Thursday, February 15, 2018

On HealthCare.gov, CSR takeup rose steadily from 2015 through 2017

One aspect of ACA marketplace enrollment that's intrigued me ever since HHS started producing enrollment statistics is "CSR takeup" -- the percentage of enrollees who are eligible for Cost Sharing Reduction (CSR) subsidies who access the benefit by selecting silver plans, the only level at which CSR is available.

Silver can be expensive for low income enrollees -- a benchmark silver plan costs an enrollee with an income at 200% of the Federal Poverty Level about $125 per month. At the same time, up to 200% FPL, CSR dramatically reduces out-of-pocket costs. (The benefit is much weaker for those in the 200-250% FPL range, and silver plan selection tapers off accordingly among enrollees over 200% FPL.)

One fact that's escaped me until now: CSR takeup rose steadily from 2015 through 2017, at least in the states using the federal exchange, HealthCare.gov (as 37 states did in 2015 and 39 in 2017). That's been somewhat obscured by the fact that the percentage of all enrollees with CSR has not risen. But enrollees' income mix on the federal platform has shifted upward as states on the platform enacted late Medicaid expansion, and as two states that expanded Medicaid early, Hawaii and Kentucky, came on board the federal platform. In 2015, 78% of enrollees were known to have incomes under 251% FPL. In 2017, 74% were below that threshold.


Here are the percentages of CSR takeup among HealthCare.gov enrollees in 2015, 2016 and 2017. A bit of extrapolation is involved to determine the number of enrollees with incomes up to 250% FPL, the threshold for CSR eligibility, and, in 2015 and 2016, the number who obtained CSR, as explained in the note at bottom.

CSR Takeup on HealthCare.gov, 2015-2017

Year
Enrollees with incomes up to 250% FPL
Enrollees with CSR
CSR takeup
2015
6,897,300
5,303,275
76.9%
2016
7,197,522
5,679,329
78.9%
2017
6,847,317
5,513,078
80.5%

Why has CSR takeup ticked up? I don't know. It could be that HealthCare.gov ramped up its signposting and steering of CSR-eligibles toward silver plans in each year. By 2017, CSR-eligibles were prompted to view silver plans first once their eligibility was determined, though they could opt to "view all plans" instead. I'm not sure of the evolution from 2016 and 2015, though I did periodically check in on CSR signposting in those years.

Perhaps, too,  enrollment assisters grew more aggressive about highlighting CSR as they gained experience over the years, though that's pure speculation.

It may also be that enrollees with CSR stayed with the marketplace longer, whether because they're sicker or because they're more satisfied with their plans. A couple of smidgens of evidence on that front: 1) Every year, California separately reports enrollment for new enrollees and for all enrollees, and silver plan takeup is always higher among all enrollees; 2) In July 2016, CMS put out a brief touting low median deductibles among HealthCare.gov enrollees as of April 2016, by which point those who never paid their first premiums were shaken out of the totals. The breakout of enrollees at each metal level and CSR level included  showed a higher level of CSR takeup -- about 3 percentage points higher -- than the earlier "final enrollment report" issued before that early-month attrition. Apparently, CSR enrollees dropped coverage at a lower rate than those who lacked the benefit.

Another factor is where and when CSR is available at a discount. ACA premium subsidies adjust for income and are based on the cost of the second-cheapest (benchmark) silver plan in each rating area. IN some cases, the cheapest silver plan costs substantially less than the benchmark, making CSR more affordable. I was able to trace the effects of such discounts in California in 2015, and in two adjacent rating areas in particular. But I don't have the wherewithal to compare cheapest silver vs. benchmark spreads across many states and years, though perhaps Cynthia Cox at Kaiser could manage it.

In any case, CSR takeup was really quite high in 2017, considering the large bite that silver plans can take out of low incomes. For those with incomes up to 200% FPL, where the benefit is really strong, it's several points higher than the overall takeup rate. That was made clear in the above-mentioned July 2016 CMS brief, which showed the percentage of HealthCare.gov enrollees at each level of CSR. From that I was able to derive takeup at each level of CSR as of April 2016. Again, these numbers are after early-month attrition, and so higher than those reported immediately after open enrollment ends.

CSR Takeup: HealthCare.gov states, 2016

Income
range
CSR
coverage
level
Enrollees
in income
range
Enrollees
With
CSR
Takeup
Percent-
age
0-150% FPL
Silver94
3.64m
3.18m
87%
151-200% FPL
Silver87
2.21m
1.83m
83%
201-250% FPL
Silver 73
1.33m
866k
65%


[Update, 2/16/18: Just noticed that in a prior post I broke out the even higher CSR uptake in 2017:

Metal Level Selections at Different Income Levels (% FPL)
HealthCare.gov states, 2017

                               Strong CSR             Weak CSR               No CSR
Metal level
100-150% 
150-200%
200-250%
250-300%
300-400%
Other
Total
bronze
 9.2%
14.4%
27.1%
39.4%
40.2%
36.2%
21.5%
silver
89.4%
83.2%
67.6%
54.4%
52.0%
43.7%
74.2%
gold
 <  1%
 1-2%
  4-5%
 5-6%
~  7%
  19%
 3-4%

Derived from CMS public use files for 2017]

The rise in CSR takeup will soon prove to have been arrested in 2018. That's due to the distortion in the market triggered by Trump's cutoff of federal payments to insurers for CSR, which hitherto was not priced into marketplace plans but rather was reimbursed to the insurers, as the statute directs. For 2018,insurers had to price in the value of CSR. Most states allowed them to concentrate the cost in silver plans, which led to large discounts for subsidized buyers in bronze and gold plans. The results are evident in state reports from Maryland and California, both of which saw large increase in gold plan selection and more modest increases in bronze.  In Maryland, as I've noted, CSR takeup dropped, though not so dramatically among those with incomes up to 150% FPL, for whom CSR provides the greatest added value.

Note on enrollment estimates

The sources for these enrollment numbers are the state-level public use files for 2017 and HHS  ASPE enrollment reports for 2016 and 2015 (in those years state PUFs don't report CSR enrollment, or not in more detail than the ASPE reports).

In 2015 and 2016, enrollees with CSR were reported as a percentage of all enrollees -- 60% in 2015, and 59% in 2016. In the table above, "Enrollees with CSR" is derived from taking those percentages from total enrollment. In 2017, the total number of CSR enrollees is given in the state public use file.

As for enrollees with incomes below 250% FPL, in 2015 and 2016 those also are derived from percentages reported at each income level -- among those enrollees for whom income is known. In 2015, income was unknown for 6% of enrollees, and in 2016, for 7.6%. I have assumed that those for whom income is unknown have incomes above subsidy eligibility, as those who are ineligible for subsidies do not have to report income. While some of those who did not report income may have incomes below 251% FPL, a small percentage of those who do report income below that level are subsidy-ineligible (because of an offer of insurance from an employer), and I'm assuming that those small subsets cancel each other out.

In 2015 and 2016, a percentage was given for enrollees with incomes below 100% FPL (2% in 2015 and 3% in 2016). In 2017, that category was rolled into "other income," along with income over 400% FPL and income unknown. I have therefore added 3% to the 2017 total for income up to 250% FPL, or 276,000 enrollees.

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