Blue Cross Blue Shield Association study: newly enrolled ACA individuals received significantly more medical care

A new study by the Blue Cross Blue Shield Association (BCBSA) shows that individuals who enrolled in Blue Cross and Blue Shield (BCBS) health plans after the Affordable Care Act (ACA) took effect have higher rates of disease and received significantly more medical care, on average, than those who enrolled in BCBS individual plans prior to 2014.

The report, “Newly Enrolled Members in the Individual Health Insurance Market After Health Care Reform:  The Experience from 2014 and 2015,” represents a comprehensive, in-depth study of actual medical claims among those enrolled in individual coverage before and after the ACA took effect. The study also compares this group to those who receive insurance through their employers. Comparing health status and use of medical services among these three groups, the study finds that:

  • Members who newly enrolled in BCBS individual health plans in 2014 and 2015 have higher rates of certain diseases such as hypertension, diabetes, depression, coronary artery disease, human immunodeficiency virus (HIV) and Hepatitis C than individuals who had BCBS individual coverage prior to health-care reform.
  • Consumers who newly enrolled in BCBS individual health plans in 2014 and 2015 received significantly more medical care, on average, than those with BCBS individual plans prior to 2014 who maintained BCBS individual health coverage into 2015, as well as those with BCBS employer-based group health insurance.
  • The new enrollees used more medical services across all sites of care—including inpatient admissions, outpatient visits, medical professional services, prescriptions filled and emergency room visits.
  • Medical costs of care for the new individual market members were, on average, 19 percent higher than employer-based group members in 2014 and 22 percent higher in 2015. For example, the average monthly medical spending per member was $559 for individual enrollees versus $457 for group members in 2015.

BCBS companies across the country have participated in the new marketplaces more broadly than any other insurance carrier. Millions of newly enrolled BCBS members thus provide the largest single group of individuals whose health status and use of medical services can be examined for key insights into the medical needs and costs associated with providing care.

“The findings underscore the need for all of us in the health care system, and newly insured consumers, to work together to make sure that people get the right health care service in the right care setting and at the right time,” said Alissa Fox, senior vice president of the office of policy and representation for BCBSA. “Better communication and coordination is needed so that everyone understands how to avoid unnecessary emergency room visits, make full use of primary care and preventive services and learn how to properly adhere to their medications.”

BCBS companies also are expanding patient-focused care programs that emphasize prevention, wellness and coordinated care so that new individual members get healthy faster, and stay healthy longer.

“Through these programs, BCBS companies around the country have documented reductions in emergency room visits, fewer hospital admissions and readmissions and reduced hospital infection rates,” Fox said. “At the same time, there have been measurable improvements in prevention, including improved cholesterol control, better adherence to best practices for treating diabetes and higher rates of screenings and immunizations.”

BCBS companies serve millions of members through the ACA marketplaces in 46 states and the District of Columbia, with coverage in 89 percent of counties in both urban and rural areas. In addition to offering products on the federal and state-run marketplaces, all BCBS companies sell individual and group health insurance products throughout the country. BCBS companies insured more than 8.6 million individual members through Dec. 31, 2015.

This is the sixth study of the Blue Cross Blue Shield, The Health of America Report series, a collaboration between the Blue Cross Blue Shield Association and Blue Health Intelligence, which uses a market-leading claims database to uncover key trends and insights into health care affordability and access to care.




The percentage of the bill you pay after your deductible has been met.


A fixed amount you pay when you get a covered health service.

Tiered benefit plan

A health care plan featuring multiple levels of benefits based on the network status of a particular provider. 


The annual amount you pay for covered health services before your insurance begins to pay.

emergency care services

Any covered services received in a hospital emergency room setting.


Includes behavioral health treatment, counseling, and psychotherapy

in-network provider

A provider contracted by your insurance company to accept an agreed upon payment for covered services. 

OUT-OF-network provider

A term for providers that aren’t contracting with your insurance company. (Your out-of-pocket costs will tend to be more expensive if you go to an out-of-network provider.)


Your expenses for medical care that aren’t reimbursed by insurance, including deductibles, coinsurance and co-payments.


If you can afford health insurance, but choose not to buy it, you must have a health coverage exemption or pay a tax penalty on your federal income tax return.


The amount you pay to your health insurance company each month. 

Preventive services

Health care services that focus on the prevention of disease and health maintenance.


Services and devices to help you recover if you are injured or have surgery. This includes physical, occupational and speech therapy.

special enrollment period

The time after the Open Enrollment Period when you can still purchase health insurance only if you have a qualifying life event (losing other health coverage, having a baby, getting married, moving).


A physician who has a majority of his or her practice in fields other than internal or general medicine, obstetrics/gynecology, pediatrics or family practice.