Squinting at likely new Medicaid and marketplace enrollment as job losses accelerate

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Charles Gaba has used early enrollment data from state-based ACA marketplaces that have opened up emergency Special Enrollment Periods to hazard an estimate: If HealthCare.gov, the federal exchange that handles ACA marketplace enrollment for 38 states, were to open a no-strings attached emergency SEP for sixty days, about a million more people than usual would enroll in marketplace plans in those two months.

That's based on a rough quadrupling of normal off-season enrollment in 3 states (Maryland, Colorado, Minnesota) that have opened emergency SEPs that enable applicants to complete an application online, more or less as they would during the yearly Open Enrollment season. (In 3 states that require emergency SEP applicants to initiate the application with a phone call (Connecticut, Washington, Nevada), enrollment is up just 22-35%.) As of 2015, about 6,000 people per day were enrolling via HealthCare.gov in nine months outside of Open Enrollment season. An extra 18,000/day for 60 days (assuming an easy, wide open SEP) would come to 1,080,000 additional new enrollees.

A few further observations:

• Process matters: The difference in states that enable online applications vs. those that require a phone call to begin the process appears dramatic, though data is scarce at this point (12 SBEs, including California and New York, have opened emergency SEPs; just six have released any data).  That said, HealthCare.gov, for which CMS refused to open an emergency SEP, requires those who lose job-based coverage to verify the date they lost coverage in writing before they can enroll in a marketplace plan.  With 10 million newly unemployed in a two-week period, that could cause an administrative train wreck.


• More than two months? While an emergency Special Enrollment Period must maintain the perception that enrollment isn't open year-round, so that people don't wait until they get sick to enroll, a continuing crisis is likely to lead to continuing extensions, as has already happened in many states.


• Early days yet: Shelli Quenga, Director of Programs at the Palmetto Project in North Charleston, South Carolina, said last week that her agency was so far busiest helping people get food stamps: "people have to eat every day, so they think more about their food benefits than they do about their health benefits." That's a typical sequence of concerns, according to Quenga.


• Early days, Part B: While enrollment from the 10-odd million newly unemployed as of April 2 hasn't fully gotten going, the tidal wave of job losses probably hasn't peaked yet.


• Medicaid will matter more: Gaba reports that in Maryland, SEP enrollment from March 16 through April 6 totaled 8,454 in Medicaid (which is open year-round) and 5,735 in the marketplace. [Update, 4/23/20: MNSure, the Minnesota ACA exchange, announced SEP enrollment numbers yesterday that showed a similar percentage of users, 60%, applying for either Medicaid or MinnesotaCare, a Medicaid-like "basic health program' available to applicants in the 139-200% FPL income range.] The CARES Act, signed into law on March 27, will likely further skew enrollment toward Medicaid. As I've noted previously, the $600/week extra unemployment benefit the new law provides for up to four months counts as income for the purpose of calculating ACA marketplace subsidies, but not toward Medicaid eligibility. Up to $10,200 of extra income will disqualify many marketplace applicants for secondary Cost Sharing Reduction subsidies and render others ineligible for premium subsidies, or else will sharply reduce those subsidies. 

One widely circulated projection, from Health Management Associates, foresees up to 35 million Americans losing job-based coverage, with a mid-range estimate of 23 million, which comes to an unemployment rate of 17.5%.  Health Management foresees enrollment in ACA-compliant private plans remaining more or less flat, as some marketplace enrollees switch to Medicaid. In the mid-range estimate, Medicaid enrollment grows by some 17 million as the uninsured population rises from 29 million to 34-35 million.

I had missed the likelihood of people shifting from marketplace to Medicaid. The differing tax treatment should accelerate that too. At the same time, the unemployment income boost should newly qualify some people in states that have refused the ACA Medicaid expansion for marketplace coverage by raising their countable household income over 100 % FPL.

Related:
ACA enrollment train wreck coming
Our emerging public option: Medicaid
CARES Act may reduce coverage gap in states that refused to expand Medicaid
Enhanced unemployment benefit will skew marketplace enrollment
Emergency special enrollment periods in 12 states: How easy?
How about an emergency Special Enrollment Period for the ACA marketplace?