At the New Year, pause to celebrate Medicaid

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Let's ring out 2020 with a final tracking of Medicaid enrollment during the pandemic.

In this 33-state sample, based on state monthly reports, Medicaid enrollment increased 11.1% from February through October, and an estimated 12.1%* from February through November. 

Since the increase reported in CMS's official tallies, currently running through a preliminary August report, generally show about a half percentage point slower growth** than my more up-to-date tally (8.3% vs. 8.8% for August), I imagine that CMS will show an increase of about 11.6%, February through November. That would mean 79.4 million people enrolled through November, an increase of about 8.25 million since February.

The ACA as pandemic safety net

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In the New York Times Upshot, Margot Sanger-Katz, Sarah Kliff and Quocktrung Bui report that the health insurance safety net as bolstered by the ACA, patchy though it is, appears to have held the uninsured rate close to steady during the pandemic months. In brief: Medicaid enrollment in the ACA expansion category is up more than 20% since February; ACA marketplace enrollment in 36 HealthCare.gov states is up 6.6% for 2021, and losses of employer-sponsored health insurance appear relatively modest.

I have been tracking these developments as they unfold. Some of the posts below corroborate the core findings cited in Upshot, and some supplement those findings. In reverse chronological order:

• ACA marketplace enrollment was already up by more than 6% year-over-year by June 2020. 

• Medicaid enrollment among those rendered eligible by the ACA Medicaid expansion is up more than 20% since February and likely exceeds 18 million.

• In states that have so far refused to enact the ACA Medicaid expansion, the ACA marketplace has picked up some slack: in nonexpansion states, marketplace enrollment is up 10% in 2021.

In response to the pandemic, ACA marketplace enrollment was likely up 6 percent-plus by June 2020, year-over-year

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CMS has released average monthly effectuated enrollment in the ACA marketplace for the first half of 2020. Combined with updated data about enrollment from February through May 2020 via the Special Enrollment Periods (SEPs) granted to people who lose access to other insurance or undergo other "life changes" outside the annual Open Enrollment period, the new data offers some measure of the extent to which Americans turned to the marketplace in response to loss of employer coverage triggered by the pandemic.

While total enrollments as of the end of Open Enrollment* were nearly identical in 2019 and 2020 (total plan selections down by 0.03%), average monthly enrollment through June (10,543,098) was up 3.4% in 2020 compared to June 2019 (10,194,206).

The average monthly enrollment comparison probably understates the impact of increased enrollment via SEP and improved retention during the pandemic months. The averages include monthly totals for January through March, when the pandemic's effects were zero to minimal. In June 2019,** effectuated enrollment was 9,797,989, 7.4% below the total for February 2019. We don't yet have a comparable figure for June 2020: it will be included in the effectuated enrollment snapshot for February 2021, which probably won't drop until this summer. But the year-over-year increase as of June 2020 was almost certainly well above the 3.4% half-year increase in average enrollment, and the increase likely continued to grow throughout 2020.

At pandemic's peak, Medicaid expansion enrollment is keeping pace

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Deep into fall and a resurgent pandemic, Medicaid enrollment growth among those rendered eligible by the ACA expansion (adults with incomes up to 138% FPL, or $1,468/month for an individual) shows no sign of abating. 

In the 18-state sample below, representing about 36% of the "expansion" population in the 37 states (including D.C.) that have have enacted the ACA expansion thus far, enrollment in this category increased 22.1% from February through October. In fourteen states that have reported through November, enrollment is up 24.7% since October. Month-to-month, enrollment increased 2.2% from September to October (18 states) and 2.3% October to November (14 states). 

Pandemic Medicaid Expansion Enrollment in 18 States

February through November

ACA marketplace enrollment up 10% in states that haven't expanded Medicaid

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CMS has reported* preliminary final 2021 enrollment figures in the ACA marketplace for the 36 states using the federal exchange, HealthCare.gov. In this pandemic year, enrollment in those states is up 6.6% compared to 2020 -- the first year of enrollment increase as of the end of Open Enrollment** since 2016.

Of course, enrollment increase is not uniform across those states -- every state market is different. Charles Gaba has helpfully broken out the 2020 vs. 2021 totals by state, and kindly lent me his charts. From the state totals one obvious pattern leaps out: enrollment is up 9.7% in states that have not enacted the ACA Medicaid expansion -- and down 0.5% in states that have expanded the expansion (including Nebraska, which opened the Medicaid expansion doors in October of this year). Below is Charles' chart broken out by expansion/nonexpansion.

ACA marketplace enrollment 2020 vs. 2021: Non-expansion states using HealthCare.gov 

NJ legislature rushing to enable de facto for-profit conversion of Horizon Blue Cross Blue Shield

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After 25 years of trying, Horizon Blue Cross Blue Shield of New Jersey, which provides health insurance to more than a third of the state's residents, is on the brink of pushing through the legislature a bill (S3218/A5119) enabling de facto for-profit conversion, or at least a stepping stone to such conversion. The bill has passed through key committees and is scheduled for a floor vote tomorrow (Dec. 17).

The complex bill, obviously written by Horizon executives, reorganizes the current nonprofit established by statute as a nonprofit -- but not charitable -- mutual holding company, with the insurer becoming a for-profit subsidiary, and the holding company empowered to create more for-profit subsidiaries, all of which can sell stock to investors. Horizon would pay $600 million up front to the state as compensation for a favorable change in its tax status, with a dubious commitment to contribute another $650 billion over nearly two decades, dependent on its degree of profitability. That money will go into the state's general fund -- not into a health foundation as in other states that have authorized conversion. Horizon has an estimated $7 billion in assets that as of now belong by statute to the people of New Jersey.

The state's dominant Democratic party is behind this legislation -- whether because of Horizon's powerful position in the state, credence lent to the company's happy talk about investment in new technologies and its existing charitable programs, or desperation for cash in the wake of the pandemic's devastation. 

The Trumping of the American Mind: Michelle Goldberg vs. Corey Robin

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Probably no one understands American conservatism and the European conservatism it grew out of better than Corey Robin, author of The Reactionary Mind: Conservatism from Edmund Burke to Sarah Palin. Goodreads summarizes:

Tracing conservatism back to its roots in the reaction against the French Revolution, Robin argues that the right is fundamentally inspired by a hostility to emancipating the lower orders. Some conservatives endorse the free market, others oppose it. Some criticize the state, others celebrate it. Underlying these differences is the impulse to defend power and privilege against movements demanding freedom and equality.

When it comes to Trump, however, Robin seems to be a classic case of a scholar blinkered by his own knowledge. In an interview with David Klion, he said:

As long as no one is thrown off Medicaid, will enrollment keep growing by 1% per month?

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I am beginning to wonder. I gather that no one has a precise idea what percentage of Medicaid enrollees are disenrolled every month by state income checks and eligibility redeterminations. The Families First Act paused those disenrollments for the duration of the national emergency -- as of now, through the end of March -- though a new interim final rule issued by Seema Verma's CMS appears to give states a green light to deem some past enrollments "invalid" and void them.

Of course, people continue to disenroll from Medicaid -- when they get a job with affordable insurance, or marry someone with insurance, or move, or age into Medicare (at which point the income thresholds for Medicaid drop in most states), or age out of CHIP, or die...etc. etc. It also seems clear that with 5 million more unemployed in November than in February, despite a snap-back from 14 million newly unemployed at the May peak, demand for Medicaid has grown.

At the same time, the Kaiser Family Foundation recently found that the ranks of those insured through employers have decreased only modestly (-1.5%) in the pandemic. Medicaid enrollment, meanwhile, has continued to grow by 1% per month or more in recent months -- at least by my compilation of state monthly enrollment reports, which shows somewhat more growth that CMS's time-lagged official monthly tally.* Certainly a significant portion, and possibly a very large portion of the enrollment growth is a result of the pause in disenrollments.

From those wonderful folks who brought you ACA nullification....

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Does the rogue's gallery of state attorneys general asking the Supreme Court to end American democracy by overturning presidential election results in Georgia, Michigan, Wisconsin and Pennsylvania look familiar? Here are the states that joined an amicus brief in support of the suit filed by indicted Texas attorney general Ken Paxton alleging that all of those states' certified election results are the product of massive but utterly undocumented fraud:

All of these states except Oklahoma and Montana* are plaintiffs in California v. Texas, the suit arguing that when the Republican Congress zeroed out the ACA individual mandate penalty in December 2017, they rendered the entire sprawling law unconstitutional, either by accident or by stealth.

Insured Americans' MOOP exposure rises relentlessly

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After premium increases exceeding 20% roiled the ACA marketplace in 2017 and 2018, premiums have been essentially flat for three years. That's good news for unsubsidized enrollees, who left the market in droves in 2017-18. The flat premiums reflect a stable market, to which insurers have been returning.

Premiums are only half of the affordability equation, however. For those who require substantial medical care, out-of-pocket costs can loom even larger. And these costs have been rising relentlessly, reflecting the degree to which medical inflation continues to outpace overall inflation, particularly in private insurance.

While deductibles are the most familiar proxy for out-of-pocket costs, the ACA's statutory annual out-of-pocket maximum (MOOP) is an at least equally important measure. The MOOP represents an enrollee's total exposure in a healthcare system in which a short hospital stay will likely hit the cap. The MOOP, moreover, applies to employer-sponsored insurance as well. Every year, the Center for Medicare and Medicaid Services (CMS) resets the highest allowable MOOP.

The MOOP cap has been rising relentlessly since the inception of the ACA marketplace, from $6,300 for an individual in 2014 to a proposed $9,100 in 2022 - a 44% increase over 9 years. (MOOP for a couple or family is double the individual amount.). The yearly increase is calculated to reflect the average increase in commercial market premiums, which in turn presumably reflects the cost of care paid for by commercial plans. For comparison, median household income increased 16% from 2014 to 2020; the maximum allowable MOOP increased 29% in that span.

Medicaid enrollment growth stays on pace in October

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The growth in Medicaid enrollment stimulated by the pandemic -- and by the pause in disenrollments mandated by the Families First Act -- appears not to have slowed in October, or not appreciably.

In the 29 states for which October numbers are recorded below, enrollment is up 1.2% in September. As usual, slow growth in California will probably drag the national rate down. In fact, California's September total is also tentative, for reasons explained at bottom. Illinois' September total remains estimated.

When all the October numbers are in, the 32-state sample below, based on state-published monthly reports, will probably show a 10.7% increase nationally since February. As I detailed in my last post, CMS's official tallies, now posted through July and updated through June, indicate a slightly slower growth rate -- 6.8% compared to my 7.4% tally for July.  A similar gap for October would suggest 9.8% growth since February, and a national enrollment total through October of 78.2 million nationally. 

State Medicaid enrollment totals in light of CMS's (lagging) reports

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Update, 12/21/20: CMS has just posted its preliminary August Medicaid/CHIP enrollment total: 76,489,912, up 8.3% since February (per below, CMS compares preliminary totals from each month for consistency; the final total for August will probably be 300-400,000 higher than the prelim). My own August estimate, based on state reports, was 8.7% growth since February. As I'm showing an 11% increase from February through October, CMS will probably come in at a bit over 10% - probably about 78.5 million total enrollment.

CMS's monthly tally of state-by-state Medicaid enrollment growth in this pandemic year is currently posted through July* -- reflecting five months in which enrollment was affected by the Covid-19 pandemic, and four-plus months in which the suspension of disenrollments mandated by the Families First Act was in effect. 

Most states post provisional Medicaid totals on state websites on a monthly basis, revising at varying intervals, and I have been tracking enrollment in 32 states in advance of CMS's 2-3-month lag. The available state reports vary somewhat from the the CMS tabulations, and both are adjusted retroactively. February-through-July is a large enough sample for me to compare my monthly tallies with the  CMS figures.

From February through July, in 32 states, I recorded a 7.4% increase in Medicaid enrollment.  Since CMS has so far only released its preliminary report for July, an apples-to-apples February-July comparison requires using CMS's preliminary rather than the updated February totals. With each month's new preliminary report, CMS reports updates the prior month state-by-state totals, and the updated totals are higher, as they include retroactive enrollment and enrollees whose applications were not finalized in the prior month. The February updated total is 405,491 higher than the preliminary February tally.** Comparing the preliminary totals for both months, as CMS does here, suggests a 6.9% increase nationally from February-July, and 6.8% in the 32 states I track, as the chart below shows. Links to the state-issued reports are provided at bottom.

The most recent published update to my 32-state sample derived from state-published supports suggests about 9.7% increase from February through September. Reducing that estimate proportionately to the July estimate would peg growth from February-September at 8.9%, suggesting total enrollment of about 77.5 million. Totals look to be up more than 1% in October, putting enrollment above 78 million.

Pennsylvania transforms its ACA marketplace with one sentence

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With a two-step regulatory change*, Pennsylvania has transformed its ACA marketplace. The measure is probably the most impactful single step a state has taken to improve its marketplace. And the move won't cost the state a cent. It simply picks up money the Trump administration left on the table when it cut off direct federal reimbursement of insurers for the Cost Sharing Reduction (CSR) subsidies they must provide to low income marketplace enrollees who select silver plans.

The new Insurance Department regulation (Revision 1b here) requires individual market insurers filing rate submissions to make this change:

CSR Defunding Adjustment of 1.20 – all individual silver exchange plans.

In other words, price silver plans proportionately to their real actuarial value (as estimated by the Department) with CSR priced in -- at 1.2 times the value of silver without CSR.  

That change dates back to 2020. For 2021, the Dept. of Insurance added a requirement that insurers must base their estimates of "induced demand" at each metal level on the scale HHS uses for its risk adjustment program, also incorporating the CSR adjustment.  "Induced demand" is a measure of how much each increase in coverage generosity is likely to stimulate more use of medical services. Left to their own devices, insurers have tended to overestimate the "induced demand" imputed to gold plans, leading to their overpricing relative to silver.

The change standardizes, and therefore in almost all cases increases, silver loading -- pricing of CSR into the premiums of silver plans only, since CSR is available only with silver plans (see note below). The result: statewide, the cheapest gold plan costs less than the benchmark silver plan against which premium subsidies are set, and bronze plan discounts have increased as well. 

ACA Medicaid expansion enrollment continues to swell as pandemic surges

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 As our woes show no sign of abating -- 120,000-plus new Covid-19 cases per day, a million new jobless claims per week -- neither does Medicaid expansion enrollment. This part of the ACA is providing a vital safety net. The sampling below (states that have reported expansion category enrollment through October) indicates that enrollment growth did not slow in October.

How representative is the sample? Well, August growth is about 1 percentage point higher in this sample than in the larger (18-state) sample I posted for that month. California, where Medicaid enrollment has been almost flat in pandemic months, drags down the all-state rate of increase by probably another 2 percentage points. I am pretty confident that expansion-category enrollment growth since February tops 20% nationally. For more about my various assumptions, see this post (and this September update).

Pandemic Medicaid expansion enrollment in 12 states
February thru October 2020

 Idaho increase through August is estimated at a rate comparable to Sept-Oct increase.

ACA Ok? Once again, Chief Justice Roberts seems to dismiss an argument from intent

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In his June 2015 decision disposing of King v. Burwell, the last lawsuit before the presenting pending one seeking to cripple the Affordable Care Act, Chief Justice Roberts summarily disposed of the plaintiffs' patently fraudulent argument about Congressional intent. 

The suit was based on a drafting error. While the law envisioned states forming their own health insurance exchanges, but gave them the option of deferring to a federal exchange, key provisions referred only to "an exchange established by a state" as the vehicle for allocating premium subsidies to enrollees. The error was a biproduct of the political warfare that affected the ACA's drafting history, preventing an ordinary reconciliation of Senate and House versions.

Recognizing that spotlighting a drafting error would not suffice to convince the courts to cripple the ACA marketplace, the plaintiffs argued that the omission was no error. They claimed that while Congress intended to authorize state-based health insurance exchanges to grant premium subsidies to qualifying enrollees, Congress intended not to authorize the federal exchange to grant those subsidies. (At the time the suit came before the Supreme Court, 37 states were relying on the federal exchange, HealthCare.gov.) Testimony by those involved in the law's creation was unanimous that no one intended to bar the federal exchange from awarding premium subsidies.

Writing for a 6-3 majority, Roberts' disposed of the intent question thusly:

Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them. 

Improving the ACA under gridlock, Part II: Innovation waivers and new revenue sources

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Earlier this week I reviewed the many ways a Biden administration might improve healthcare access and affordability by administrative action, on the assumption that with a Republican Senate majority, major legislation to improve the ACA or revolutionize drug pricing is off the table. The laundry list was courtesy of Elizabeth Warren, except for a final item, maximizing silver loading, would likely have the largest impact on the ACA marketplace.

Now let's think about another non-legislative means by which insurance coverage might be boosted: the ACA Section 1332 innovation waivers available to states. 

Under these waivers, states can propose to change almost any aspect of ACA marketplace coverage -- subsidy structure, metal level, essential health benefits, employer mandate -- in an effort to improve affordability and access. There are tight constraints, however: the proposed alternative must  provide coverage as comprehensive and affordable to as many people as does the existing marketplace design (or rather, will again, with CMS director Seema Verma gone), without increasing the federal deficit. 

That fiscal constraint amounts almost to a Catch-22, as the requirement not to boost spending is on an absolute, not per capita basis. If the state's changes boost enrollment, even while reducing cost per person, the state must foot any excess spending.

I have reviewed potential state innovations many times, e.g., here and here (one major option for states to consider, a Medicaid-like Basic Health Program for enrollees with incomes up to 200% FPL, is enabled by a different ACA provision, Section 1331).

Here I want to focus not on potential alternative schemes themselves, bur rather on fiscal opportunities that have opened up for states in the Trump years and that potentially make waivers more viable. By both accident and design, the federal government has put new money on the table.  Potential revenue sources include:

Trump's corrupt schemes didn't help him -- but they didn't hurt him either

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Some time in the night, I found myself thinking about this claim of Greg Sargent's, which I found clarifying when it was published on October 7:

When you step back and survey the last two years of U.S. politics, one of the biggest story lines that comes into view is this: One after another, a whole string of deeply corrupt schemes that President Trump has hatched to smooth his reelection hopes have crashed and burned.

The "corrupt schemes" run from attempting to extort a bogus investigation of Biden from the Ukrainian president to trying to retail the same Biden smears in U.S. media to a retaliatory investigation of those who conducted the investigation of Russian influence to siccing federal troops on protestors to sabotaging the Post Office, smearing vote-by-mail and promising legal challenges against full vote counts.

While it's true that all of these schemes have failed (so far), it's also true that none of them hurt Trump's standing much. His support is pretty much where it was in November 2016. 

A healthcare reform plan for Joe Biden with a Republican Senate

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If, as seems likeliest but by no means certain, we have a President Biden and a retained Republican majority in the Senate, the ACA's core programs are likely to limp along fully funded but not radically improved.

Biden had proposed major reforms to the ACA, including: 1) establishing a public option, 2) allowing those with access to affordable employer-sponsored insurance to buy in to the marketplace on a subsidized basis, 3) capping premiums for a benchmark plan at a maximum 8.5% of income, with no income cap on subsidy eligibility, 4) boosting subsidies at every income level, and 5) offering free marketplace coverage to low income people in states that refused to enact the ACA Medicaid expansion.

None of that is likely to happen. At best, Biden may be able to convince McConnell to render moot Texas v. California, the case before the Supreme Court seeking to have all or part of the ACA declared unconstitutional on patently fraudulent grounds, by either repealing the individual mandate or raising the penalty to $1. 

There's much that can be done to improve the ACA -- and the entire U.S. healthcare system -- administratively, however. And we have a blueprint -- provided by an indefatigable and aggressive reformer with administrative smarts: Elizabeth Warren.

You may recall that during the campaign, Warren jumped through some convoluted hoops to straddle the gap between Medicare for All and more incremental (though still sweeping) and swiftly achievable reform.  

To that end, she released a transitional plan for her prospective first term as president last November. What's relevant now: a sweeping set of proposed administrative actions.  They include:

If Republicans had succeeded in ACA repeal in 2017: state snapshots

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Last week, David Anderson, Louise Norris and I looked at how many more Americans would be uninsured if the Republican effort in 2017 to "repeal and replace" the ACA's core programs had succeeded, as it very nearly did (90% of Republicans in Congress voted for the main House or Senate bills). 

"Repeal and replace" was a misnomer: the Republican bills would have established an inadequate replacement for the marketplace -- but simply ended the ACA Medicaid expansion, which has had more impact. According to CBO projections, the repeal bills would have reduced Medicaid enrollment by 8 to 9 by this year, and by 14-15 million as of 2024, when the phase-out of enhanced federal funding for the expansion population would be complete. With the expansion intact, Medicaid enrollment has increased by about 8 million during the pandemic. Enrollment by those specifically rendered eligible by the ACA has increased by about 20% since February.

We also prepared several state-specific versions, as frankly we were apparently caught in a pre-election op-ed tsunami and couldn't quickly place the original.  Below, I've pasted state-specific outtakes.

What if Republicans had succeeded in repeal of the Affordable Care Act?

I've teamed up with friends for this final pre-election reminder of what the Republican healthcare agenda is really all about.

By Andrew Sprung, David Anderson and Louise Norris

On November 10, the Trump administration will ask the Supreme Court in oral argument to declare the Affordable Care Act unconstitutional – and nullify the law in the midst of a pandemic, uninsuring an estimated 23 million people. As Republicans rushed to confirm the nomination of Amy Coney Barrett to the Supreme Court, Senate Majority Leader Mitch McConnell  asserted that “no one believes” the Court will strike down the law – implying, as many hard-pressed Republican incumbents have also implied, that Republicans have no wish to do so.

But ACA repeal has been Republican policy since President Obama signed the bill into law in March 2010.  In 2017, a Republican House and Congress came within a whisker of repealing the ACA’s core programs, and 90% of Republicans in Congress voted for repeal. Where would be now if they had succeeded? How many more Americans would be uninsured, and what options would be available to the millions who have lost job-based coverage since the pandemic reached our shores? 

A narrow look at the broad middle of the ACA marketplace

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 This is a rather unilluminating post.  Are you still here?

I have been expecting to see more discounts in gold plans this year than in prior years, given CMS's report showing that lowest-cost gold plan premiums in 20201 are down an average of 6% from the year prior, while lowest-cost bronze and silver plans are down just 1%.  Yesterday's sampling of premiums in the 10 counties with the highest enrollment nationally offered some evidence in favor, albeit with really cheaply gold concentrated mostly in Texas' largest markets, Harris County (Houston) and Dallas.

As a followup, I took a look at middling markets -- literally: zip codes where enrollment was at the median for all 27,365 zip codes in the U.S. That is, 13 zip codes that each had 239 on-exchange enrollees. These markets are scattered through the country's broad middle (four were in Tennessee, but the plan offerings varied considerably among them). Population ranged from 3800 to 11,300.

The one consistent pattern was an increase in participating insurers -- often resulting in higher premiums for lowest-cost plans. Market watchers know that new competition is more likely to weaken discounts for subsidized enrollees than to improve them, and that's the case here (though new entrants may provide important new options where provider networks are concerned).  On average, lowest-cost bronze and silver premiums for subsidized enrollees in these markets rose from 2020 to 2021. Lowest-cost gold was all over the map, but also rose a bit.

Cheaper gold in the ACA marketplace's high-enrollment counties

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Last week, CMS reported that in 2021, average premiums in HealthCare.gov states are dropping for the third straight year. I noted that since lowest-cost gold plans were dropping an average of 6%,  compared to a 1% drop for lowest cost silver and bronze, we should see steeper discounts in gold plans this year. 

Perhaps, that is, the markets will move a bit closer to the gold-cheaper-than-benchmark-silver norm envisioned by the prophets of silver loading prior to Trump's cutoff of direct CSR funding in October 2017 (see this post for an explanation). 

That appears to be the case, to judge by premium changes in the ten U.S. counties with highest marketplace enrollment in 2020. Enrollment in these 10 counties accounts for 17% of all enrollment nationally.

In NJ Spotlight News: "Happy Launch, GetCoveredNJ: Don’t Forget NJ FamilyCare"

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In New Jersey Spotlight News, I put in a plea that New Jersey's new state-based exchange GetCoveredNJ, and the coming "get covered" outreach during Open Enrollment, give due emphasis to Medicaid:

GetCoveredNJ and state officials should avoid repeating a mistake endemic to state exchanges: overemphasizing the private-plan marketplace at the expense of Medicaid (NJ FamilyCare)...

From the ACA’s passage in 2010 to the present, the private-plan marketplace has sucked up all the political passion. But the Medicaid expansion has insured far more people who would otherwise be uninsured. In New Jersey, as of September, 597,000 enrollees in NJ FamilyCare were rendered eligible by ACA criteria. About 175,000 New Jerseyans were subsidized in the private-plan marketplace...

Gov. Murphy and the state Legislature have used financial judo to fund improvements in the state’s health insurance marketplace, capturing funds that previously went to the federal government to finance enrollment assistance, advertising and supplementary subsidies. To best protect New Jerseyans from becoming uninsured during the current crisis, however, they need to focus equal energy on maximizing Medicaid enrollment.

We all have our hobbyhorses...  here again is the full article in NJ Spotlight News.

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September update: ACA Medicaid expansion enrollment up 19% since February in 16-state sample

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Time for an update on "expansion" Medicaid enrollment in the pandemic months -- new enrollees since February rendered eligible by ACA expansion criteria. That is, adults with household income below 138% of the Federal Poverty Level who are not blind or disabled or eligible according to other pre-ACA criteria.

In 16 states that have reported expansion-category enrollees through September, enrollment in this category is up 19.2% since February, and 1.9% since August. That points toward perhaps 2.9 million new enrollees in this category -- minus perhaps 400,000 in California, which has had mysteriously weak Medicaid enrollment growth in the pandemic. A bit more than 2 million have likely been rendered "newly eligible" by the ACA.  See the previous post on pandemic expansion enrollment for details.

Pandemic Medicaid "expansion" enrollment in 16 states
February through September 2020

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ACA marketplace 2021: Cheap gold proliferates

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In October 2017, when Trump cut off direct federal reimbursement of ACA marketplace insurers for the Cost Sharing Reduction subsidies they are obliged to provide to low income enrollees who select silver plans, he boasted that he'd destroyed Obamacare. The likely effect, however, had been anticipated at least since January 2016: inflated silver premiums triggering deep discounts in bronze and gold plans, stimulating enrollment. 

Briefly: CSR raises the actuarial value of a silver plan from its baseline 70% to 94% for enrollees with incomes up to 150% of the Federal Poverty Level and to 87% at incomes from 150-200% FPL. Gold plan AV is 80%. When CSR, available only with silver plans, is priced into silver plan premiums, that inflates subsidies, which are set to a silver plan benchmark and designed so that the enrollee pays a fixed percentage of income. That creates discounts for subsidized buyers in bronze and gold plans.

The prophets of silver loading, however, expected deeper discounts in gold plans than we've gotten so far. Here's what Linda Blumberg and Matt Buettgens of the Urban Institute anticipated in January 2016:

In addition, as discussed, the increase in silver plan premiums means that the premium for silver plan (70 percent actuarial value) coverage becomes higher than the premium for gold plan (80 percent actuarial value) coverage. This means that individuals above 200 percent of FPL can obtain higher-value plans at a lower cost if they shift from silver to gold plans. Consequently, virtually all tax credit–eligible individuals with incomes above 200 percent of FPL move to gold plans; their tax credit, computed using the second-lowest-cost silver plan, goes further when used for a gold plan.

New Jersey's new state-based ACA marketplace subsidies *rise* with income

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The "preview plans and prices" tool on New Jersey's spanking new state-based ACA exchange, GetCoveredNJ,  is live for 2021. The tool works well -- you can punch in ages and income and get results in short order. The results come with a surprise.

The new state-based supplemental premium subsidies (tacked onto federal subsidies for enrollees with incomes up to 400% of the Federal Poverty Level) average $578 per person per year ($48/month), as Governor Murphy announced this week. The key word here is "average." The new subsidies are not flat. In direct contrast to federal subsidies, they rise with income. 

For a single individual with an annual income of $19,000, a hair below 150% FPL, the state supplement is $20/month. At an income of $25,000 (just below 200% FPL), that rises to $30/month.  At $38,000 (just under 300% FPL), it's $95/month. That's the maximum, available at a solo income up to $51,040 (400% FPL).

That may seem counterintuitive, as enrollment losses in New Jersey's individual market, which have been steep, are especially concentrated at lower incomes, as illustrated below. 

Estimate: Total Medicaid enrollment stands at 78 million

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Update, 10/24/20: September totals added for IN, MD, ME, MI, MO, NV and UT. I also had to correct misallocated months in Kansas.
-----

Enough Medicaid enrollment data is in for September to venture an estimate that total Medicaid enrollment now stands at 78 million, up by about 7 million or 10% since February. 

In 13 states with total enrollment of about 24 million, enrollment rose 1.3% from August to September, roughly in line with recent month-to-month increases.  As in previous months, California will probably drag down the total, perhaps to 1%.

Please see this post for the assumptions behind my August estimate of 77.3--77.6 million, further updated here. Note that the August total for Illinois is still estimated, based on increases in prior months. Any error there would have a negligible effect on the total.

Job losses and the uninsured rate in the pandemic: A one-state snapshot

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Let's try a somewhat ambiguous one-state snapshot -- in New Jersey, my home state --  of the extent to which ACA programs may have blunted an increase in the uninsured population during the months when Covid-19 triggered huge increases in unemployment. 

According to the New Jersey Department of Labor, job losses due to the pandemic peaked at about 835,500 and stood at 426,110 as of August. Estimates of the ratio between the number of people losing jobs and the number losing insurance vary quite a bit, and the ratio probably varies quite a bit by state, depending on the types of jobs lost. The pandemic created novel conditions, in which a fair number of workers were furloughed and were able to keep their job-based insurance, at least for a while. 

In New Jersey, as in most states that enacted the ACA Medicaid expansion, Medicaid is the primary safety net for the newly uninsured.  Enrollees rendered eligible by the expansion -- adults with incomes up to 138% of the Federal Poverty Level -- are driving rapid growth in Medicaid enrollment in the state. Here's the story since February: 

Medicaid Enrollment Growth in New Jersey in the Pandemic

Coverage group	Feb 2020	Sept 2020	Increase Feb-Sept	% increase Feb-Sep
ACA expansion adults	510,850	597,002	86,152	16.9%
Non-ABD children	773,544	835,543	61,999	8.0%
All Medicaid	1,682,621	1,853,928	171,307	10.2%

Source: NJ FamilyCare Monthly Enrollment Statistics

ACA marketplace enrollment in Covid-19 season: Flat? Up a million? Both?

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 As millions of Americans lose job-based health insurance during the pandemic months, Medicaid, bolstered by the ACA Medicaid expansion, has served as a far more potent protection against becoming uninsured than the ACA marketplace, for several reasons:

1. As family incomes crash, about twice as many newly unemployed and uninsured become eligible for Medicaid as for subsidized marketplace coverage, according to Urban Institute calculations (2.4 times as many in expansion states; 1.6 times as many in nonexpansion states).  Medicaid eligibility is determined on a current monthly basis, while marketplace subsidies are calculated on the basis of estimated annual income.


2. The emergency extra $600/week unemployment insurance provided for up to four months (now expired) by the CARES Act does not (did not) count with respect to Medicaid eligibility, but did count in calculation of marketplace subsidies, severely weakening them (it continues to count, since the relevant measure is annual income).

Estimate: Between 42 million and 50 million people have enrolled in ACA-compliant plans since 2014

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While only about 5% of the nonelderly U.S. population is insured through the ACA-compliant individual market for health insurance, a far larger percentage of us are likely to access the market at some point in our lives (if it survives). At healthinsurance.org, I've estimated that between 42 million and 50 million people have accessed the ACA marketplace since its launch in January 1, 2014.

I've referred readers of that post here for more explanation of the basis of that estimate. CMS does not provide a simple count, yearly or cumulatively, of unique enrollees at all times and venues: during the annual Open Enrollment, via Special Enrollment Period year-round, and off- as well as on-exchange. So here is what I have pieced together:

1. New enrollment on-exchange during Open Enrollment

In its reports and Public Use Files tallying annual marketplace enrollment, CMS breaks out the number of new enrollees (as opposed to renewals). Each year, after reporting on total signups during the Open Enrollment period, CMS later reports on effectuated enrollment  -- that is, the number of enrollees who have paid their premiums. Effectuated enrollment at its peak each year has averaged about 89% of initial signups.  In the right column below, I have estimated effectuated new enrollment in each year and in total.

Total New ACA marketplace enrollment, 2014-2020

    Source: CMS Public Use Files (see note at bottom for adjustments)

From 2014 through this year, approximately 27.7 million people have purchased plans during the annual Open Enrollment period and paid their first premiums, effectuating coverage ("approximate" because I'm applying the overall effectuated percentage to the new enrollees specifically).  Some "new" enrollees may have dropped out and returned.

Medicaid enrollment (likely) up 9% since February

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As my post tracking pandemic Medicaid enrollment through August has gotten rather clotted with updates, I've posted the totals afresh below.

The big addition is California. The state has adjusted its August tally to a slight increase, in line with those of prior months, which have also been adjusted.  I am using the raw totals from the state database of certified eligibles. California's adjusted totals show a slightly bigger increase than previously, but still well below national averages, a mystery examined here. Adding California pulls down the 32-state increase from February through August by 1.7 percentage points.

For context and discussion of some data issues, such as how I reconcile states that report monthly totals  as of the beginning or end of each month, please see the prior post. In particular, the most recent update at the top of that post explains the basis of my estimate that Medicaid enrollment nationally is somewhere between 77.3 million and 77.6 million as of August, based on what's now a 32-state sample below. 

In brief, the 51-state enrollment increase from February thru August is probably about 9%. Nationally, Medicaid enrollment is now about 37% higher than it was in the third quarter of 2013, the pre-ACA point of comparison.

As the chart text was getting rather small, I've removed columns providing info about the programs each state tracks and the extent to which their tracking matches CMS's. See note, and chart with those columns retained, at bottom.

Trump's healthcare plan, revealed

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Let it not be said that Trump doesn't have a healthcare plan. It's this:

• Defund the ACA marketplace and Medicaid expansion
• Strangle Medicaid long-term via block grants or per capita caps
• Privatize Medicare

Oh right, that's the healthcare plan of the entire Republican Party.  

I have a post up on the BlueWaveNJ that lays this program out:

Estimate: ACA Medicaid expansion enrollment has increased by more than 2 million in the pandemic

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Ever since I was a child -- okay, ever since the ACA was a child -- I've been reading that 12 million Medicaid enrollees were rendered newly eligible by the ACA Medicaid expansion, which extended eligibility to adults with incomes up to 138% of the Federal Poverty Level (e.g., $1468 per month for an individual, $1303/month for a family of four). That's been the case since July 2016, rounding up from 11.6 million at that point. In June 2019, the last month tallied by CMS, enrollment of the "newly eligible" stood at 12.0 million.

A larger number -- 15.3 million in June 2019 -- are rendered eligible by ACA criteria and not by standard pre-ACA criteria. But 3.3 million of them are in states that had expanded adult eligibility to at least 100% FPL pre-ACA*. The federal government pays the ACA's enhanced "match rate" of 90% of costs for this larger group, classified as Group VIII.

Nationally, total Medicaid enrollment shrank by about 5% from early 2017 to early 2020.  Then came the pandemic.  As the economy crashed, Medicaid enrollment surged. It has probably increased by more than 6 million from the end of February through August. Here I'd like to venture an estimate, based on the enrollment data below: about 2.2 million of the new enrollees are ACA expansion enrollees. That would put current Group VIII enrollment at about 17.5 million.

If we assume that 78% of the new Group VIII enrollees are "newly eligible," that comes to about 1.7 million, raising current "newly eligible" enrollment to about 13.7 million. These enrollees stand to lose their coverage if the Supreme Court voids the ACA in its entirely.  And new enrollment triggered by the ACA expansion is far from over. In my 28-state tally (second chart here), the increase from July to August, 1.5%, is the same as from June to July.

At The American Prospect: Medicaid, the ACA's mainstay

As in 2018, political warfare over healthcare -- now escalating in the wake of Ruth Bader Ginsburg's death -- is focused on "protection for people with pre-existing conditions." While the war of words focuses on rules governing the individual market for health insurance, which insures about 3% of the population, the real fight is over the extent to which the federal government will subsidize health insurance for those who lack access to employer-sponsored insures. The pre-existing condition that matters most is low income.

The main engine by which the ACA has reduced the uninsured population is Medicaid. Obscuring this fact distorts our political debate as well as federal and state government response to the pandemic.  I made that case in 2018 in USA Today, and today I've made it again in The American Prospect:

Medicaid expansion enrollment far outstrips marketplace enrollment and is the chief bulwark against huge spikes in uninsured population

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As millions lose jobs and health insurance during the pandemic, I have railed against ACA marketplaces for submerging information about Medicaid* and focusing their messaging almost exclusively on the private plan marketplace.

In expansion states, at least twice as many of the newly uninsured will be eligible for Medicaid as for subsidized marketplace coverage, according to estimates by the Urban Institute and Kaiser Family Foundation. You'd never know it to look at most state-based marketplaces, and to a lesser extent, HealthCare.gov.

The exchanges were conceived primarily as private-plan marketplaces and still view routing people to the ACA's Qualified Health Plans as their primary -- almost sole -- mission. But in expansion states, they also qualify or enroll applicants into Medicaid where appropriate, and it's high time they recognized Medicaid enrollment (or routing) as a core mission.

The Medicaid expansion has been the primary engine for ACA-triggered reductions in the nation's uninsured population. To illustrate the point, I've set ACA Medicaid expansion enrollment next to marketplace enrollment in the 34 states (including DC) that had enacted the expansion as of June 2019, the last month for which CMS has recorded expansion enrollment data. Nationally, Medicaid enrollees who fit the ACA's expansion enrollment criteria outnumber marketplace enrollees by a 3-to-1 margin, subject to a couple of caveats at bottom. Links to data sources are in the headings.

What's the matter with California? The mystery of flat Medi-Cal enrollment, revisited

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As part of a May budget revision in California, the state Department of Health Care Services (DHCS) projected that in response to job losses triggered by the Covid-19 pandemic, enrollment in Medi-Cal, the state Medicaid program, would increase  to 14.5 million by July -- roughly a 16% increase.

According to the state's current tally, from February to July enrollment in fact increased by just .02%, from 12.48 million to 12.50 million. Twenty-five other states that have reported enrollment through July show an 8.6% increase since February.  The Center for Medicare and Medicaid Service's most recent 50-state tally shows a 3.4% increase from February through May.

What gives? Why has Medicaid enrollment in California so far been essentially flat in the months since Covid-19 triggered mass unemployment?*

The DHCS cites several potential factors potentially inhibiting enrollment:

Pandemic Medicaid enrollment powers into August

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Update, 10/4: see this post for 32-state enrollment through August (California included).

Update, 9/27: I'd like to venture a top-line estimate for Medicaid enrollment through August.  In the 25 states I can track through August (I've added Mississippi), enrollment is up 10.5% Aug-Feb. In tracking through July, California's near-flat enrollment drops total growth Feb-July by 1.9% percentage points. Assuming continued weak growth in CA in August, let's assume 8.6% enrollment growth since February. According to CMS's February tally, that would peg total enrollment through August at 77,293,798 -- call it 77.3 million, up about 6 million from February. (Preliminary August numbers for California are in, and they show a drop, which will probably be adjusted up to a very modest increase, based on recent history.)
      Of course, enrollment growth in the twenty states not tracked below could be different from the that of the tracked states. It's just occurred to me that I can tally the growth in those states through May, the last month tallied by CMS, and compare it to growth through May in the states tracked below. Then again, growth in many states surged after May -- but by definition this near-real-time tracking is tentative. Stay tuned. [Update: increase through May for the 20 states not included in my July chart is essentially identical to the 50-state increase excluding California -- 3.6% vs 3.7%. As of May, California pulled down the national average to 3.2%, from 3.7% excluding California. That's a 13.5% decrease in the increase, to put it awkwardly. Shaving the same percentage off the 10.5% August increase recorded for 25 states below suggests a 9.1% national increase since February and a national total upwards of 77.6 million enrolled in Medicaid.

Update, 9/22: California wrecks the average for July. Minus California, states below are up 8.8% through July; CA knocks that down to 6.9%. California has also posted a raw total for August that's below July's, but that total will doubtless be adjusted up, as July's has been. Also, South Dakota is up 1.3% July to August.
      The California monthly totals below were supplied by the state Dept. of Health Care Services. Raw totals recorded in two public state databases (1, 2) are slightly different from these totals. California deems the data preliminary for a full 12 months, and the state's monthly totals have changed considerably in the period in which I've been tracking. Growth remains surprisingly low, however.

Earlier updates at bottom.

------

Original post: (9/2/20): A handful of states have posted Medicaid enrollment totals as of the end August (or, in the case of New York, as of mid-August or beyond*). The main takeaway is that growth in Medicaid enrollment triggered by the pandemic does not appear to be slowing down.  In the states charted below, enrollment grew by 1.5% from June to July. In the four states that have reported through all or most of August below, enrollment also increased 1.5% over the prior month. [Update 9/4: Minnesota up 1.2%; 5 states up 1.4% July-August.]

The sustained Medicaid enrollment growth five months after the first pandemic-induced lockdowns  should not be a surprise. As I've noted before, Medicaid enrollment is a lagging indicator. A United Hospital Fund study found that in the Great Recession of 2007-2009, Medicaid enrollment in New York peaked seven months after unemployment peaked. Robin Rudowitz of the Kaiser Family Foundation tells me that Medicaid enrollment continued to climb nationwide after the Great Recession officially ended, and that state Medicaid directors whom Kaiser surveyed at the end of April anticipated increases extending throughout the year.

Pandemic Medicaid Enrollment in 31 States (updated 9/30)
February through July or August 2020
Expansion states in blue; nonexpansion states in red; Medicaid to 100% FPL in purple
Totals as of the end of each month

On Aaron Carroll's Coronavirus cap-and-trade

It feels odd for me to take issue with recommendations from Aaron Carroll on how to deal with the risk of coronavirus infection, individually and collectively. In March, Carroll was prescient on what we as a country needed to do (and, with Trump in charge, inevitably failed to do) after we'd already let community transmission run rampant -- reduce infections via shelter-in-place, and use the breathing room to ramp up testing. He is a trusted source on nutrition, medicine and healthcare policy, able to sift through piles of published studies and assess the evidence, as he did on core nutritional questions in The Bad Food Bible.

But I feel there's something off about Carroll's approach in today's column to risk balancing in response to the pandemic. No one should have any beef with the main point: when you give up one major form of risk mitigation (e.g, when you go back to school), don't give up all others (e.g., by congregating in basements). But how, then, to balance risks? Envisioning our individual conduct as "piles" of risk-mitigating and risk-enlarging decisions, Carroll writes:

Obama's montage of American history darkens

Hey America, ICYMI:

Addressed to the summer's young protesters:

You can give our democracy new meaning. You can take it to a better place. You're the missing ingredient -- the ones who will decide whether or not America becomes the country that fully lives up to its creed.

That work will continue long after this election. But any chance of success depends entirely on the outcome of this election. This administration has shown it will tear our democracy down if that's what it takes to win. So we have to get busy building it up -- by pouring all our effort into these 76 days, and by voting like never before -- for Joe and Kamala, and candidates up and down the ticket, so that we leave no doubt about what this country we love stands for -- today and for all our days to come.

Stay safe. God bless.

That's the 44th president of the United States warning that the 45th president will end democracy in America if we let him.

That warning represents quite a journey for Obama. He rose to prominence and won election by telling us that we are not as divided as we seem, that we are forever in the process of making our union ever more perfect, that Americans at pivot points in our history bent the arc of the universe toward justice.

Has Medicaid enrollment reached 77 million? (updated)

Update, 9/2: Four states post reports in recent days that bring totals through August. Discusson in  this post. 

Update, 8/27: Texas has reported June enrollment, and it's up 9% since February.  June chart below is updated. Most recent July chart, last updated 8/23, is unchanged.

One note about the apparent flat enrollment in California: the percentage of Medi-Cal enrollment that is Latinx, 50% in 2018, is about double the national average. The Trump administration's changes to the public charge rule, suspended though the new rule is, are likely continuing to chill enrollment among legally present noncitizens, and the effect may be particularly strong in California.

8/24/20:  Today the big addition is California enrollment through June. The state is a major outlier among expansion states, in that enrollment is up just 1.1% since February (after a slight dip in March). Adding CA dropped the all-state enrollment increase from February through June from 7.0% to 5.6%. The weak growth is apparently a mystery to state officials and advocates. I'll have more to say about that later in the week. [Update, 9/1: California has now published a raw total for July that shows a drop of 74,000. I had noted the July drop in this database, but as California is notoriously slow to account for retroactive liability, the July total is likely to be adjusted up.]  

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Pandemic Medicaid Enrollment in 29 States 
February through June 2020 (as of 8/27)
Expansion states in blue; nonexpansion states in red; Medicaid to 100% FPL in purple

California totals include about 850,000 enrollees in programs not counted by CMS, e.g., enrollees funded without a federal match rate. (As noted in the 8/23 update below, CMS state tallies now run through May 2020. The monthly totals for California listed above may yet be published online; they were sent to me. They are roughly congruent with eligible individuals tracked in this database.

UPDATED  9/2/20
Pandemic Medicaid Enrollment in 23 States 
February through July or August 2020
Expansion states in blue; nonexpansion states in red; Medicaid to 100% FPL in purple

The ACA today: A mid-pandemic assessment

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High-CSR coverage in Nebraska (top) vs. unsubsidized coverage in Alaska (bottom)

Enrollment in ACA marketplace plans totaled 12.7 million at the end of Open Enrollment 2016 and 11.4 million at the end of OE 2020.  Enrollment as of the end of OE has shrunk in every year since the 2016 peak.

Those top-line fact tend to shape basic perceptions of how the marketplace has fared. But in itself the top line is almost meaningless. The marketplace, and the U.S. healthcare system more generally, have undergone an array of changes, some of which mitigate the impression of modest, steady erosion, and some of which reinforce or even intensify it. Among the OTOHs:

• Collapse in unsubsidized enrollment.  Enrollment in ACA-compliant health insurance plans by people who did not qualify for ACA premium subsidies stood at 6.7 million in the first quarter of 2016 and at 3.4 million in Q1 2019. * Huge premium increases in 2017 (triggered by a genuine market correction) and 2018 (in response to Republican attempts to repeal the ACA and sabotage the marketplace) appear to have driven half of unsubsidized enrollees out. The ACA's failure to provide affordable insurance to a large percentage of those who don't qualify for subsidies stands out as one of its core failures -- offset though it may be by the law's provision of subsidized insurance (mostly Medicaid) to some 20 million people who would otherwise have remained uninsured.