Tuesday, July 12, 2016

About one in five ACA marketplace enrollees should be in Medicaid

In March 2015, I calculated that about 2 million enrollees in the  ACA private plan marketplace  had incomes that would have qualified almost all of them for Medicaid if they did not live in states that had refused to implement the ACA Medicaid expansion. I estimated that these enrollees with incomes between 100% and 138% of the Federal Poverty Level (FPL)  represented about a third of all enrollees in nonexpansion states and about 22% of all marketplace enrollees.

It was necessary to estimate because until yesterday, HHS's income breakouts for marketplace enrollees used a range of 100-150% FPL. Those in the 139-150% FPL range are eligible for private plan subsidies in all states; almost all of those from 100-138% FPL are subsidy-eligible only in nonexpansion states (the exception is legally present noncitizens time-barred from Medicaid, who are subsidy eligible at any income level below 400% FPL). Based on the percentage of enrollees from 100-150% in the expansion states, almost all of whom would be over 138% FPL, I estimated that 68% of those in the 100-150% FPL band in nonexpansion states were under 139% FPL, and so mostly "should have been" in Medicaid.

Yesterday, in a new data release of ACA enrollment by county in the 38 states using HealthCare.gov, HHS provided a 100-138% FPL band for the first time. And it turns out I way underestimated the percentage of 100-150% FPLers who were in fact under 139% FPL. Charles Gaba has done the math (with a proportionate estimate for Idaho, the only nonexpansion state not using HealthCare.gov and so not included in the HHS income breakout). 85% of those previously shown in the 100-150% FPL range are under 139% FPL.  36.4% of all enrollees in the nonexpansion states are in the 100-138% FPL band.

In Louisiana, currently implementing a Medicaid expansion effective July 1, 86% of those in the 100-150% FPL band are between 100% and 138% FPL -- and so nearly all of those 84,,807 private plan enrollees are currently eligible for Medicaid.

As Charles points out, the fact that there are roughly 258,000 enrollees with incomes in the 100-138% FPL band in expansion states gives some idea of the percentage in that band who may be either legally present noncitizens barred from Medicaid, or ineligible for marketplace subsidies and paying full freight.

IN all, 28% of the 9.6 million enrollees on HealthCare.gov and so probably about 24% of all marketplace enrollees (3 million in all, counting the state-based marketplace enrollments) are in the 100-138% FPL band. Most of them would be Medicaid eligible if the expansion were universal.

More on this in a bit - have to run.

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