Wednesday, January 04, 2017

Who are the "20 million" insured via the ACA?

In references to the roughly 20 million people the ACA has said to have insured, three things tend to be conflated: 1) the net increase in the insured population since ACA enactment (roughly 20 million), 2) the number insured through the ACA marketplace (10-11 million at present), and 3) the number insured through the individual market (18-20 million, about half of them subsidized).

Below, a few points aiming to clarify who's benefiting and to what degree. Teaser: don't miss my slicing of CPS data in the chart below.

1. The contributing streams to the 20 million increase in insured Americans include  a) an increase of 17 million in Medicaid enrollment since July-Sept. 2013, including nearly 12 million categorized by states as rendered newly eligible by the ACA; b) 8-9 million subsidized enrollees in the ACA marketplace, contributing to an increase in overall individual market enrollment of roughly the same size;c)  2-3 million adults under age 26 added to their parents' health plans; and 4) a possible moderate increase in enrollment in employer-sponsored plans.

2. Adding together roughly 12 million beneficiaries of the Medicaid expansion, 8-9 million subsidized marketplace enrollees, and 2-3 million adults under age 26 on their parents' plans gives a rough count of those who are currently in coverage directly enabled by the ACA. But that total -- roughly 22 million -- is not the same as the roughly 20 million net increase in the insured population recorded in surveys conducted by government and private research organizations.

3. As with employment data, reported net increases in the number of insured people cover a lot of churn. Some people who gained coverage in 2014 have doubtless lost it. Some who were insured in fall 2013, prior to full ACA implementation, have lost coverage and then gained it.  Some have passed seamlessly from COBRA to cheaper marketplace coverage and then to new employment-sponsored insurance, or from the marketplace to a university plan...etc. etc. Far more than 20 million people have availed themselves of ACA benefits since full enactment.

4. According to data from the National Health Interview Survey (NHIS) highlighted this fall by HHS, the ACA has cut the ranks of the uninsured at surprisingly comparable rates across income groups. Here is the breakout by income from 2010-2015 (FPL = Federal Poverty Level):

5. But since the uninsured are concentrated in lower income groups, so are most of those newly insured by the ACA.  And as a rule of thumb, the lower the beneficiary's income, the likelier she is to be satisfied with her newly obtained coverage. Let's dive into the those assertions a bit.

Below, I've put together estimates of the uninsured by income group in 2013 and 2015 from the Census Bureau's Current Population Survey's Sept. 2016 report on health insurance survey data through 2015.

The Uninsured by Income Group, 2013-2015 (CPS ASEC)
(in thousands)

Income group
Uninsured 2013
Uninsured 2015
Change '13-'15
% of uninsured,
% of total change '13-'15
0-100% FPL
> 400%

The bands marked in red overlap the basic divisions and indicate significant benefit thresholds: first, the ACA's expansion of Medicaid eligibility to 138% FPL in participating states (now numbering 32, including DC), and second, the availability of strong Cost Sharing Reduction (CSR) subsidies in the ACA marketplace for enrollees with incomes up to 200% FPL.  Note that 60% of the newly insured have incomes below 201% FPL -- and almost 40% have incomes under 138% FPL.  Most of those who gained coverage in these groups are in plans (Medicaid or marketplace silver enhanced with strong CSR) that keep out-of-pocket costs lower than the average employer-sponsored plan.*

6. To a significant degree, satisfaction with health insurance gained through the ACA or altered by the ACA varies inversely with income. In 2016, the Commonwealth Fund's annual tracking survey found that 88% of new Medicaid enrollees were satisfied with their coverage. Most marketplace enrollees also report satisfaction: in the Commonwealth survey,  78% reported themselves satisfied (38% "very," 40% "somewhat.") But as I noted recently, the Kaiser Family Foundation's 2016 tracking survey found that 1) satisfaction among marketplace enrollees had declined, from 74% in 2015 to 66% in 2016; 2) the percentage of enrollees in plans with high deductibles had climbed, from 36% to 49%; and 3) the increased dissatisfaction was linked to the higher deductibles. And in the marketplace, most enrollees saddled with high deductibles have incomes over 200% FPL; below that income level, over 80% obtain plans with CSR that keeps deductibles in the $0 to $1000 range. Almost two thirds of marketplace enrollees have incomes under 200% FPL, and 57% of all marketplace enrollees are in plans with CSR.

7. Many enrollees in individual market plans who don't qualify for ACA subsidies may deem themselves hurt or at least not very well served by the law, , which raised median unsubsidized premiums at the outset and exposed unsubsidized buyers to premium increases averaging about 25% this year. But as the Kaiser Family Foundation recently highlighted, about a quarter of the general population has pre-existing conditions that likely would have shut them out of the pre-ACA market entirely. In that market, according to an AHIP survey, a third of enrollees paid above-baseline rates because of pre-existing conditions; others were only able to obtain coverage that excluded treatment of their condition; and the oldest enrollees often paid five times as much as the youngest, as opposed to the 3-to-1 ratio allowed by the ACA.

One third of the U.S. population is in households with incomes under 200% FPL, but 55% of the uninsured just prior to ACA enactment had incomes below that threshold, according to the CPS. The ACA has, on the whole, served this population well, and the same is probably true for a good number in CPS's 200-300% FPL band, for reasons outlined in the note below. At higher income levels, the law's impact on those who look to the individual market for health insurance  has been a mixed bag. If only we had a Congress and president that would look to improve the offering for those currently hurt by high premiums -- without wiping out precious benefits currently available to the poor and near-poor.


*A couple of caveats are in order. The CPS calculates household income on a different basis from the ACA marketplace: CPS counts all members living under one roof, whereas the marketplace counts those included in a household tax filing. My impression is that the CPS method yields higher FPLs. If so, some of those counted as under 100% FPL are eligible for marketplace subsidies, some of those over 138% FPL are Medicaid eligible, some of those with incomes over 200% FPL are eligible for "strong" CSR, and some of those with incomes over 250% FPL may be eligible for the weaker CSR available to marketplace enrollees whose tax-household income is in the 200-250% FPL range. On the other hand, some of the uninsured and newly insured in each category are eligible for no ACA benefits at all -- they may be undocumented, or they may have an employer offer of insurance that disqualifies them for marketplace benefits.

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