Monday, August 15, 2016

Could the ACA help the Democrats take Florida?

The latest battleground state polls show Trump trailing Clinton by a narrow margin in Florida, a must-win state for him. One factor tilting the Florida field against Trump is surging voter registration among Latinos.  As flagged by Greg Sargent, Politico's Marc Caputo reports:
Since the 2012 presidential election, Florida’s voter rolls have grown by 436,000 — and only 24 percent of that increase is from non-Hispanic white voters while non-whites grew by 76 percent, according to new voter registration numbers released in advance of the Aug. 30 primary.

The number of Hispanic voters leaped by 242,000, which was 55 percent of the increase. Latinos are now 15.4 percent of the voter rolls, up from 13.9 percent overall in 2012, when President Barack Obama narrowly carried Florida thanks to the outsized backing of minority voters.

Recent Florida polls show Trump is losing the Hispanic vote by historic margins to Hillary Clinton after the Republican’s incendiary comments about illegal immigrants, which offended a broad array of Latino leaders, including many in his own party.
Latino voters have no shortage of reasons to reject Trump.  But what about positive motives to come out for Clinton and the Democrats generally? The Affordable Care Act -- generally a political loser for Democrats to date -- could be a factor. Latinos in particular, and minorities generally, have benefited hugely from the ACA in Florida. Here are the salient enrollment facts:
  • Notwithstanding state government hostility, Florida has had the most successful ACA private plan enrollment in the nation. 1.7 million Floridians enrolled in plans via HealthCare.gov during open enrollment, which ended Jan. 31,  and 1.5 million were still enrolled as of March 31 -- a relatively low attrition rate compared to most states (many never make their first premium payment). 
  • Fully 91% of Florida enrollees obtained premium subsidies -- the highest percentage in the nation. And according to the Kaiser Family Foundation's estimate, 92% of state residents who were eligible for premium subsidies were enrolled as of March 31 -- again, the highest percentage in the nation.  In marked contrast to the nation as a whole, the Florida marketplace is firing on all burners.
  • Among the slightly more than half of Florida enrollees who reported their ethnicity*, 33% were Latino. Another 14% were African American, and 6% were Asian -- two other groups that have no cause to love Donald Trump (for HHS table, see p. 25 here).

  • If 33% of the entire Florida enrollee population (including those who did not report ethnicity) is Latino, enrollees would constitute about 11.5% of the state's Latino population.
  • Zooming in on the state's three largest counties by enrollment: In Miami-Dade County, which accounted for almost a quarter of state enrollments, 74% of enrollees who reported their ethnicity (though just 42% did so) were Latino. In Broward County, 33% of those who declared ethnicity identified as Latino, 31% as African American, and 6% as Asian. In Palm Beach County, 27% of those reporting ethnicity were Latino, 22% African American, and 6% Asian. In Orange County, 38% of ethnic self-identifiers were Latino, with African Americans accounting for 16% and Asians 12% . (HHS county data is here.)
  • Most Florida private plan enrollees obtained plans that cover a high percentage of their out-of-pocket costs. 71% of the state's enrollees obtained Cost Sharing Reduction (CSR) subsidies with their plans -- and over 90% of those CSR-enhanced plans have an actuarial value of either 94% or 87% (actuarial value is the percentage of the average user's medical costs the plan is designed to cover).

  • Private plan enrollment would have been much more modest had the state's Republican governor and legislature not rejected the ACA Medicaid expansion. Among  the 96% of Florida enrollees who provided income information, a staggering 48.3% had incomes between 100% and 138% of the Federal Poverty Level (FPL), which would qualify them for Medicaid had the state expanded eligibility.
  • While subsidized private plans have covered most previously uninsured Floridians in the 100-138% FPL income range, the state's refusal to expand Medicaid leaves those below the poverty line (100% FPL) in the cold. According to Kaiser's most recent estimate, about 560,000 Floridians are in the "coverage gap" -- earning too little to qualify for subsidized private plans, but denied the Medicaid the ACA was designed to provide (before the Supreme Court made the expansion optional for states in 2012). And in fact, enrollment in several states that expanded Medicaid late have exceeded Kaiser estimates.
In  2010, Democrats paid in political blood for enacting the ACA, which mainly benefits the lower third of the nation's income distribution. In 2014 and 2015, Democrats did not seem to benefit from dramatic drops in the uninsured rate in states with heavy ACA enrollment. In the most noteworthy example, Kentucky, which slashed its uninsured rate from 22.5% in 2013 to 9.6% in 2015 under Democratic governor Steve Beshear, elected  avowed enemy of the ACA Matt Bevin as governor in 2015, placing Medicaid coverage for 428,000 expansion beneficiaries at risk. But minority turnout is much higher in presidential elections, as is turnout among lower income voters generally.  The prospect of maintaining or obtaining subsidized coverage may help boost Democratic turnout in 2016.

If the presidential race reverses its apparent current course and tightens dramatically it would be a sweet irony for Democrats if ACA enrollees and coverage gappers helped put them over the top in Florida or elsewhere.

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* Only 53% of Florida's enrollees reported their ethnicity. How representative are they? Cynthia Cox of Kaiser points me to this Kaiser tool that provides demographic data by zip, but for the whole population, not the potential ACA market per se. With that caveat, she notes, "Quickly comparing the reported enrollment demographics to the area demographics in Miami Dade, they don’t seem radically different. (Assuming people would select “White” if they are non-Hispanic white, and “Latino” if they are Hispanic, and keeping in mind that we don’t know the local demographics for those who are actually eligible to enroll)". I would add that while in parts of other counties cited above, African American enrollment is about double the group's percentage in the overall population, that may make sense assuming that whites are wealthier on average and likelier to have access to employer sponsored insurance.

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