expected pool of enrollees won’t necessarily translate to significantly higher premiums in 2015.  Insurers will weigh a number of factors when they set their 2015 premiums, such as who they expect to enroll next year and how their prices will stack up next to their competitors.  Some companies will want to keep premiums down to maximize their market share as more people become familiar with health reform’s benefits and enroll in marketplace plans, and as the penalty for not having health insurance further encourages healthy people to obtain insurance.  In addition, health reform already includes several programs to compensate insurers if their costs are higher than expected, and insurers will factor that into their 2015 premium rates.