Left behind: the uninsured who don't qualify for ACA subsidies

HHS released ACA signup numbers updated through January today. And while much of the news is good -- January exchange signups exceeded pre-launch projections -- one pattern repeated from the December update troubles me a bit.  While most of those who go through the application process and qualify for subsidies are enrolling in plans, those whose income disqualifies them for subsidies are hanging back.

This pattern was evident when signup numbers through December were released a month ago. A headline number was that 79% of those who had enrolled in exchange plans qualified for premium subsidies. However, as Corey Husak, a staff assistant to Senator McCaskill, pointed out to me on Twitter, only about 65% of those who had "applied for coverage in completed applications," not all of whom had enrolled, were eligible either for subsidies or for Medicaid/CHIP. More to the point, of the 5.14 million who had completed applications and were found eligible for marketplace plan enrollment, nearly half, 2.38 million, were not eligible for subsidies, versus 2.76 million who were subsidy-eligible.

At that point, 2.15 million had actually enrolled -- that is, selected a marketplace plan. Of those, approximately 1.70 million (79%) were subsidy-eligible. That 1.7 million constitutes  71% of those who had completed an application and been found subsidy-eligible.  In contrast, just about 452,000 of the 2.38 million who had completed an application and were not subsidy-eligible went all the way and selected a plan. That's just 19%.

The newly updated numbers tell a similar story. Fully 82% of the 3.3 million people who have selected a marketplace plan are eligible for subsidies. That would be 2.49 million.  Overall, 7.27 million people have been determined eligible to enroll in a marketplace plan.  Of those, 4.16 million, or 57%, are eligible for subsidies. 60% of them (2.49 out of 4.16) have pulled the trigger and selected a plan Of the 3.11 million who have completed applications and been found ineligible for subsidies, just 594,000 -- again, 19% -- have enrolled in plans.

The low signup rate thus far for the subsidy-ineligible is perhaps unsurprising. Unsubsidized insurance on the exchanges is expensive. In New Jersey, a single 27 year-old earning a bit over $32,000 will pay $249 per month for the cheapest silver plan; two 60 year-olds earning $63,000 will pay $1,346 per month.  Perhaps many of the unsubsidized will sign up near the deadline; perhaps a significant percentage have bought insurance off the exchanges.  

Most Americans under 65 with enough income to be subsidy-ineligible have access to employer-sponsored insurance -- and many with such access may not notice that insurance accounts for perhaps 15-20% of their compensation. Nonetheless, those who are just over the ACA subsidy line have it tough.

Update: a couple of tweeps have told me that they are no subsidy-eligible and bought insurance off-exchange this year for less than they paid pre-ACA. I want to explore the off-exchange market further. If you'd like to tell me your experience or share your expertise, please email me - contact info here.