Blue Cross Blue Shield Association Examines The Health Conditions And Costs Of Caring For Newly Enrolled Individual Members In 2014 And 2015

Data show newly enrolled individuals received significantly more medical care

CHICAGO – 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.

For more information, visit

* The study includes individuals who purchased coverage through both state-based and federally-facilitated marketplaces, as well as individual, ACA-compliant policies sold outside of the government marketplaces. The data were collected from independent BCBS companies and focus on members ages 21 through 64 (excludes Medicare and Medicaid).

About BHI

Health Intelligence Company is the nation’s premier health intelligence resource, delivering data-driven insights about healthcare trends and best practices, resulting in healthier lives and more affordable access to safe and effective care. HIC accesses healthcare claims data from more than 140 million individuals nationwide, collected over nine years, in a safe, HIPAA compliant and secure database. The resulting conformed, reliable data set has the broadest, deepest pool of integrated medical and pharmacy claims, reflecting medical utilization in every ZIP code. Health Intelligence Company, LLC operates under the trade name Blue Health Intelligence (BHI) and is an Independent Licensee of BCBSA. For more information, visit

About Blue Cross Blue Shield Association

The Blue Cross and Blue Shield Association is a national federation of 35 independent, community-based and locally operated Blue Cross and Blue Shield companies that collectively provide health care coverage for one in three Americans. BCBSA provides health care insights through The Health of America Report series and the national BCBS Health Indexsm. For more information on BCBSA and its member companies, please visit We also encourage you to connect with us on Facebook, check out our videos on YouTube and follow us on Twitter.

The Blue Cross Blue Shield Association is an association of 35 independent, locally operated Blue Cross and/or Blue Shield companies.