Tuesday, August 14, 2018

Silver loading vs. sabotage in non-expansion states

This post continues the story of how, where and to what extent silver loading offset all the factors pushing ACA marketplace enrollment down in 2018: the shortened enrollment period, massive cuts to advertising and enrollment assistance, Trump screaming the ACA is dead, huge premium spikes turbo-charged by CSR cutoff and yearlong uncertainty, etc. etc.

In previous posts I noted that silver loading, which created discounts in bronze and gold plans for subsidized buyers (see note at bottom), seems to have boosted enrollment by about 8 percentage points in the 200-400% FPL income range, both in 39 HealthCare.gov states and in California.

Enrollment losses were concentrated first and foremost among the unsubsidized, off- and on-exchange, and next among those at the lower income range of subsidy eligibility (100-200% FPL), where the CSR benefit still outweighed the bronze and gold discounts. They were partly offset at 200-400% FPL, where negligible or no CSR is available, and where in many locations, the discounts created by silver loading meant more value for less money was on offer than in previous years.

Here we'll take a look at the 18 states using HealthCare.gov that had not accepted the ACA Medicaid expansion as of 2018* (one more expansion state, Idaho, has a state-based exchange, and the enrollment breakouts we're looking at here are not available there).

In nonexpansion states, eligibility for subsidized marketplace enrollment begins at 100% FPL, as opposed to 138% FPL in expansion states, where people below that threshold are eligible for Medicaid. About 36%**of all enrollees in nonexpansion states have incomes between 100% and 138% FPL, which means that CSR-enhanced silver plans with an actuarial value of 94% are available to them for 2% of income or less. People eligible for the two strong levels of CSR (94% or 87% AV) were mostly unaffected by silver loading, and in all markets the various forms of ACA sabotage inflicted by Republicans took a toll on enrollment among them, i.e. at the 100-200% FPL income range. Here again is how enrollment at each income level compared with 2017 enrollment in HealthCare.gov states:

Enrollment by income level, 2017 vs. 2018

HealthCare.gov 

Year
Total enrollment
100% to 150% FPL
150% to 
200% FPL
200% to 250% FPL
250% to 300%  FPL
300%- 400%  FPL
Other FPL*
2017
              9,201,805
       3,208,242
                        2,050,555
         1,312,520
       752,403
   786,678
     1,091,407
2018
              8,743,642
       2,979,236
            1,885,778
         1,277,488
       747,165
   867,198
            986,777
Change
-5.0%
-7%
-8%
-3%
-1%
+10%
-10%

"Other FPL" is comprised mostly of unsubsidized enrollees. About 20% are likely enrollees with incomes under 100% FPL, most of whom are likely legally present noncitizens time-barred from Medicaid, who are subsidy-eligible.



The nonexpansion states show basically the same pattern - not surprising, perhaps, as they account for more than two thirds of HC.gov enrollment. Here's how enrollment shifted there:

Non-expansion states, excluding Idaho


Year
Total  enrollment
100-150% FPL
150%-200% FPL
>200% to ≤250% FPL
>250% to ≤300%  FPL
>300%- ≤400%  FPL
Other FPL
2017
6,320,036
2,750,502
1,281,503
792,247
433,904
435,790
626,090
2018
6,060,844
2,587,081
1,202,256
786,543
438,500
489,249
557,215
Change
-4%
-6%
-6%
-1%
+1%
+12%
-11%


About 85% of enrollees with incomes under 150% FPL in fact have incomes below 139% FPL -- i.e., they should be in Medicaid. It's worth noting that the 6% drop in this income band is perhaps likeliest to signal a drop in the uninsured population.

There's naturally a lot of variation within the states. Florida, which accounts for 28% of the 18-state total, was down 2.5% overall; Texas, accounting for 19% of all enrollment in these states, was down 8%.

What's striking is the consistency of relative results between income brackets in the three markets or submarkets - HealthCare.gov, nonexpansion states, and Covered California. In each case, the performance spread between the subsidized market below 200% FPL compared to 200-400% FPL is about the same.

Enrollment by income level, 2017 vs. 2018

HealthCare.gov states

Year
100-200% FPL
200-400% FPL
2017
5,258,797
2,851,601
2018
4,865,014
2,891,851
Change 2017-2018
-7.0%
+1.0%


Nonexpansion states on HealthCare.gov

Year
100-200% FPL
200-400% FPL
2017
4,032,005
1,661,941
2018
3,789,337
1,714,292
Change 2017-2018
-6.0%
+3.1%


Covered California

Year
138*-200% FPL
200-400% FPL
2017
642,910
564,370
2018
635,180
602,000
Change 2017-2018
-1.0%
+6.7%


* In Medicaid expansion states such as California, eligibility for marketplace subsidies begins at 138% FPL, as Medicaid is available to adults with incomes below that threshold. In 18 nonexpansion states using HealthCare.gov, marketplace subsidy eligibility begins at 100% FPL, and nearly 2 million enrollees are in the 100-138% FPL range.

The spreads between the 2018 enrollment performance (compared to 2017) at incomes below 200% FPL vs. in the 200-400% FPL bracket range from 7.7% to 9.1%. That's a pretty tight range. Of course, one "market" is a rather large subset of the other, but the repeat pattern pretty clearly shows the impact of silver loading on the one hand and of degraded enrollment conditions on the other.

Postscript: It's also pretty striking that 78% of all enrollment in the 100-200% FPL range in 38 HeatlhCare.gov states is in these 18 nonexpansion states. Viewed another way, about 2.2 million of these enrollees ought to be in Medicaid.
----

* The nonexpansion states using HealthCare.gov in 2018 were AL, FL, GA, KS, ME, MO, MS, NC, NE, OK, SC, SD, TN, TX, UT, VA, WI and WY.

**  In HealthCare.gov states, 2,587,081 out of 6,060,884 enrollees had incomes in the 100-150% FPL range. In 2016, we learned that about 85% of enrollees in that somewhat larger category in nonexpansion states have incomes in the 100-138% FPL range, and so would be eligible for Medicaid if their states had accepted the expansion.

Note: What's silver loading and how does it work?

President Trump accidentally created a windfall for many subsidized ACA marketplace enrollees last fall when he cut off direct reimbursement of insurers for Cost Sharing Reduction (CSR) subsidies they are required to provide to qualifying ACA marketplace enrollees, forcing insurers to price the CSR benefit into premiums. Most states allowed or encouraged insurers to concentrate the CSR cost in silver plans only, since CSR is available only in silver plans (and in many cases to offer silver plans free of the CSR load off-exchange). Since  the ACA's premium subsidies are income-adjusted and set to a silver benchmark, "silver loading" created discounts in other metal levels, varying considerably by state and rating area, but substantial in most states.

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