Saturday, March 31, 2018

Open thread: How Trump's cutoff of CSR funding affected Maryland enrollment

My last post looked at the drop-off in silver plan selection among Marylanders eligible for strong Cost Sharing Reduction subsidies in 2018. CSR is available only with silver plans. When Trump cut off federal funding for CSR, insurers in Maryland priced it into on-exchange silver plans only,which generated large discounts in bronze and gold plans for subsidized buyers . For an explanation of how that worked, see the first note at bottom. For a summary of the discounts to the subsidized on offer in Maryland in 2018, see the second note.

Today, let's kick back and squint at the changes in metal level choices in Maryland at each income level (including the upper brackets this time) from 2017 to 2018. I'll offer a couple of observations below the charts now, and maybe more through the weekend. I invite you to offer your own.

Here are the percentages who chose each of the three main metal levels in each income band in both years. In both years, a bit under half of all enrollees had incomes under 200% of the Federal Poverty Level, and so were eligible for strong CSR (about 98% of them, anyway).  At bottom, the raw numbers at each metal level are charted, courtesy of the Maryland Health Connection. (Platinum and catastrophic plans accounted for 3% of enrollment between them in both years.)

2017

Income (% FPL)
% bronze
% silver (CSR)
% gold
< 100 
 3
96
  0.7
100-138
 4
95
  0.5
138-150
 7
92
  0.5
150-200
10
88
  1.0
0-200 (strong CSR)
 7
92
  0.8
200-250 (weak CSR)
21
74
  3.2
250-300
30
60
  6.0
300-400
31
57
  7.4
>; 400
33
48
11.6
Unknown
26
54
11.0
Total
18
74
 0.5

2018


Income (% FPL)
% bronze
% silver (CSR)
% gold
< 100
<100 p="">
10
80
  7
100-138
  8
84
  7
138-150
  9
83
  8
150-200
13
76
10
0-200 (strong CSR)
11
79
  9
200-250 (weak CSR)
24
46
28
250-300
32
32
33
300-400
37
25
34
> 400
42
24
27
Unknown
35
34
22
Total
23
55
19


Thoughts:

1. Maryland's 2017 enrollment is a kind of platonic ideal of ACA marketplace selection. To the extent that ACA subsidies are sufficient -- and they're not sufficient -- the choices reflect the architecture as it was designed to work. CSR takeup is the highest I've seen in any state in any year -- 92% among those eligible for "strong" CSR, which boosts the actuarial value of a silver plan from a baseline of 70% (for those with no CSR) to 94% (for those up to 150% FPL) or 87% (for those from 150-200% FPL). That's roughly platinum-equivalent (90% AV) for plans priced as if they had an AV of 70%. Choices among those with incomes above 200% FPL make sense too, as both bronze and gold choices rise steadily with income.

2. Choices in 2018, when bronze plans were nearly free to everyone under 200% FPL and gold plans were either close in price to silver (for about 85% of enrollees)  or slightly cheaper than silver (for about 15%) are also pretty on-point. The main problem, as noted in the prior post, is a dropoff in CSR takeup. Those under 200% FPL who bought gold chose "dominated" plans -- that is, plans offering less AV per premium dollar than silver (though in rural counties the cheapest gold plan was a few pennies cheaper -- literally -- than cheapest silver). On the other hand, the extraordinarily high level of gold selection among those above 200% FPL reflects pure bounty for an under-subsidized cohort (excepting the subsidy-ineligible, for whom gold was merely less overpriced than silver).

3. In both years, Maryland has a large number of enrollees with incomes unknown. HealthCare.gov, serving 39 states, always has a much smaller but still substantial "unknown" contingent -- generally 6-7%.  I have always assumed that most enrollees in the "unknown" category have incomes too high to qualify for subsidies. The Maryland breakout more or less bears this out, as choices at that level are fairly close to those of those with incomes over 400% FPL.

That's it for now. Any thoughts, please comment. Here are the raw numbers as supplied by MHC. You may note that the 2017 totals are about 17,000 higher than those reported at the end of OE 2017. I'm told they reflect enrollment as of Dec. 22, 2017. That's strange, because there's usually steady attrition throughout the year. In both years, though, the somewhat higher silver selection and lower bronze selection among the "unknowns" suggests to me that some fraction of them may actually be subsidized, and their incomes undetermined for some reason, though reported. I'd like to ask the MBH compilers about this.

I'm doing this by snip because these charts keep generating HTML problems.

Note: Effects of CSR funding cut-off 

To review briefly: when Trump cut off federal reimbursement of insurers for the Cost Sharing Reduction subsidies they're legally required to provide to lower income ACA marketplace enrollees who select silver plans (57% of marketplace enrollees in 2017), most states allowed or required insurers to concentrate the cost of CSR in premiums for silver plans only. States in which 70% of individual market enrollees live concentrated the cost of CSR in on-exchange silver plans only, allowing for cheaper silver plans to be sold off exchange.

Since ACA premium subsidies are keyed to the price of the benchmark (second cheapest) silver plan in each rating area, subsidies rose to cover inflated silver premiums, generating often dramatic discounts in non-silver plans, i.e. gold and bronze (platinum availability and purchase is negligible). In many states, steep increases in silver plan premiums resulted in zero-premium bronze plans becoming available to many buyers (or nominal $1-3/month premiums), and gold plans that were either cheaper than silver or close in price.

Cheap gold plans were a particular boon to enrollees with incomes between 200% and 400% of the Federal Poverty Level (FPL). These buyers are not eligible for strong CSR, which makes silver plans roughly equivalent to platinum plans for buyers up to the 200% FPL threshold. Normally,  enrollees in the 200-400% FPL range would pay between 6% and 10% of their income (percentage rising with income) for a benchmark silver plan with an actuarial value of 70%, i.e. with an average deductible of around $3600). With CSR priced into silver plans in 2018, gold plans  (80% AV, with an average deductible of around $1100) came within reach of many in this income range.  Gold plan selection quadrupled in Maryland in 2018.

Note 2: Gold and bronze discounts in Maryland, 2018

Throughout the state, all subsidy-eligible enrollees with incomes below 200% of the Federal Poverty Level (FPL) could obtain an bronze plan for under $20 per month. Most at this income level -- e.g., everyone over 30 -- could get a bronze plan for under $4 per month. In the state's most populous counties, subsidy-eligible buyers could get a gold plan for just a few dollars more than a silver one.  And in several rural counties, an enormously expensive benchmark (second cheapest) silver plan, which determines subsidy size, rendered silver and gold plans as well as bronze plans free for many enrollees. For more detail, see note in this post.

Maryland 2018 Series (Maryland was first out with detailed enrollment data for 2018)
A downside to silver loading: CSR takeup drops in Maryland (3/28/18)
Who'd be hurt by restored federal CSR funding? A snapshot from Maryland (3/18/18)
Choosing a metal level in the CSR-addled Maryland marketplace (1/12/18)
Subsidized ACA marketplace enrollment rose 2% in Maryland in 2018
Maryland ACA enrollment spotlights effects of Trump's CSR sabotage (1/8/18)

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