Policymakers in New Jersey were disappointed by enrollment in the state's ACA marketplace in 2019, which came in 7.1% behind 2018 enrollment. In the 39 states using HealthCare.gov, the federal exchange, enrollment was down 3.8%, and in the 12 states (plus DC) that have their own exchanges, it's likely to come in flat (enrollment is not over in several of them).
The state had acted swiftly in the first half of 2018 to pass a state-based individual mandate and get a reinsurance program enacted by legislation and approved/funded by CMS. As a result, premiums were down an average of 9% in 2019, and 22% below where they would have been had no action been taken.
But base premiums affect only unsubsidized buyers, and in 2019 premiums in New Jersey were actually higher than in 2018 for most subsidized enrollees, as benchmark silver plan premiums, which determine subsidies dropped further than the average for all plans. For a 40 year-old with an income of $30k, the cheapest bronze plan cost 12-22% more in 2019 than in 2018 (varying by region) -- that is, $13-$25 more per month. Cheapest silver was also up slightly in most of the state. There's some hope that off-exchange enrollment will show some improvement, as that's where the benefit from lower premiums comes home. We'll know when the state publishes first-quarter off-exchange enrollment in the spring.
For what it's worth, Jersey's enrollment performance is smack in the middle of the cohort that may be most relevant: states that enacted the ACA Medicaid expansion but did not create their own exchanges and instead rely on HealthCare.gov. For reasons that remain somewhat murky, the expansion states on HealthCare.gov accounted for almost all the net enrollment loss, lagging not only states that run their own marketplaces but also nonexpansion states on HC.gov. Collectively 2019 enrollment in nonexpansion states on HC.gov was less than 1% below the 2018 total -- whereas in the expansion states on the platform (excluding Virginia and Maine, expanding in 2019), enrollment was down 7%.
Here's how enrollment shook out for states on HealthCare.gov that had expanded Medicaid as of 2018.*
New Jersey policymakers and activists may be disappointed that the state individual mandate apparently did not have its intended effect -- though we don't know what enrollment would have looked like in its absence. But the state suffers not only from the moderate premium hikes for subsidized buyers but from a lack of discounts generated by silver loading** that partially offset losses in 2018 and 2019 in many other states. That is, bronze plans are not particularly cheap, let alone free as they are for most low income enrollees in many states (or parts of states), and gold plans remain out of reach for most enrollees (whereas in many states they are cheaper than silver plans, or close in price).
Again, the state market's one advantage this year is reduced base (unsubsidized) premiums, which may drive improvement off-exchange -- or among the on-exchange unsubsidized, which we'll know when CSM releases a final report that breaks out enrollment by income.
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* I've omitted Virginia, which enacted an expansion effective this month, for which eligible people could enroll throughout open season, and Maine, where the incoming governor has just instructed her government to begin enactment, and where expectation of that step may have depressed enrollment.
** Silver loading refers to concentrating the cost of CSR subsidies (directly reimbursed to insurers by the federal government as stipulated by the ACA until Trump stopped payment in October 2017) in the premiums of silver plans, since CSR is available only with silver plans. Since premium subsidies, designed so that the enrollee pays a fixed percentage of income, are set to a silver plan benchmark (the second cheapest silver plan), inflated silver premiums create discounts for subsidized buyers in bronze and gold plans. And in states that allowed insurers to offer silver plans off-exchange with no CSR load, unsubsidized enrollees were protected from CSR costs, theoretically at least.
The state had acted swiftly in the first half of 2018 to pass a state-based individual mandate and get a reinsurance program enacted by legislation and approved/funded by CMS. As a result, premiums were down an average of 9% in 2019, and 22% below where they would have been had no action been taken.
But base premiums affect only unsubsidized buyers, and in 2019 premiums in New Jersey were actually higher than in 2018 for most subsidized enrollees, as benchmark silver plan premiums, which determine subsidies dropped further than the average for all plans. For a 40 year-old with an income of $30k, the cheapest bronze plan cost 12-22% more in 2019 than in 2018 (varying by region) -- that is, $13-$25 more per month. Cheapest silver was also up slightly in most of the state. There's some hope that off-exchange enrollment will show some improvement, as that's where the benefit from lower premiums comes home. We'll know when the state publishes first-quarter off-exchange enrollment in the spring.
For what it's worth, Jersey's enrollment performance is smack in the middle of the cohort that may be most relevant: states that enacted the ACA Medicaid expansion but did not create their own exchanges and instead rely on HealthCare.gov. For reasons that remain somewhat murky, the expansion states on HealthCare.gov accounted for almost all the net enrollment loss, lagging not only states that run their own marketplaces but also nonexpansion states on HC.gov. Collectively 2019 enrollment in nonexpansion states on HC.gov was less than 1% below the 2018 total -- whereas in the expansion states on the platform (excluding Virginia and Maine, expanding in 2019), enrollment was down 7%.
Here's how enrollment shook out for states on HealthCare.gov that had expanded Medicaid as of 2018.*
Enrollment performance, 2019 vs. 2018:
Expansion states on HealthCare.gov
STATE 2018 2019 2019 vs. 2018
19,799
|
20,193
|
102%
|
|
68,100
|
67,413
|
99%
|
|
18,313
|
17,805
|
97%
|
|
22,486
|
21,820
|
97%
|
|
165,758
|
160,456
|
97%
|
|
47,699
|
45,374
|
95%
|
|
156,105
|
148,180
|
95%
|
|
89,569
|
84,620
|
94%
|
|
389,081
|
365,888
|
94%
|
|
293,940
|
274,058
|
93%
|
|
334,979
|
312,280
|
93%
|
|
274,782
|
255,246
|
93%
|
|
53,217
|
49,210
|
92%
|
|
24,500
|
22,562
|
92%
|
|
91,003
|
83,449
|
92%
|
|
49,792
|
45,001
|
90%
|
|
49,573
|
44,581
|
90%
|
|
230,127
|
206,871
|
90%
|
|
166,711
|
148,404
|
89%
|
|
109,855
|
92,948
|
85%
|
|
27,409
|
22,599
|
82%
|
New Jersey policymakers and activists may be disappointed that the state individual mandate apparently did not have its intended effect -- though we don't know what enrollment would have looked like in its absence. But the state suffers not only from the moderate premium hikes for subsidized buyers but from a lack of discounts generated by silver loading** that partially offset losses in 2018 and 2019 in many other states. That is, bronze plans are not particularly cheap, let alone free as they are for most low income enrollees in many states (or parts of states), and gold plans remain out of reach for most enrollees (whereas in many states they are cheaper than silver plans, or close in price).
Again, the state market's one advantage this year is reduced base (unsubsidized) premiums, which may drive improvement off-exchange -- or among the on-exchange unsubsidized, which we'll know when CSM releases a final report that breaks out enrollment by income.
-----
* I've omitted Virginia, which enacted an expansion effective this month, for which eligible people could enroll throughout open season, and Maine, where the incoming governor has just instructed her government to begin enactment, and where expectation of that step may have depressed enrollment.
** Silver loading refers to concentrating the cost of CSR subsidies (directly reimbursed to insurers by the federal government as stipulated by the ACA until Trump stopped payment in October 2017) in the premiums of silver plans, since CSR is available only with silver plans. Since premium subsidies, designed so that the enrollee pays a fixed percentage of income, are set to a silver plan benchmark (the second cheapest silver plan), inflated silver premiums create discounts for subsidized buyers in bronze and gold plans. And in states that allowed insurers to offer silver plans off-exchange with no CSR load, unsubsidized enrollees were protected from CSR costs, theoretically at least.
I'm not surprised by your findings. I found healthcare.gov to be much less user-friendly than previously. System demands to reverify unchanged household income (due to "data match inconsistencies") caused weeks of anxiety, as this consumer wondered just how compromised ACA data was following the October data hack.
ReplyDeleteI suspect this unnecessary requirement to verify unchanged data points was an widespread, systemic barrier thought up by Trump's HHS - intended to discourage applicants from following up and making that crucial premium payment in December, thus voiding their application.
What with the marriage penalty (especially onerous on the older set), the bronze loading, and skeletal networks from our single-county ACA insurer/provider, I don't plan to actually consume ANY health care until I reach Medicare age. Although it is nice to have an insurance card and a promise of coverage in the event of a medical catastrophe.