Thursday, July 09, 2015

Where are Pennsylvania's low-income 2014 private plan enrollees?

As I've noted before,  I've been been trying to determine what happened to Pennsylvania's apparently large number of  low-income 2014 private plan enrollees who became eligible for Medicaid when the state belatedly enacted the ACA Medicaid expansion, effective Jan. 1 2015. My working hypothesis has been that large numbers of them stayed auto-enrolled in QHPs -- or re-enrolled prior to the expansion kickoff in December. Detailed enrollment data released by HHS early this month calls that notion into question however.

Here was the original premise. Most of Pennsylvania's 2014 enrollees in private plans (so-called Qualified Health Plans, or QHPs) re-enrolled for 2015.  As of May 2014, Pennsylvania had 318,000 enrollees. As of the end of open enrollment in mid-Feburary 2015, 276,732 were re-enrolled, according to the breakout HHS published this month. A large percentage of those re-enrollees might now be Medicaid-eligible -- and so theoretically ineligible for private plan subsidies. I had originally estimated that about one third of QHP enrollees as of late 2014 -- perhaps 90,000 -- had incomes under 138% of the Federal Poverty Level (FPL), which would qualify them for Medicaid. Then I learned that by February, CMS had compiled a a list of 141,000 Pennsylvania households with at least one QHP enrollee determined to be Medicaid-eligible (CMS has confirmed this for me.)  If accurate, that's close to or more than half of PA's QHP enrollees as of late 2014 (Those households had some 175,000 members).

Moreover, for 2015 the state had 160,961 auto-enrollments - enrollees who took no action and so were automatically re-enrolled in their 2014 plan or a substitute provided by their insurer.  That suggests a large potential pool of people who may not have noted or chose to ignore their eligibility for what was originally Pennsylvania's "private option" Medicaid expansion, which was quite rocky at the outset.

Why am I now questioning this premise? The current income distribution of Pennsylvania's QHP enrollees, revealed in the data HHS published in early July, looks more like that of an expansion state than a nonexpansion state. As of of the end of open enrollment in mid-February 2015, 131,470 out of a total of 472,697 Pennsylvania QHP enrollees, or 28%, had incomes in the 100-150% FPL range.

In March, HHS provided aggregate income data for enrollees in the 37 states on healthcare.gov, contrasting the states that had expanded Medicaid with those that had refused.  In nonexpansion states 47% of enrollees had incomes in the 100-150% FPL range (unfortunately, HHS does not break out enrollment for those between 100% and 138% FPL, the population that would gain Medicaid eligibility when a state expands). In expansion states, just 22% of enrollees are between 100% and 150% FPL. Since Medicaid is available to those with incomes under 138% FPL in expansion states, all enrollees in those states that HHS places in the 100-150% FPL band actually have incomes ranging from  just 138-150% FPL. In Pennsylvania as of mid-February, 131,470 out of a total of 472,697 -- again, 28% -- had incomes in the 100-150% FPL range.

If we assume that as in other expansion states, 22% of Pennsylvania's new enrollees in 2015 had incomes from 100-150% FPL, one calculation suggests that a substantial number of Medicaid-eligibles remain in QHPs, while another suggests that they may be transitioning out at an appropriately fast pace.

As of February 22, 131,470 Pennsylvania QHP enrollees had incomes from 100-150% FPL.  If 22% of new enrollees, or 43,108, had incomes in that range, then so did 88,362 re-enrollees We should account, however, for attrition as of March 31 (mostly no-pays) that HHS recorded in numbers released in June, In Pennsylvania, that attrition was 9.6%. If proportionate in all income groups, that suggests about 79,900 re-enrollees with incomes from 100-150% FPL by that point. How many of them were in the 100-138% range and so eligible for Medicaid? We don't know. I've previously calculated that in all nonexpansion states, a bit more than two-thirds (67.8%) of those in the 100-150% FPL band have incomes below 138% FPL.** That would suggest about 54,000 Medicaid-eligibles still in QHPs as of 3/31.*

On the other hand, if my assumption that about 22% of new enrollees were in the 100-150% FPL range is accurate, then just 31% of re-enrollees (88,362 out of 276,732 as of 2/22) had incomes in that range. That's only 9 percentage points above the norm (22%) for expansion states in this income band -- and again, in expansion states as a group, the 22% in this band actually all have incomes in the narrow income sliver from 138-150% FPL.  22% of all re-enrollees would be 60,881, leaving only about 19,000 Medicaid-eligible people still in QHPs  as of 3/31.

On balance I'd have to say that the evidence suggests that my original premise is exaggerated, and that Medicaid-eligible Pennsylvanians may be transitioning out of QHPs at a reasonable rate. Perhaps the number of Medicaid-eligibles who were still in QHPs as of 3/31 was somewhere between 54,000 and 19,000. Since Medicaid enrollment continues year-round, presumably the number transitioning from QHPs to Medicaid may have grown further since then. The enrollment has been somewhat rocky, and those who were potentially eligible for Medicaid were advised to first apply and only disenroll from their QHPs when their Medicaid enrollment was confirmed.

I really can't reconcile Pennsylvania's apparent low QHP disenrollment rate and high percentage of 2014 QHP enrollees with incomes under 138% FPL with the relatively lower percentage of current enrollees in the 100-150% FPL range. Something does not quite compute.
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* Of course, in expansion states, the proportion of enrollees in the 100-150% FPL income band with incomes under 138% is zero.)

** My estimate of the percentage of those in the 100-150% FPL band who have incomes at or under 138% FPL may be conservative; Charles Gaba estimates 76%.

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