Tuesday, April 03, 2018

"Strong" CSR takeup dropped only slightly on HealthCare.gov in 2018

Update/correction: This year, for the first time, CMS broke out enrollment at each level of CSR (at actuarial values of 73%, 87%, and 94%) -- and separately, metal level enrollment at each income level (indirectly - see note below). As explained below, the percentage of apparently subsidy-eligible enrollees with incomes up to 200% FPL who obtained strong CSR (94% or 87% AV) is somewhat lower than the percentage who selected silver plans. 

I noted recently with respect to Maryland ACA marketplace enrollment, the downside of "silver loading" the cost of CSR is a drop in takeup of the strong CSR available to enrollees with incomes below 200% FPL. CSR is available only with silver plans (please see the prior post to un-abbreviate all this).

That downside (for the subsidized) is outweighed by the upside. In Maryland, about 30,000 enrollees with incomes over 200% FPL obtained steep discounts in bronze and gold plans, whereas about 6,000 fewer enrollees under 200% FPL obtained strong CSR than would have had Trump not disrupted the market by cutting off federal funding for the benefit (see appendices to post linked to above for a quick explanation).

Now we have enrollment numbers for the all states -- with, as usual, more precise breakouts for the the 39 states using the federal exchange, HealthCare.gov than for the whole country.  In HealthCare.gov states, CSR takeup among those with incomes up to 200% FPL downticked only slightly.  -- to  about 82%. Silver selection among those with incomes ranging from 100-200% FPL dropped from 86.9% in 2017 to 85.3% in 2018. For 2017, we don't know how many silver enrollees in the income bracket did not obtain CSR.

Nationally, in 2018, 53% of enrollees obtained CSR, versus 58% at the end of open enrollment 2017. On HealthCare.gov, the 59.9% obtained CSR in 2017 vs. 54.4% in 2018. But the difference was largely concentrated in the 200-250% FPL income bracket, where CSR is negligible (boosting AV from 70% to 73%) and enrollees had ample cause to take gold and bronze discounts. In 2017, 67.6% of enrollees in the 200-250% FPL income category selected silver plans. In 2018, just 53.4% did.

There was also a significant drop in the 150-200% FPL bracket, where CSR boosts the AV of a silver plan to 87%. At 100-150% FPL, however, where CSR-boosted silver is 94% AV, and the percentage of income required to obtain benchmark silver is 2-4%, silver selection rose slightly. Here is the breakout - keeping in mind that 2-4% of those who selected silver did not obtain CSR.

Metal Level Selections at Different CSR-eligible Income Levels (% FPL)
HealthCare.gov states


                                Strong CSR                 Weak CSR                
Metal level
< 1%


                                Strong CSR                Weak CSR                
Metal level
  0.09 %

Viewed another way, the drop in CSR enrollment on hc.gov in 2018 was about 300,000 larger than the total drop in enrollment (458,163 fewer enrollees; 754,207 fewer with CSR). The drop was proportionately steepest in the 200-250% FPL band, as the chart above indicates. There were 204,954 fewer silver enrollees in the 200-250% FPL group in 2018 than in 2017, a 23% drop, whereas total enrollment in the income band dropped less than 3%.

That drop-off is not surprising, as many enrollees had access to substantial discounts in gold and bronze, thanks to the loading of the cost of CSR onto silver plans only in most states. About two thirds of the drop-off in silver at 200-250% FPL went to bronze, and one third to gold.

CSR procurement lower than silver selection among CSR eligibles

According to the public use files just released by CMS, 4,067,973 enrollees chose silver plans with strong CSR (2.6 million at the highest level, with an actuarial value of 94%, and 1.4 million at 87% AV).  4,865,013 enrollees had incomes between 100% and 200% FPL.  Another 348,268 are in the "other FPL" category -- i.e., they supplied income data, but they're either under 100% FPL or over 400% FPL. In 2016, HHS reported that 3% of hc.gov enrollees for whom income was known, or about 267,000, had incomes under 100% FPL. That suggests about 240,000 this year.

California reports that just 65% of enrollees with incomes below the Medicaid eligibility threshold (138% FPL) are subsidized (legally present noncitizens who are time-barred from Medicaid are subsidy eligible  If the same proportion holds for hc.gov states, then about 156,000 with incomes under 100% FPL are subsidy eligible. In addition, California's breakout suggests that perhaps 1% of those with incomes from 100-200% FPL may be subsidy-ineligible, as is the case for those who have an offer of insurance from and employer.

These estimates net out to about 4,970,000  eligible for strong CSR, with roughly 4,068,000 obtaining it, or 82%. As noted above,  it appears that 85% of enrollees with incomes in the 100-200% FPL range selected silver plans.

Note on metal level selection totals 

For each metal level, CMS breaks out what percentage of total enrollees were at each income level. The number that I'm concerned with -- the percentages at each income level that select each metal level -- has to be extrapolated from that, and it's rounded as a whole percentage. For example, in 2017 there were 6,827,122 silver enrollees on hc.gov, and 42% of them had incomes in the 100-150% FPL range. That comes to 2,865,291, a number that really probably should be rounded, given the rounded percentage.  But I take it as 89.3% of the 3,208,242 enrollees in the income bracket.

Update, 4/26/18: In estimating CSR takeup among those eligible for strong CSR, today I brought in the California breakout of subsidized/unsubsidized below the Medicaid line to estimate the subsidy-eligible under 100% FPL, as well as California's breakout of unsubsidized enrollees up to 200% FPL  and adjusted the totals accordingly.Originally I had 5,105,000 eligible for strong CSR rather than 4,970,000.

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