Tuesday, May 05, 2020

ACA enrollment in a pandemic: What we know so far

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Roughly 30 million Americans have filed jobless claims in the last six weeks. Slightly fewer than half that number may have also lost health insurance, according to an analysis by the Economic Policy Institute.*

The Urban Institute estimates that 59% of those in industries most vulnerable to job loss who lose job-based coverage will have access to government-supported insurance -- Medicaid, CHIP, or the ACA marketplace. How many accept the help is a different question.

The SEP imperative

The answer may depend in part on how wide the ACA online exchanges open the door. Normally, the uninsured can seek coverage only during a limited Open Enrollment Period (Nov. 1 - Dec. 15 in the federal exchange, longer in the 13 state-based exchanges), unless a change in life circumstances during the off-season renders them newly eligible. In that case they are granted a Special Enrollment Period (SEP). Applying for a SEP adds steps to the already complicated ACA enrollment process. Under normal circumstances, an applicant has to upload or mail in proof of loss of coverage, or proof of another SEP trigger, such as marriage.

As job losses started cascading in mid-March, twelve of the thirteen states (including D.C.) that run their own ACA exchanges opened emergency Special Enrollment Periods in which anyone who was uninsured could apply for coverage. That simplifies the messaging as well as the process: If you're uninsured, look at what's available. Four of these emergency SEPs have expired; eight are still open.

Medicaid enrollment is open year-round, but may not be on the radar for many of the newly unemployed who are rendered eligible by a sudden drop in income. As Medicaid enrollment by the newly unemployed is likely to far outstrip marketplace enrollment (more on that below), an emergency SEP's chief benefit may be to send a simple message: if you're uninsured, check out your options. Help is likely available.

The Trump administration declined to open an emergency SEP on HealthCare.gov, the federal exchange serving 38 states.  CMS did ease the SEP application process for those who lose employer-based insurance: at present such applicants need only attest to recent loss of coverage, not document it.  The door is cracked a bit wider than usual, but is still considerably less open than in the state-based exchanges that opened emergency SEPs.  So how is enrollment of the newly uninsured going?

Seven states running emergency SEPs have released data showing marketplace enrollment accelerating to varying degrees. Most notably, California's exchange, Covered California, which accounts for half of all enrollment in the state-based exchanges (SBEs), has reported marketplace enrollment during the first weeks of its emergency SEP (March 20-April 14) at just shy of triple the rate for the same time last year.*  California did not report on Medicaid enrollment in this period.

Through HealthCare.gov's cracked gateway

What about the 38 states using HealthCare.gov? No government data is yet available.**  There is, however, a proxy:  The commercial online broker HealthSherpa, which has an "enhanced direct enrollment" (EDE) platform embedded in the federal platform.

HealthSherpa can process marketplace applications in all 38 HealthCare.gov states -- and Medicaid applications as well, in 25 states that use HealthCare.gov and have enacted the ACA Medicaid expansion. The HealthSherpa platform shows all plans available on HealthCare.gov.  Fast and easy, mobile-friendly, and popular with brokers, HealthSherpa accounts for between a fifth and a sixth of all HealthCare.gov enrollments, according to CEO George Kalogeropoulos. Its enrollment numbers are likely to be broadly consistent with HealthCare.gov's.

In March, HealthSherpa marketplace applications were up 22% over February, according to Aleka Gurel, HealthSherpa's manager of partnerships. They then dipped in April to just 9% above the February total.  Medicaid applications were up 87% in March and another 65% in April, the company announced yesterday -- more than triple the February total.

Enrollments are not keeping pace with need. "Medicaid is up a lot more than marketplace, both on our site and on HealthCare.gov," Kalogeropoulos told me, "but nowhere near what you would expect, given the sheer number of unemployment claims. It should be like 5 times."

Kalogeropoulos noted that people may delay the health insurance decision and process, concentrating first on filing for unemployment and other primary concerns (e.g., food and rent), and possibly electing COBRA as a placeholder of sorts. Those who elect COBRA have 45 days to make a first payment, and they can drop the election in favor of marketplace or Medicaid coverage if they enroll within the 60 days allowed by a SEP. But inertia is an enemy -- as is ignorance.

COBRA, as the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 is known, requires than if an employer offers group health insurance and has at least 20 employees, it give departing employees  the option to continue their group coverage, usually for up to 18 months, and usually at their own expense (though some employers contribute a portion for a fixed period). For those eligible for marketplace subsidies or Medicaid, COBRA is usually the most expensive option.

"There's a huge awareness gap. This is what we're focused on right now," says Kalogeropoulos. "How do you tell people who are used to having employer coverage that you need to take the time to screen for marketplace and Medicaid and not just sit on the COBRA letter?"

House Democrats have proposed that the next Covid-19 relief bill provide 100% federal funding for COBRA premiums. Some Republicans are reportedly receptive to at least some federal support for COBRA. But the prospects are uncertain and distant.

HealthSherpa is advertising online, urging people to check out their options -- which most people can do in under a minute from the site's home page by typing in their zip code, household members and their ages, and income (this "screening" takes only slightly longer on HealthCare.gov).  Some of the company's advertisements are targeted directly at Medicaid enrollment. Medicaid is likely to pick up the bulk of the unemployed who seek government-supported health coverage.

The federal government is noticeably absent in efforts to get word out. Since Trump took office, CMS has cut marketplace advertising by 90%, and federal funding for enrollment assistance in HealthCare.gov states by 84%. Compounding the failure to open an emergency SEP is that persisting unwillingness to broadcast the federal aid available and fund help for people to navigate the sometimes complicated process of obtaining it.

To its credit, CMS has added some clear messaging to HealthCare.gov, and a simple on-site screener for Medicaid eligibility is not too hard to find. HealthCare.gov's general "see plans and prices" screening tool also works well, though it can miss Medicaid eligibility because it asks for an estimate of annual rather than current monthly income, and Medicaid eligibility depends on the former.

Medicaid for new millions

Affordable insurance should be available to millions of the newly unemployed. The average unemployment benefit in the U.S. is $378 per week, and far lower in many states. In normal times, a shockingly low percentage of the unemployed (under 30%) actually obtain the benefit. ***

In the 35 states (plus D.C.) that have enacted the ACA Medicaid expansion, the eligibility ceiling is $1,468 per month for an individual, $1,983/month for a couple, and $3,014 for a family of four.  Clearly, many households living on unemployment -- or failing to obtain it -- will have incomes qualifying them for Medicaid.

The $600 per week extra unemployment benefit provided through July 31 by the CARES Act, the Covid-19 relief bill signed into law on March 27, does not count toward Medicaid eligibility. It does count in the income calculation that determines marketplace subsidies, which will further skew enrollment toward Medicaid. But subsidized marketplace coverage will also be available to millions.  Getting word out and simplifying enrollment as much as possible should be government priorities.

Advertising Medicaid availability and streamlining the enrollment process should be Job 1. During the Great Recession, Edwin Park of Georgetown University notes (citing the Kaiser Family Foundation), Medicaid enrollment grew by 6 million from December 2007 to December 2009 as the unemployment rate climbed from 5% to 10%. That was prior to the ACA expansion of Medicaid eligibility to any citizen and some legally present noncitizens with a household income up to 138% of the Federal Poverty Level. To date, 35 states**** have enacted the expansion, with Nebraska scheduled to do so later this year. Given the current pace of job losses, an analysis by Health Management Associates foresees about 17 million new Medicaid enrollees in its mid-range estimate.  Health Management expects enrollment in ACA-compliant private plans to remain more or less flat, as some marketplace enrollees switch to Medicaid.

"Honestly, compared to enrollment in other stuff, what we do is more complicated and harder," Kalogeropoulos acknowledges. "We try to make it easy, but it's harder than doing nothing or signing up for some substandard crap like short-term insurance."  His message to the newly uninsured: "Really, really, if you lost your job, go screen. It's worth screening for five minutes -- you might end up dramatically better off than if you didn't. "

UPDATES, 5/6/2020
1. An Urban Institute analysis uses two models to estimate losses of insurance and increases in Medicaid/marketplace employment, one using data from the last recession through 2018, the other a longer time sequence (1998-2018) encompassing two recessions. For a 15% unemployment rate, the first model forecasts an increase of 8.2 million in Medicaid enrollment and 4.3 million in marketplace enrollment. The model based on the longer time horizon forecasts increases of 14.3 million in Medicaid and 7.3 million in marketplace enrollment.  The authors note that they did not model people down-shifting from marketplace to Medicaid, as Health Management Associates did.

2.  Politico's Rachel Roubein and Dan Goldberg report that states, their budgets crushed by the pandemic, are already cutting Medicaid spending (though they can't disenroll people, thanks to the second Covid-19 relief bill).  They also report significant enrollment data from three states:
Arizona in the last two months saw 78,000 more people enroll in Medicaid and the Children’s Health Insurance Program, which receives more generous funding from the federal government. Virginia has seen a 20 percent increase in enrollment applications since mid-March.

In New Mexico, where 42 percent of the population was already enrolled in Medicaid, sign-ups in the first two weeks of April surged by about 10,000 more people than expected before the pandemic.
3. Given state budget vulnerability and inflexibility, healthcare researchers at Georgetown (Edwin Park) and the Center for Budget and Policy Priorities (Aviva Aron-Dine et al.) are calling on Congress to further increase the federal share in each state's Medicaid payments. The second Covid relief bill boosted the FMAP by six percentage points; the 2008 stimulus bill did so by 12 points, and this budget crisis is far more acute than that of the Great Recession.  Park further calls on CMS to suspend a damaging change to rules governing federal Medicaid reimbursements to states.

* Seven state-based exchanges that have enacted emergency SEPs have reported enrollment within the SEP period. Only California has offered a clear comparison with a prior period (year-over-year or period immediately preceding the SEP). Charles Gaba has roughed out some possible rates of increase in other states compared to national SEP enrollment in ordinary times, but these estimates -- which suggest dramatic increases in some states -- are preliminary and tentative.
       The states that have opened emergency SEPs vary considerably in how easy they make off-season enrollment and how clearly they broadcast that enrollment is open to anyone who lacks insurance. Covered California offers perhaps the clearest sense of SEP potential, in that it a) accounts for 49% of all SBE enrollment, b) makes emergency SEP enrollment as easy as Open Enrollment, and c) has released a year-over-year comparison.

** CMS reports Medicaid enrollment data on a monthly basis and marketplace enrollment as of the end of the first and second quarters, but in both cases there are large time lags. The most recent monthly Medicaid report is for January 2020. Marketplace enrollment as of March will probably be reported in June and as of June 30, in December.

*** While the percentage of unemployed who obtain UI benefits is likely to rise this year, given the expanded eligibility provided in the CARES Act and state efforts to reduce barriers they've thrown up in recent years, a large percentage will clearly still go without.

**** Barring near-term Republican control of the presidency and both houses of Congress, more or all of the fourteen states that have refused to enact the ACA Medicaid expansion will likely get with the program in the new era of Depression-level unemployment. Seven red states have done so since 2016, four of them via referendum. The pressure exerted by tens or hundreds of thousands of newly uninsured residents, rural hospitals in distress, and federal tax dollars going to other states, will become irresistible. By the Kaiser Family Foundation's most recent estimate (Jan. 2020), about 2.3 million people in nonexpansion states are stuck in the "coverage gap" -- income too low to qualify for ACA marketplace subsidies, but no Medicaid available. Another 2.1 million people with incomes in the 100-138% FPL income range currently eligible for ACA subsidies but remaining uninsured would probably come in by Kaiser's estimate, as would those enrolled in the marketplace at that income level. In all, that's about 5 million people -- and in the current crisis you can probably double the estimate.   The big enchiladas are Texas and Florida, followed by Georgia and North Carolina.

Boosting ACA marketplace coverage in a time of mass unemployment: State options
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?

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