As the ACA market shifts,brokers in some states have moved significant numbers of individualclients into ACA-compliant small group coverage, when possible.(Photo: Getty)

Brokers offer their perspective on the impact of the latestAffordable Care Act policy changes in the report, “Views From the Market — Insurance Brokers'Perspectives on Changes to Individual Health Insurance,” postedon the Robert Wood Johnson Foundation blog by Georgetown Universityresearchers.

Consumers buying plans on ACA exchanges had already been facedwith increasingly limited plan choices, relatively narrow providernetworks and rising unsubsidized premiums, but in the past year,policy decisions made by Congress and the Trump administration have“exacerbated trends,” according to the researchers.

Related: Medicaid expansion cheaper than ACAsubsidies

Such policy decisions include the repeal of the individual mandate penalty, cuts to ACA-relatedoutreach funding and enrollment assistance, and the encouragementof alternative coverage options that are exemptfrom the ACA's consumer protections, such as short-term limitedduration insurance and association health plans.

Brokers' compensation for selling ACA-compliant individualmarket health insurance has declined, leading brokers to reducetheir participation in the market, according to the report.

“Brokers cited reduced or eliminated commissions and the amount of time it takes tohelp someone through the enrollment process, particularly thoseeligible for premium assistance,” the researchers write.

Healthy, higher-income consumers are being pushed out of theindividual market, brokers told the researchers. The ACA appears tohave spurred increased demand for coverage among those previouslyuninsured, but significant premium increases in the states withinthe study — combined with fewer plan options and limited providernetworks — resulted in a decline in enrollment in ACA-compliantcoverage among higher-income and healthier consumers.

Healthy consumers are considering less-expensive products withfewer benefits and less consumer protections over ACA-compliantindividual market insurance, particularly short-term plans andhealth care sharing ministries.

“Short-term plans and HCSMs do not need to comply with the ACA'sconsumer protections, often exclude preexisting conditions andoften do not cover benefits such as maternity, mental healthservices, or prescription drugs,” the researchers write.

Brokers also report interest in direct primary care arrangements and fixedindemnity plans. Brokers in some states have moved significantnumbers of individual clients into ACA-compliant small groupcoverage, when possible. Small-group market plans in these statestend to have lower premiums and wider provider networks than ACAmarketplace options. Some brokers are also interested in thepotential growth of AHPs, and brokers in Iowa showed particularenthusiasm about the future Iowa Farm Bureau plan.

Most broker respondents operating in states within the studyreport receiving higher commissions for selling non-ACA-compliantcoverage options, such as short-term plans, fixed indemnity plans, andHCSMs. Brokers also reported extensive efforts by HCSMs to offertrainings to educate them about their coverage model anddirect-to-consumer marketing of HCSMs and short-term plans.

All the brokers in the study sell some alternative coverageoptions to people who are ineligible for subsidies and looking forless expensive coverage. Many brokers expect these markets willgrow, particularly for short-term plans and AHPs, in the wake offederal regulations designed to expand their sale.

“At the same time, the marketing of other alternative productsto brokers, including health care sharing ministries and directprimary care arrangements, is increasing,” the researchers write.“Consequently, the individual health insurance market is expectedto become smaller and sicker.”

Brokers also predict that premium rates will increase forACA-compliant plans, pushing more healthy people into cheaper,less-comprehensive alternatives. The study focused on states withparticularly fragile markets that had higher than average increasesin premiums and a loss of insurers in recent years.

“But with the elimination of the individual mandate penalty andthe expansion of alternative coverage options, many states that donot take steps to protect their ACA-compliant market could facesimilar instability,” the researchers write.