Thursday, July 12, 2018

No, CMS, ACA marketplace enrollment isn't up this year, and doesn't justify navigator funding cuts

To justify gutting funding for the navigators who help low income people enroll in health insurance subsidized by the ACA (Medicaid as well as marketplace), CMS is turning a bogus talking point it concocted last year inside out. Here's the current claim, as reported by KHN's Phil Galewitz:
CMS also notes that after last year’s navigator funding was reduced, the overall enrollment in Obamacare plans increased slightly (when counting people who paid their first month’s premiums) to 10.6 million people.
Comparing 2017 and 2018 totals at the end of open enrollment  (before many enrollees have paid their first premium), total ACA marketplace enrollment was down 4% this year. CMS's comparison above uses the totals from the "effectuated enrollment snapshots" from 2017 and 2018, which tracked how many people were enrolled (and had paid their first premiums) as of February in each year. The reported total at that point was 10.3 million in 2017, vs. 10.6 million this year.

As Charles Gaba pointed out last year (and revisits here), however, the 2017 "snapshot" exaggerated early attrition by failing to take into account the fact that those who enrolled between 1/15 and 1/31 (the final day of OE in 2017) did not have payments due until March 1.  There were 539,352* enrollees in that time frame.  None of them could effectuated their coverage for February, which is the population counted in the "snapshot." If those enrollees effectuated coverage at the same rate as enrollees before 1/15 (88.5%), there were 10.8 million who had effectuated or would soon effectuate as of the time of CMS's tally. That total outstrips this year's by 2% .**

Some CMS-y data for the ACA marketplace

The Public Use Files for ACA marketplace enrollment published annually by CMS provide useful detailed breakouts of enrollment in various categories, but they're not error-free.

Having recently compared the rates at which subsidized and unsubsidized enrollees dropped out early in 2018 (mainly by never paying their first premium), I thought I'd look at the attrition rate for those who obtain Cost Sharing Reduction (CSR) subsidies. And I happned on a large error in the reported total of CSR enrollees in California.

According to the 2018 state-level PUF, 939,688 of California's 1,521,524 enrollees as of the end of Open Enrollment obtained CSR. That's a high but not impossible percentage. But...only 853,787 California enrollees are listed as having chosen silver plans. And CSR is available only with silver. I am told by Covered California, the state's ACA exchange, that CoveredCA submitted the incorrect data figure for that cell to CMS and is working to correct it.

Tuesday, July 10, 2018

Sabotage triage: New Jersey's instructions to individual market health insurers

It's hard to keep up with Trump administration sabotage of the ACA marketplace. Credit New Jersey's Dept. of Banking and Insurance (DOBI) with doing what it can to help health insurers cope.

In light of CMS's abrupt and capricious suspension of risk adjustment payments* to marketplace insurers in response to what should have been a minor legal glitch, DOBI has moved the deadline for individual market insurers to file rate requests from tomorrow (July 11) to July 18. DOBI has also instructed insurers to take two contingencies into account: the possibility that risk adjustment payments will remain suspended, and the likelihood that CMS (yes, the same CMS that planted the risk adjustment IED late last week) will approve the state's waiver application for federal funding for a reinsurance program, submitted on July 2.

The guidance issued today instructs insurers to file rate requests that a) assume risk adjustment payments will continue for 2019, and b) do not take the possibility of reinsurance into account. But insurers are also instructed to a)  discuss the potential impact on rates if risk adjustment payments were to be discontinued for 2019, and b) file alternative rates that assume the reinsurance program will be in place in 2019, under the terms proposed in the state's waiver application.

Thursday, July 05, 2018

Unsubsidized ACA marketplace enrollees drop out early

Early this week, CMS reported that unsubsidized enrollment in ACA-compliant plans dropped 20% in 2018, while subsidized enrollment dropped just 3%. I pointed out that on-exchange unsubsidized enrollment dropped much more modestly, just 6%. That bespeaks a still steeper drop in off-exchange enrollment, suggesting that some previous off-exchange enrollees may have moved on-exchange in 2018 -- some obtaining subsidies, others not.

Today Charles Gaba notes that while unsubsidized on-exchange enrollment did not drop precipitously this year, first-month attrition among the unsubsidized who enrolled on-exchange was massive -- in a year in which overall attrition appears lighter than usual (over 80% of on-exchange enrollees are subsidized). While only 5.6% of subsidized enrollees are reported to have dropped coverage as March 15, 28%* of unsubsidized enrollees did.  This may not be surprising in a year in which premiums rose an average of 27%, largely as a result of Republican sabotage (cutoff of direct CSR reimbursement, radical cuts in enrollment assistance and advertising, weak enforcement of the individual mandate).

While the attrition among the unsubsidized this year is startling, it continues a pattern. Far higher percentages of unsubsidized than subsidized enrollees also dropped out in 2017 and 2016, rising each year. At the same time, attrition among subsidized enrollees dropped each year.

Wednesday, July 04, 2018

Six ways New Jersey is fighting off Obamacare sabotage

Statue of Liberty from Liberty State Park

Since Trump's inauguration, the ACA marketplace has undergone multiple waves of sabotage from the administration and the Republican Congress. Leaving aside some short-term hits, such as the cutoff of advertising at the end of Open Enrollment for 2017, these are the structural elements:
  • Radical reduction in federal funding for enrollment assistance and advertising
  • Cutoff of direct federal reimbursement to insurers for the Cost Sharing Reduction (CSR) subsidies they are obligated to provide to low income enrollees (now priced into premiums)
  • Effective repeal of  the individual mandate, which requires those for whom coverage is deemed affordable to obtain it or pay a penalty (Republican Congress zeroed out the penalty)
  • Regulatory promotion of a parallel market in medically underwritten short-term plans and association health plans -- measures designed to worsen the risk pool in the ACA-compliant market.
The ACA was designed to promote state innovation and autonomy, within fairly firm boundaries. While those boundaries have been breached on multiple fronts, states still have leeway to stay within them or actively reconstitute them. Meanwhile, thanks to the failure of Republicans' repeal legislation, federal funding for the core programs remains in place -- and has even been inefficiently enhanced, via the CSR funding cutoff, since reimbursing CSR is more cost-effective for the federal government than paying premium subsidies inflated by CSR.

It strikes me that New Jersey is unique in the degree to which it has acted to fend off the sabotage. Going into 2019 enrollment, the state has:

Tuesday, July 03, 2018

Time for New Jersey's Health Insurers to Do Their Part to Counter ACA Sabotage

Jersey City skyline

New Jersey's legislature, governor and Department of Banking and Insurance (DOBI)) have acted swiftly and decisively to protect the state's individual market for health insurance from several rounds of Republican sabotage.

On May 30, Governor Murphy signed into law two bills designed to hold down individual market premiums. The first created a state "individual mandate" -- a  requirement that those for whom affordable insurance is available obtain it or pay a tax penalty -- to replace the federal mandate that the Republican Congress repealed as part of its tax bill last September. The second measure directed DOBI to seek federal funding for a reinsurance program that would restrain premium increases.  DOBI submitted its proposal on July 2,  designed to reduce premiums by 15% per year compared to what they would have been without the reinsurance.

Both of those measures benefit insurers as well as consumers -- the mandate by keeping healthier enrollees in the risk pool, the reinsurance program by reducing insurers' risk.  Now it's time for health insurers to do their part -- by structuring their offerings to maximize federal subsidies and hold unsubsidized buyers harmless from a prior round of Trump administration sabotage.

Monday, July 02, 2018

Off-exchange ACA enrollment dropped 20% in 2017. Why did unsubsidized on-exchange stay stable?

In October 2017, Matt Fiedler of the Brookings Institute estimated that premium hikes averaging 20.5% nationally in the ACA-compliant individual market in 2017 were likely to reduce unsubsidized enrollment by 12.3%.

Today, CMS is out with a report claiming that unsubsidized enrollment dropped 20% nationally in 2017. Average monthly enrollment among the unsubsidized was down 1.3 million. Subsidized enrollment was down just 3%, despite Republican repeal threats and a late cutoff of advertising (along with active denigration of the offerings) by the Trump administration. The subsidized were insulated from the premium hikes; the unsubsidized of course were not.

One peculiarity: all of the drop in unsubsidized enrollment was apparently off-exchange. In fact, unsubsidized enrollment on and the state exchanges rose slightly in 2017, from 2.1 million to 2.2 million (though the "unknown" subsidy status of 83,516 enrollees all but closes the gap).

Friday, June 29, 2018

Hispanic Enrollment on up 13% since 2016

To return to a point I addled somewhat last week...

Applicants for health insurance on, the federal platform used by 39 states, are prompted to identify their race, and separately, whether they are of Hispanic/Latino "ethnicity." The questions are optional. Race is reported as unknown for 30% of enrollees, and ethnicity as unknown for 25%. The data is self-reported and somewhat volatile. I've been warned it should be taken with a grain of salt -- or considerably more.

That said, in 2018 self-identified Hispanic/Latino enrollment on is up 7.5% compared to 2017, to 1,033,699, and up 12.7% from 2016. Overall enrollment on is down 9% since 2016, to 8,743,642. Those self-reporting as Hispanic in 2016 accounted for 9.5% of total enrollment on; in 2018, they accounted for 11.8%.

In Florida, the state with the highest ACA marketplace enrollment and the highest takeup among those who are subsidy-eligible, Hispanic enrollment was way up in 2018, from 327,965 to 378,471. That's a 15% increase, and accounts for most of the 39-state increase. Overall Florida enrollment was down 2.5%. In Miami-Dade County, however, which is about two thirds Hispanic, enrollment was up by about 7,000, to 394,677. In Osceola County, 45% Hispanic, enrollment was up about 1,700, to 40,414.

Here is Hispanic and total enrollment, 2018 vs. 2017, in the 10 Florida counties with the highest Hispanic enrollment this year.  In all of them, Hispanic enrollment is up this year -- not surprising given the large overall increase.

Monday, June 25, 2018

ACA marketplace enrollment, 2018: Answers and questions

In 2018, ACA marketplace enrollment dropped 5% in the 39 states using the and 4% nationally. The more detailed data that CMS compiles for the states (accounting for three quarters of all enrollees) show that enrollment dropped most sharply at the lowest income levels -- where, thanks to Cost Sharing Reduction (CSR) subsidies, the most comprehensive coverage is available.*

Here's the breakdown of enrollment by income level in 2018 vs. 2017** on

Enrollment by Income Level on, 2018 vs. 2017

Total enrollment
100% to 150% FPL
150% to 200% FPL
200% to 250% FPL
250% to 300%  FPL
300%- 400%  FPL
Other FPL*

2018 as % 2017
 "Other FPL" is comprised mostly of unsubsidized enrollees. About one quarter are likely enrollees with incomes under 100% FPL, most of whom are likely legally present noncitizens time-barred from Medicaid, who are subsidy-eligible.

Why was enrollment down sharply at 100-200% FPL, down modestly from 201-300% FPL, and up at 300-400% FPL? The higher the income, the more definite the answers.

Sunday, June 24, 2018

Actuarial Value in the ACA Marketplace: Down a bit

In 2018, CMS has for the first time ever published data making it possible to calculated the average weighted actuarial value of health plans sold in the 39 states that use the federal marketplace,

The actuarial value is the percentage of the average enrollee's costs a health plan is designed to pay, calculated according to a fixed formula mandated by CMS. Take that with a grain of salt, sprinkled on in a couple of caveats at bottom. Still, AV is a standardized measure that makes comparisons possible. Average AV for both employer plans and Medicare has been calculated to be a bit over 80%.

The ACA mandated specific AV for each of four metal levels (with some wiggle room, per below): 60% for bronze plans, 70% for silver, 80% for gold, 90% for platinum. But secondary Cost Sharing Reduction (CSR) subsidies, available to enrollees with incomes up to 250% of the Federal Poverty Level, complicate the formula. CSR, available only with silver plans, raises AV: to 94% for those with incomes up to 150% FPL; to 87% for those in the 151-200% FPL range; and to 73% at 201-250% FPL.

This year, for the first time, CMS reported exactly how many people were enrolled at each CSR level, albeit only in states, which account for just about three quarters of marketplace enrollees.* So who obtained what in the ACA marketplace this year? Here's the data.

Actuarial value obtained by enrollees on, 2018 

Metal level
Actuarial value
Total enrolled
% enrolled
Weighted AV
Silver - CSR1
Silver - CSR2
Silver - CSR3
Silver - no CSR


* There were just 16,731 platinum (90% AV) enrollees on, and 58,176 catastrophic plan (57% AV) enrollments. Combined, that comes to a weighted AV of 64%, used above to avoid splitting percentages.

Friday, June 22, 2018

Steep enrollment drops in New Jersey's individual market

ACA marketplace enrollment was down 7% in New Jersey as of the end of open enrollment, according to CMS. That's a somewhat steeper drop than the 4% national average and the 5% average among states using, but in range.

This week the state Department of Banking and Insurance (DOBI) released first-quarter enrollment results for the entire individual market, off-exchange as well as on-. It shows more severe drops on both fronts -- particularly off-exchange:

NJ Total Covered Lives Comparison, individual market 2017-2018
New Jersey suffered an average weighted premium increase of 22% in 2018, with steeper increases for market hegemon Horizon Blue Cross. As I noted recently, unsubsidized enrollees didn't get any benefit from silver loading, as there were no discounted silver plans available off-exchange. Unsubsidized enrollees basically had four choices: eat huge premium increases, downshift to bronze, switch to narrow network AmeriHealth, or drop out.

It appears that a significant number of unsubsidized enrollees made that last choice. Off-exchange enrollment was down not only compared to the first quarter of 2017, but compared to the last quarter, when enrollment is at low ebb (overall enrollment is up 6% since Q4 2017, but down 11% since Q1).

Off-exchange enrollment stats are hard to come by, but steep enrollment drops are to be expected.  Matt Fiedler of the Brookings Institute estimated last fall that premium hikes averaging 20.5% nationally in 2017 were likely to reduce overall unsubsidized enrollment by 12.3%. New Jersey's numbers would seem in line with that estimate.

A few notes and question marks regarding both off- and on-exchange enrollment: