Four-star review The star ratingsare largely new to the federal exchanges, which operate in 39states. (Image: Shutterstock)

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ST. LOUIS — As millions of Americans shop for individual healthinsurance for 2020, they will see federal ratings comparing the qualityof health plans on the Affordable Care Act's insurancemarketplaces.

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But Christina Rinehart of Moberly, Mo., who has bought coverageon the federal insurance exchange for several years, won't beswayed by the new five-star rating system.

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That's because only one insurer sells on the exchange where the50-year-old former public school kitchen manager lives in centralMissouri. Anthem Blue Cross Blue Shield in Missouri was not rankedby the Centers for Medicare & Medicaid Services.

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"I'm pleased with the service I get with that and the coverage Ihave," she said, noting she focuses on cost and whether hermedications and checkups are covered.

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Read more: ACA premiums to fall 4 percent next year–but noteverywhere

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Rinehart's case illustrates one reason why the star ratings areunlikely to play a big role in people's decision-making for thefirst year of the national rollout. Nearly a third of health planson the federal exchanges don't yet have a quality rating —including all the plans in Iowa, Kansas and Nebraska. Only oneinsurer is available in nearly a quarter of counties across the U.S. And consumers maynot find the information behind the star ratings valuable withoutadditional details, insurance experts say.

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Across Missouri, Cigna is the only one of seven insurers to getratings. The others have not yet been in the marketplace for thethree years needed to merit a score.

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Missouri is one of eight states that don't have any health plansthat earned at least three stars. The others are Iowa, Kansas,Nebraska, Nevada, New Mexico, West Virginia and Wyoming. Stateswith the most three-star or higher health plans are New York (12), Michigan(10), Pennsylvania (9), Massachusetts (8) and California (7).

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The star ratings are largely new to the federal exchanges, whichoperate in 39 states. About 80 percent of plans in the federal marketplaces earnedthree or more stars overall, CMS said. Only 1 percentearned five stars.

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The new federal star ratings are based on three main areas:evaluations of the plans' administration, such as customer service;clinical measures that include how often the plans providepreventive screenings; and surveys of members' perception of theirplan and its doctors.

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Ratings can be viewed at healthcare.gov, where consumersreview plans' benefits and prices. Open enrollment runs from Fridaythrough Dec. 15 for the federal exchange states, though enrollmentlasts longer in the District of Columbia and most of the 11 statesthat operate their own marketplaces.

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Last year, about 11.4 million people bought coverage on all theexchanges, with more than 80 percent getting federalsubsidies to lower their premiums.

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The good news for consumers is premium prices on the federalexchanges are dropping by about 4 percent on average for2020.

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And consumers generally will have a wider array of choices asmore companies enter the markets. Nationally, the average number ofhealth plan choices per customer has risen from 26 to 38, accordingto Joshua Peck, co-founder of Get America Covered, a nonprofit thathelps people enroll and find coverage. Missouri, for example, willhave 28 plans from its seven insurers, he said, up from 14 thispast year.

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Jodi Ray, who runs Florida's largest patient navigator programas director of FloridaCovering Kids & Families at the University of SouthFlorida, is skeptical consumers will use the new ratings. Instead,she said, they will likely focus first on whether their doctor ison the plan, if their medications are covered, the size of thedeductible and the monthly costs.

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"The star ratings may fall out the door at that point," shesaid.

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Many of the states that operate their own exchanges have alreadyoffered quality ratings, which were required under the ACA.California's insurance exchange has been providing quality ratingsfor several years, though it's unclear how much weight consumersgive them.

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"They have a limited effect on consumers but have a significanteffect on health plans," said Peter Lee, executive director ofCovered California, the state's insurance exchange. "It does tiphealth plans to focus on what they can do to improve care, and Ithink that is a positive effect."

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Kaiser Permanente (which is not affiliated with Kaiser HealthNews) is the only insurer in the California exchange to garner themaximum five stars, Lee said. It also has the most enrollment ofany plan in the state's exchange. But, he noted, the plan has alower share of the enrollment in Southern California partly becauseits prices are higher compared with rival insurers, indicating lowcost may trump high rankings in attracting enrollees.

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"It's good news that nationally the federal marketplace isputting quality data out there for consumers," Lee said. Still, headded, customers would want to see the specific criteria thatmatter to them, such as how well plans care for patients withdiabetes. Currently, that data is not immediately accessible forconsumers at healthcare.gov.

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Consumers tend to stick with their insurer even when prices andbenefits change, said Katherine Hempstead, a senior policy adviserat the Robert Wood Johnson Foundation, the nation's largest publichealth philanthropy. "People think changing health insurance plansis a huge pain and they don't know if things will get better orworse." But, she added, "people respond to consumer ratings andreviews."

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The federal government already uses star ratings to helpconsumers choose a Medicare Advantage plan as well as comparehospitals. It began testing the exchange ratings in a handful ofstates over the past two years.

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Heather Korbulic, executive director of the Nevada healthexchange, worries the ratings could be steered by a relativelysmall number of member surveys. "It's such a narrow sample," shesaid, noting one plan's rating was partly based on just 200 memberreviews.

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Even though many counties have only one insurer in 2020 ― mostof them rural areas or clustered in the Southeast ― the number ofenrollees with access to just one insurer is falling to 12 percent next year from20 percent now.

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In Missouri, that's the case in more than two-thirds of thecounties. Sidney Watson, director of the Center for Health LawStudies at St. Louis University, attributes the lack of choices inMissouri to the failure to expand eligibility for Medicaid. Peoplewho earn between 100 percent and 138 percent ofthe poverty line who would be eligible under Medicaid expansioninstead are enrolling in marketplace plans, she said. Since theytend to be less healthy, they drive up premiums in themarketplaces.

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States that have not expanded Medicaid see premiums that are7 percent higher than states that have, according to a2016 study from the U.S. Department of Health and HumanServices.

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"If you look at Arkansas, they've got nice competition in theirmarketplace, but they've also expanded Medicaid," Watson said. "Welook a lot like Mississippi, which is struggling to get insurancein rural counties."

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That leaves people, like Rinehart, stuck with one insurer.

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Rinehart remains loyal to Anthem particularly after it helpedher get care and deal with the costs of suffering four heartattacks in 24 hours nearly three years ago. She's thrilled Anthem'sprices are down slightly for 2020.

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"I wasn't able to afford insurance before [the Affordable CareAct]," she said, "so it was a blessing to have."

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Kaiser HealthNews (KHN) is a national health policy news service. It is aneditorially independent program of the Henry J. Kaiser Family Foundation whichis not affiliated with Kaiser Permanente.

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