Tuesday, April 01, 2025

Tell Congress: Hands off Medicaid!

 

Tell Congress: Hands off Medicaid!

·      Huge cuts to Medicaid are pending: The budget resolution that passed the House with no Democratic votes directs the Energy & Commerce Committee to cut federal spending by $880 billion in ten years – almost all of which would have to come from Medicaid.

·     The Affordable Care Act’s Medicaid expansion is on the chopping block: The ACA provides Medicaid to 21 million poor and near-poor adults (550,000 in our state). House Republican leadership has made it clear that they intend to eliminate dedicated federal funding for the ACA Medicaid expansion – a $650 billion spending cut.

·       Uninsuring millions: If the federal 90% contribution for “expansion” enrollees is eliminated, no state will be able to afford to maintain the expansion.  Based on past estimates by the Congressional Budget Office, 15-20 million people will lose coverage.

·      Republicans are lying about their plans: Republican leadership, and on-board representatives  like Tom Kean Jr. (NJ-7), say that they will “protect” Medicaid for children, seniors and the disabled and only cut “waste, fraud, and abuse.” In Republican-speak, “waste” means coverage for low-income adults.

·      Say no to work requirements: Republicans also aim to make all states impose “work requirements” on most adult Medicaid enrollees – though the vast majority of non-disabled enrollees either work or are caregivers or students.  Work requirements have been tried – and the red tape drives eligible Medicaid recipients off the rolls in droves – as Republicans intend.

Take Action

·       Contact NJ’s Republican House Reps: Tell them Hands off Medicaid! Preserve the ACA Medicaid expansion. Say no to work requirements.

Jeff Van Drew (NJ-2) --  (202) 225-6572 or ( 609) 625-5008
Chris Smith (NJ-4) –  (202) 225-3765 or (732) 780-3035
Tom Kean Jr. (NJ-7) -- (202) 225-5361 or  (908) 547-3307

Van Drew and Smith, both of whom would prefer not to cut Medicaid, are receptive to out-of-district calls; Kean, not so much.


Thursday, March 27, 2025

Defend the ACA Medicaid Expansion directly

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The Maginot Line

Forgive me for slipping into Ancient Mariner mode here, but I must again voice my obsessive plea to elected Democrats, healthcare advocates, and all those who don’t won’t to see 15-20 million Americans uninsured: Defend the ACA Medicaid Expansion! Explicitly!

As documented in my last two posts (1, 2), House Republican leadership is almost certainly coalescing on defunding the expansion — that is, ending the 90% federal match rate for low-income adults rendered eligible by the expansion’s criteria — 21 million of them at last count, as of June 2024. Since Trump ordered his troops to “cherish” Medicaid and not “touch” it while also commanding passage of a budget resolution that would cut hundreds of billions of dollars in Medicaid funding, they justify this $650 billion cut in the name of “protecting” Medicaid for children, the disabled, and elderly enrollees — those Medicaid was “originally designed for.

By long reflex, stakeholders defending Medicaid more often than not mount their defense in the name of the same vulnerable groups Republicans are vowing to “protect.”* Here is the core defense in a letter from Families USA, co-signed by more than 300 advocacy groups, to Senate Majority Leader John Thune, asking him to reject the house budget resolution:

Monday, March 24, 2025

New Jersey may follow Texas and other states and make gold plans cheaper than silver

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I delivered this testimony today to the NJ Senate Commerce Committee in favor a bill that would put gold and silver plan pricing roughly on a par in year one and price silver at a 90% AV in year 2.  Laura Waddell of New Jersey Citizen Action also testified in favor. The bill passed out of Committee on a 5-0 vote.

TESTIMONY BEFORE SENATE COMMERCE COMMITTEE

March 24, 2025
Statement by Andrew Sprung
Health Care Committee Co-chair, BlueWaveNJ

Re:  S1971 -  An Act imposing certain rate filing requirements concerning certain health benefits plans available on the state-based exchange.

Chair Lagana, Vice Chair Cryan, and members of the Committee:

S1971 would correct a severe pricing imbalance in New Jersey’s ACA marketplace that weakens coverage for middle-income enrollees in health plans offered on GetCoveredNJ.

At a time when the fate of the enhanced premium subsidies established by the American Rescue Plan Act is uncertain, as under current law they are funded only through 2025, S1971 would also increase federal premium subsidies at no cost to the state and so partially offset the rising costs to enrollees that would result from expiration of the ARPA subsidy enhancements.

The imbalance: New Jersey is unique among U.S. state marketplaces in that in New Jersey gold-level plans – the metal choice that offers a coverage level closest to the average employer-sponsored plans – are priced out of reach for almost all enrollees.  In New Jersey in 2024, just 1.4% of on-exchange enrollees selected gold plans, versus a national average of 12.5%. Nationally, the lowest-cost gold plan premium in each state market is 4% higher than the lowest-cost silver premium in 2024. In New Jersey in 2025, the lowest-cost gold premium is priced 41% above the lowest-cost silver plan.

In Pennsylvania and Texas, two states that have taken measures similar to S1971, lowest-cost gold plans are priced well below lowest-cost silver plans, as shown below, and bronze plans are also a relative bargain.  

Wednesday, March 19, 2025

Democrats are fighting the last war on Medicaid

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See update at bottom for the purest expression of emerging Republican policy and messaging in the drive to cut Medicaid— from Brian Blase, Republicans’ chief ideologist on this front.

What’s wrong with this Democratic Party broadside against Republican plans to cut federal Medicaid funding?


The problem: In their likeliest path to cutting Medicaid, Republicans may well leave coverage for kids and seniors more or less untouched. They’re gunning for a different group of enrollees: 20 million low-income adults rendered eligible by the ACA Medicaid expansion.

Thursday, March 13, 2025

The Tom Kean code: ACA Medicaid expansion is "waste"

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See 3/17/25 update at bottom.

A man may smile, and smile, and uninsure 20 million

I have an op-ed up this today on nj.com decoding a statement by the famously uncommunicative Rep. Tom Kean Jr. (R-NJ-7) that signals in Republican-speak that he’s on board with defunding the ACA Medicaid expansion. Below is the TLDR:

* * *

How will Republicans honor Trump’s promise not to “touch” Medicaid while reducing federal funding for the program by hundreds of billions of dollars? Leave it to purported “moderate” Rep Tom Kean Jr. (NJ-7) to channel the emerging MAGA party line. On March 6, Kean told the Record:

I support strong Social Security, Medicare, and Medicaid programs for those who depend on them. Children, seniors, and those who are disabled rely on these crucial programs…I do not support these programs being riddled with waste, fraud, and abuse — that is a direct threat to their actual missions.

While Kean vows to protect coverage for children, seniors, and the disabled, note the group of Medicaid enrollees his vow excludes: low-income adults who are not on disability. That’s the group rendered eligible for Medicaid by the Affordable Care Act. They are the “waste” Republicans propose to uninsure to help fund the resolution’s target $4.5 trillion in tax cuts for corporations and the wealthy....

Thursday, March 06, 2025

WSJ editorial board: Insuring low-income "able-bodied" adults is a waste of federal money

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Providing ideological cover for Republicans who seek to cut hundreds of billions of dollars out of federal Medicaid funding, the Wall Street Journal editorial board would have you believe that federal Medicaid spending is out of control, that rich states get more than their fair share of federal Medicaid funding, that cuts to the projected spending growth rate under current law are not cuts, and that Medicaid isn’t much worth having anyway. That’s all false of course.

Let’s look at these nostrums one by one.

Undue spending in Medicaid growth. The WSJ editorialists write:

Medicaid spending as a share of federal outlays rose to 10% from 7% between 2007 and 2023, while the share of Social Security and Medicare remained stable.

Well yes, of course. The ACA Medicaid expansion, rendered optional by the Supreme Court in 2012, offered Medicaid eligibility to all lawfully present U.S. adults with income up to 138% of the Federal Poverty Level, excepting those subject to a federal 5-year bar on new immigrants. As of the program’s full launch in 2014, 24 states had enacted the expansion, and as of now, 40 states plus D.C. have done so. Medicaid enrollment has accordingly grown by 38% since 2013 (and had swelled even higher as of 2023, the year cited by the Journal, as a result of the pandemic-induced three-year moratorium on disenrollments. Medicaid enrollment has dropped 17% since the 2023 peak.)

Democratic states grab more than their fair share of federal largesse. We are asked to believe:

Democratic-run states receive disproportionately more federal Medicaid dollars. New York received $3,046 for each state resident in 2023 based on the most recent federal data. Federal Medicaid dollars also subsidize California ($2,167 per resident) and Illinois ($1,715) much more than Florida ($991) and Texas ($1,239).


Friday, February 28, 2025

On gutting/not gutting Medicaid

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Van Drew promises to square a circle



I have not posted for the last couple of weeks because I’ve been engaged, as co-chair of the healthcare committee of Blue Wave New Jersey, in the effort to stop the savage cuts to Medicaid written into the House Republican budget resolution that passed on a strict party line vote on Tuesday night.

New Jersey has three Republican House members: Jeff Van Drew, a lapsed Democrat (NJ-2); Chris Smith, who voted against ACA repeal in 2017 (NJ-4); and Tom Kean, who represents one of the country’s most competitive districts (NJ-7).

Below is a version of a note that went to the Blue Wave healthcare committee that I think captures a couple of key points about where we’re at in the battle to prevent the gutting of Medicaid.

Saturday, February 15, 2025

The ACA's 2025, projected

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Project 2025ifying the ACA

On February 10, KFF (f.k.a. the Kaiser Family Foundation) hosted a webinar on the fate of the ACA under Republican rule (read the transcript). Moderated by Larry Levitt, who oversees all research at KFF — probably the chief nongovernmental source of data on U.S. healthcare coverage and usage — the discussion featured Cynthia Cox, director of KFF’s ACA-related research; Sarah Lueck, VP for Health Policy at the Center on Budget and Policy Priorities; and Brian Blase, president of the Paragon Institute, a conservative think tank, and former special assistant to Trump at the White House’s National Economic Counsel.

Blase is noteworthy as an inveterate enemy of the ACA marketplace, ACA Medicaid expansion, and really Medicaid generally, which he would shrink radically, as Republicans in Congress are now proposing. His Paragon Institute has put out position papers recommending that the enhanced premium subsidies enacted in 2021 in the American Rescue Plan Act (ARPA), which are funded only through 2025, not be extended, and that the federal funding mechanism for the ACA Medicaid expansion — a 90% federal match rate (or FMAP) — be phased out over ten years, along with further cutting the FMAP for “wealthy” states. The 90% FMAP phase-out appears to be envisioned in the Republican House budget resolution released this week.

Blase provides an ideological basis for Republicans to refuse to extend the ARPA subsidies — and in so doing, wields a political cudgel against Republican reps who would prefer not to uninsure tens of thousands of their constituents by letting the enhanced subsidies expire. So what he says is worth listening to for its likely practical effect.

Blase’s case against extending the ARPA subsidy increases is based mainly on allegations of pervasive fraud in ACA applications. These allegations, as Cox and Lueck acknowledged, have a basis in truth, as agent-induced fraud increased rapidly in 2023 and 2024. But as Lueck suggested, Blase exaggerates the extent of fraud and would needlessly disenroll millions to combat it. I responded to his arguments in detail in this post and added a TLDR in this one, pasted as a noted below.

What stood out to me in the roundtable was Blase’s concessions to those aiming to salvage as much of the marketplace status quo as possible under Trump. Those concessions reflect Trump’s grudging intimations in the campaign that he was not looking to repeal the ACA, which in public perception means the ACA marketplace — though Republicans are apparently aiming again to defund the ACA Medicaid expansion, which was always the submerged core issue. (Larry Levitt kept this discussion away from Medicaid.)

Here were the noteworthy concessions, if that is the right word:


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No abolition: While Blase wants to stand up an ACA-noncompliant market as the Trump administration did in 2018 — that is, a market of medically underwritten plans not required to cover Essential Health Benefits or provide an out-of-pocket limit — he acknowledges that eradicating the ACA marketplace is not on the table. Below, he complains about the year-round enrollment for people with income below 150% FPL implemented by the Biden administration in early 2022. In that context, he concedes (my emphasis):

If you're going to have guaranteed issue and community rating... And I think we have decided that there's a political consensus to have a market that has guaranteed issue and community rating... You need to have an open enrollment period, otherwise you're going to have severe adverse selection forces that come in and disrupt that market.

The counterargument here is that year-round enrollment is appropriate at low incomes, where people’s situations change frequently and awareness about available programs is low. Medicaid enrollment is year-round, and the income bracket in which year-round enrollment is currently available in the marketplace is capped at a level — 150% FPL — only slightly above the ACA’s Medicaid eligibility level, 138% FPL (inoperative in nonexpansion states, where most marketplace enrollment below 150% FPL occurs). Moreover, year-round enrollment at 100-150% FPL has probably had an effect opposite to adverse selection, in that much of it is driven by year-round agent/broker marketing (some of it fraudulent), which is finding people who otherwise would not have enrolled and giving them something for free with relatively little friction.

But I digress. The point worth noting here is the alleged political consensus to more or less leave the ACA marketplace standing as it was pre-ARPA — albeit probably adulterated and confused by a more robust ACA-noncompliant parallel market than the one Trump 1.0 managed to stand up.

Preserving part of ARPA: Blase voices the conservative chestnut that people who get zero-premium health coverage (e.g., 79 million Americans on Medicaid?) don’t value it. (Lueck countered by citing positive feedback from low-income enrollees, and Cox alluded to usage data showing that they are getting needed care.) Blase regards the ARPA subsidy boosts at the low end of the income spectrum as wasteful — notwithstanding (or because) the ARPA subsidy boosts drove enrollment at the 100-150% FPL income level from 3.9 million in 2021 to 9.4 million in 2024,* with most of those gains coming in states that have refused to expand Medicaid. He alleges widespread fraud in the income estimates of people whose applications put them in this income bracket, untroubled by the fact that the 6-odd million enrollees who claim income in the 100-138% FPL range in the ten states that have not expanded Medicaid would be in Medicaid if their states accepted the expansion (which he also regards as wasteful spending).

On the other hand, the smaller contingent of those who gained coverage because ARPA removed the income cap on subsidy eligibility — about 1.5 million** — do gain his sympathy and willingness to help.

Cynthia Cox recounted that the pre-ARPA subsidy cliff did hurt a significant number of modestly affluent people, and that their predicament was a political cudgel against the law (as well as a genuine failure to live up to its promise of affordable coverage for all):

So this was a really vocal group. It's a relatively small number of people, but it was a group that was arguably harmed by the Affordable Care Act. Especially if they were relatively healthy before, they might've gotten a lower premium. And then with the protections that were put in place with the ACA that required that people with pre-existing conditions be able to get coverage, premium increases were probably fairly common for this group, and they didn't get a subsidy to offset it. So this was a really sympathetic group, especially in 2016 [sic] when we were talking about repealing and replacing the Affordable Care Act. It was often that news coverage would focus in on a really sympathetic group like a family, maybe a small business owner or a farmer or an entrepreneur who didn't get coverage through their job but did have a fairly good income, but it just wasn't enough to afford full-price insurance.

Blase agrees that something should be done about the pre-ARPA subsidy cliff (my emphasis):

We should have unsubsidized options for upper/middle income people to choose. I do think if I was going to keep any portion of the enhanced subsidies, I would look at the area just above 400% of the poverty line, at least until there's some broader ACA reforms. Because in some parts of the country, premiums are really expensive and I think there would be an abrupt cut at 400% of the poverty line, and you could think about keeping a portion of those subsidies. That's not my preferred policy. My preferred policy is to eliminate the enhanced subsidies entirely and pursue regulatory changes to the ACA. But if Congress was looking to keep a portion of them, I think that is where they should focus.

So there you have it. Whether the Republican-controlled Congress does anything to improve the marketplace’s pre-ACA subsidy schedule depends on whether Republicans can pass any budget legislation without Democratic votes — and if not, how much leverage Democrats can muster and to what extent they’ll concentrate it on healthcare generally or the marketplace in particular. The other wildcard, as with anything related to the federal government now, is Musk, DOGE, Russell Vought, as the possibility of unconstitutional executive branch meddling with financing and programs currently in place or altered by the current Congress.

Revolutionary fascist interference of the DOGE variety aside, Blase, whose work is cited twice in the Project 2025 blueprint (and who appeared in this webinar sporting a 2025 sweatshirt or sweater), is a major ideological influence on Republican healthcare policy. His own blueprint for health coverage policy — leave the pre-ARPA ACA marketplace more or less in place, possibly provide some relief for some prospective enrollees with income above 400% FPL, stand up a medically-underwritten, lightly regulated parallel market, and defund the Medicaid expansion — probably represents mainstream Republican policy. It remains possible that Democrats will be able to salvage some or even all of the ARPA subsidy schedule, perhaps with a short-term extension, and — more importantly — fend off major Medicaid cuts. It’s also possible that DOGE will slash and burn the programs as established by law, or that the team assembled by RFK Jr. will catastrophically mismanage all programs. But the policy course outlined here is worth noting.

- - -

Here is my TLDR re Blase’s attack on the post-ARPA marketplace (again, from this post on Vance’s October remarks about Trump’s ACA plans :

Republican opponents of ARPA subsidy expansion are leaning heavily on a paper by Brian Blase, formerly a special assistant to Trump’s National Economic Counsel, alleging rampant overpayment of subsidies in the ACA marketplace. Blase does have a legitimate complaint in the recent explosion of unauthorized enrollment and plan-switching by unscrupulous ACA brokers. That fraud was stimulated in part by ARPA’s zeroing out of premiums for benchmark coverage for enrollees with income under 150% FPL (currently $21,870 for an individual), in combination with an administrative rule enacted in early 2022 that allows not only year-round enrollment to people below that threshold, but also a monthly Special Enrollment Period (SEP), enabling endless plan-switching. While I agree with Blase that that monthly SEP should be eliminated, and that CMS needs to act aggressively to quell broker fraud (as it appears to be doing), Blase attacks the subsidy enhancements with more dubious claims fraud in ACA enrollees’ income estimates — that is, raising or lowering income estimates to maximize subsidies (or access them at all). To those claims, I responded in detail here. The TLDR:

1) Most of the Post-ARPA enrollment increase in the ACA marketplace, as well as most of the increase at incomes where Blase alleges fraud is concentrated, is in states that have refused to enact the ACA Medicaid expansion, where most adults who estimate their incomes below 100% FPL get no government help at all. If substantial numbers of enrollees do in fact have incomes below 100% FPL, the solution is to…enact the ACA Medicaid expansion. People with income below 100% FPL should not be left with no access to affordable coverage.

2) ACA subsidies are based on an estimate of future income, which is inherently uncertain, especially for people at low incomes, who often work uncertain hours, change jobs, are self-employed, or depend on tips. Mismatches between income reported to the IRS and income projected in ACA applications probably have as much to do with inaccuracies in tax reporting as with inaccurate income projections in the ACA application. As for mismatches between income data based on ACA enrollment and data from the Census Bureau’s consumer surveys, those, like mismatches between IRS data and survey data, are perpetual.

3) Blase misreads CMS figures regarding former Medicaid enrollees, disenrolled in the post-pandemic “Medicaid unwinding,” who enrolled in the ACA marketplace in 2024. In HealthCare.gov states, according to CMS tracking, about a third of Medicaid disenrollees enrolled in the marketplace — not 70%, as Blase claims.

CMS needs to stop the broker fraud; should probably end the monthly SEP (though not year-round first-time enrollment for those with income under 150% FPL); and perhaps ramp up income checks on enrollees who may be underestimating their income (as opposed to overestimating it to get over the 100 % FPL threshold). Killing the ARPA subsidies to quell broker fraud would be throwing the baby out with the bathwater. But of course that baby — affordable insurance for those who lack access to affordable employer-sponsored health insurance — is a perpetual target for Republicans. And killing the ARPA subsidy boosts would further another core Republican goal — undermining the ACA’s protections for people with pre-existing conditions.

- - -

* In 2024, 6.9 million marketplace enrollees reported income in the 100-138% FPL range. In the broader 100-150% FPL category, 9,407,463 enrolled in 2024. The 100-138% FPL bracket was not reported in 2021, the last pre-ARPA year. From 2021 to 2024, enrollment in the 100-150% FPL bracket increased from 3.8 million to 9.4 million. That’s an increase of 5.5 million, more than half of the total increase of 9.4 million from 2021 to 2024. See the Marketplace OEP Public Use Files. To compare all-state totals at 100-150% FPL for 2021 and 2024 I excluded Idaho, which did not provide income breakouts to CMS in 2021.

** In 2024, 1.5 million on-exchange enrollees nationwide reported income above 400% FPL, which would have rendered them ineligible for subsidies pre-ARPA. Another 856,000 did not report income at all, most of whom probably knew they were ineligible for subsidies even with the post-ARPA 8.5%-of-income cap on the premium for a benchmark silver plan.

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Friday, January 31, 2025

Girding for healthcare battle at Families USA's Health Action 2025

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The Families USA conference convened in February 2017 felt a bit like the U.K. after the Dunkirk evacuation — an all-hands-on-deck mobilization to prevent Republicans from tearing down what many of those present* had worked for decades to build (the ACA, and Medicaid as it had evolved over decades).

It was my first Health Action conference, and I was heartened by the concentrated expertise and determination of the speakers — activists and advocates, healthcare scholars, former government officials — who shared a wealth of practical knowledge as to how to move elected officials and mobilize people with stories to tell.

Though I’m not a Lord of the Rings fan, I was reminded of a scene where the fellowship accompanying Frodo and his fellow hobbits on their quest to deep-six the ring of power is assaulted by a pack of super-wolves. As the wolves circle, there’s this exchange:

My heart’s right down in my toes, Mr. Pippin,’ said Sam. ‘But we aren’t etten yet, and there are some stout folk here with us. Whatever may be in store for old Gandalf, I’ll wager it isn’t a wolf’s belly.’

The dominant chord was struck by incoming FUSA executive director Frederick Isasi: "Our action should lead to inaction" — that is, failure to pass a repeal bill. That dictum proved prophetic.

At this year’s conference, the mood was grimmer but the determination was the same, as was the focus on grassroots action. As to the legislative prospects compared to 2017, both the stakes and the odds are hard to gauge — they appear both better and worse.**

Monday, January 27, 2025

ACA marketplace enrollment growth in 2025 reflects year-round enrollment

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Renewals tend to increase over the years (until they don't)

Writing about the ACA marketplace at this point has an elegiac feel (as does writing about almost any not-depraved or degraded aspect of American life). As of 2026, coverage is likely to be far less affordable, out of pocket costs will rise as more enrollees fall back on bronze plans, and enrollment is likely to drop precipitously. And that’s a near-best-case scenario, barring repeal or some kind of not fully imaginable regulatory assault (or judicial assault, e.g., on free preventive care).

That said, I’ve been mulling this year’s new peak in enrollment, driven primarily by a large number of renewals. That’s fueled not only by the 31% year-over-year enrollment surge in OEP 2024 but by continuous off-season enrollment for applicants with income under 150% FPL (in place since early 2022) and by off-season enrollment from those disenrolled from Medicaid during the unwinding, which was essentially done by last summer. (New enrollment dropped from 5.2 million in OEP 2024 to 3.9 million in OEP 2025.)

All that said, I wanted to look at year-round enrollment patterns through the Trump and Biden eras. I no longer refer to the January-to-December enrollment fluctuations as a question of “retention,” as there has been so much off-season enrollment since 2022; a slight drop or even increase from January to December does not give a clear picture of how long people are remaining enrolled. On the other hand, one perhaps-obvious fact that jumps out from the table below is that in all years, almost everyone who is enrolled as of December renews, actively or passively. And in the Biden years, thanks mainly to the ARPA subsidy boosts, fall-off from the end of OEP to “early effectuated enrollment in February is minimal - -that is, the auto-re-enrolled do not drop coverage in droves when the first premium payment (often $0, thanks to ARPA) is due (retention also improved through the Trump years, as cuts to outreach and marketing and a shortened OEP apparently culled more marginal enrollees).