Thursday, July 02, 2015

Refusal to expand Medicaid swelled Florida's private plan ACA signups

Today CMS released detailed county-by-county enrollment data for private plans signups in the 37 states using in 2015, as of February 22, just past the end of open enrollment,*. State-by-state income and metal level selection figures can be toted up from the county data Let's take a quick look at Florida and specifically Miami-Dade county, site of 2015's strongest signup surge.

We already knew that Florida -- which to date has refused to enact the ACA Medicaid expansion -- became the state with the most private plan enrollments, logging just shy of 1.6 million by the end of open season in February. According to the Kaiser Family Foundation, the state had enrolled 57% of its potential marketplace population as of March 31, 2015 (at which point Kaiser shows private plan enrollment at 1.4 million), second best in the country.  Of the 1.6 million state enrollees reported by HHS, 392,000 were in Miami-Dade County. Kaiser's research has previously spotlight Hialeah, a mainly Hispanic region just outside Miami (and in Miami-Dade County), as home to the zip code with the largest number of signups in the U.S.  Enrollment fever took hold there -- "Consumers can sign up for coverage in a mall, at a discount store, at a shoe store, and even at a barber shop," reported the Miami Herald in January.

"You oughtta be in Medicaid..."

Today's data release confirms that as in states that refused the Medicaid expansion generally, Florida's and Miami-Dade's private plan enrollments were swelled by enrollees who would have been eligible for Medicaid if the state had accepted the expansion. In Florida, 856,092 private plan enrollees -- more than half (53.6%) of the total -- had incomes between 100% and 150% of the Federal Poverty Level (FPL).  That compares with 47% in all states using that refused to expand Medicaid, and just 22% in expansion states.

Those with incomes in 100-138% FPL range would be Medicaid-eligible if the state had expanded. We don't know exactly how many there are, but my prior analysis of national enrollment numbers suggests that at least two thirds of the 856k in the 100-150% FPL range are Medicaid-eligible -- a bit more than a third of all private plan enrollees in the state (and maybe a good deal more).

In Miami-Dade, the proportion of low-income enrollees is even more eye-popping. Fully two thirds of enrollees -- 259,000 out of 392,000 -- had incomes in the 100-150% FPL range.  Some 85% had incomes under 200% FPL, the threshold below which really strong Cost Sharing Reduction (CSR) subsidies are available with silver-level plans.

In the state as a whole, 75.8% of all enrollees (1,209,961) had incomes under 200% FPL That's compared to 73% below that level in all non-expansion states on

Who accessed Cost Sharing Reduction?

In Florida, 85.6% of buyers (1,37 million) had incomes under 250% FPL, the threshold for CSR eligibility. 70% of all buyers in the state - 1.12 million -- accessed CSR. That means that 81.7% of CSR-eligible buyers selected silver plans and accessed the benefit. That's a bit better than the 77% of CSR-eligibles who accessed silver in all states.

Since CSR weakens to almost nothing at  201% FPL, I generally consider the more meaningful stat to be the percentage of buyers under 200% FPL who select silver plans and so gain access to "strong" CSR (raising the actuarial value of a silver plan from 70% to 87% or 94%).  Unfortunately we don't know how many buyers under 200% FPL selected silver. But silver plan selection generally falls off sharply -- and rationally -- at 201% FPL.  If 55% of those between 200 and 250% FPL chose silver -- a mid-range estimate -- then about 85% of those below 200% FPL did as well.

[added 7/3] In Miami-Dade, 80.1% of CSR eligibles bought silver plans. Since only 7% of CSR-eligibles had incomes in the upper bracket of eligiblity, 201-250% FPL, where CSR bumps up the actuarial of a silver plan just 3 points to 73%, it's fair to say that far too many low-income people are buying bronze plans, which generally carry deductibles in the $5,000-6,600 range for an individual. Only 15% of private plan buyers in the county had incomes over 200% FPL, and 18% of all buyers bought bronze. That's too many.

*As of a May enrollment update, effectuated enrollment had dropped from the original 11.7 million to about 10.2 million. The county breakout released today, and so this discussion, is based on the initial enrollment figures, released by HHS on March 1o. Presumably percentages of people in various income bands and metal level selections remained more or less proportionate as the initial wave of no-pays dropped out.


  1. I am curious about whether an appreciable fraction of the cash influx a state loses by rejecting Medicaid expansion is recovered for the rejecting state in premium subsidies for the 100-138%-ers.

    1. Richard Mayhew at Balloon Juice has taken this question and run with it. On a rough calculation, perhaps 28% of those who would have been eligible for Medicaid in states that refused the expansion are now in subsidized private plans. Kaiser estimates the number of those in the Medicaid gap at 4m, and I estimated here that 1.9m QHP enrollees should have been eligible for Medicaid. Attrition since that post ran would bring it down to 1.6 million.