New Jersey poised to add state premium subsidies to federal in ACA marketplace

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New Jersey's tweeter-in-chief

The New Jersey bill that would replace the ACA's repealed health insurance assessment with a similar state tax, S2676/A4389, has passed out of all committees and is scheduled for floor votes in the state Senate and Assembly tomorrow (July 30). Update, 7/31: the bill passed the New Jersey Assembly and Senate yesterday on a near-straight-party vote, after withstanding a late $1 million dark money assault. 

The bill levies a 2.5% tax on fully insured employer plans and individual market plans operating in New Jersey and deposits that revenue in a Health Insurance Affordability Fund devoted to

increasing affordability in the individual market and providing greater access to health insurance to the uninsured, including minors, with a primary focus on households with an income below 400 percent of the federal poverty level [FPL], expanding eligibility, or modifying the definition of affordability in the individual market, through subsidies, reinsurance, tax policies, outreach and enrollment efforts, buy-in programs, such as the NJ FamilyCare Advantage Program, or any other efforts that can increase affordability for individual policyholders or that can reduce racial disparities in coverage for the uninsured.

The bill was amended late to exempt the New Jersey small group market  -- which also means that that market is excluded from benefiting from the Affordability Fund (MEWAs and dental plans were also exempted).

In the immediate term, the New Jersey Department of Banking and Insurance (DOBI) has indicated that it plans to spend the entirety of an estimated $224.4 million* in revenue collected in 2021 on the New Jersey's individual health insurance market. $77 million would go toward the state's share of the reinsurance program implemented in 2018 (designed to reduce premiums to 15% below where they'd be without the fund). The remaining $147.4 million would be used to supplement ACA marketplace subsidies with state subsidies for all New Jersey marketplace enrollees with incomes below 400% FPL.** Those subsidies would be on offer during Open Enrollment this fall, when the state's new state-based marketplace is set to be unveiled and New Jersey bids farewell to HealthCare.gov, the federal exchange.

As of February 2020, 174,978 New Jerseyans were receiving premium subsidies in the New Jersey health insurance marketplace. Were the extra subsidies to boost enrollment at incomes below 400% FPL to 200,000, the per-person state supplemental subsidy would come to about $60 per month. DOBI has floated a lower estimate, $42 month [see update 4 below]. Supplemental subsidies in this range -- $40-60 per month -- could have a substantial impact.

Surprise/no surprise: ACA marketplace enrollment is UP in 2020 (on-exchange only)

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Mystery of the ACA marketplace: every year since 2016, while total signups during Open Enrollment have ticked down, the percentage of those who effectuate their enrollment by making their first payment has risen.

On Friday CMS released 2020's first Effectuated Enrollment Snapshot, showing enrollment as of February. Enrollment is about 1% higher than in February 2019, though it was about 0.3% lower as of the end of Open Enrollment. It's also slightly higher than in February 2018.  The gap between total plan selections as of the end of Open Enrollment and effectuated enrollment after all first payments are due is the lowest ever.

Want a SEP? You'll have to schlep...CMS ends application streamlining on HealthCare.gov

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Update, 7/29/20: CMS confirms that it has reverted to the standard pre-crisis SEP verification process,  "as part of its efforts to safeguard taxpayer funds, promote market stability, and ensure affordable premiums."  As noted below, insurers were not calling for this change -- they are not concerned that looser SEP verification at this point will worsen the risk pool. As for safeguarding taxpayer funds, inhibiting marketplace enrollment will always do that. Meanwhile, HHS has been showering billions in CARES Act relief funds on the nation's wealthiest hospital systems, many of which hold huge reserves, while safety net hospitals go begging.

In late March, as twelve of the thirteen state-based ACA marketplaces opened emergency Special Enrollment Periods in which anyone who lacked health insurance could enroll, CMS was rumored to be on the brink of following suit in HealthCare.gov, the federal exchange used by 38 states.

Ordinarily, enrollment in ACA marketplace health plans is only open to all during an Open Enrollment season, which on HealthCare.gov runs from November 1 to December 15.  Those seeking coverage at other times must apply for a Special Enrollment Period and provide documentation showing that they had a qualifying life change, most often loss of health insurance. The emergency SEPs in some states did away with that requirement, functioning as in Open Enrollment. Others required mere attestation by phone or box-checking of loss of coverage or other life change, without documentation. (I reviewed various emergency SEP processes and presentations here.)

HHS ultimately declined to open an emergency SEP in HealthCare.gov. Reportedly the agency was ready to do so, but the Trump White House - killed it. Putting the marketplace forward as a vital service in time of intense need was a bridge too far for Trump & Co.  CMS did, however, accept attestation of loss of coverage prior to enrollment, with documentation to be supplied later. That change occurred around April 20.

Now, that limited but important accommodation has ended. Jenny Hogue, a health insurance broker based in Murphy, Texas, got wind of the change early this week. Shelli Quenga, director of programs at the South Carolina-based Palmetto Project, which provides marketplace enrollment assistance as a nonprofit brokerage, confirmed this to me, as did Jodi Ray, Director of the Florida Covering Kids and Families Project at the University of South Florida. "We have had appointments in the past week where consumers were asked for documentation to be uploaded," Ray emailed.

Testimony in support of a Health Insurance Assessment in New Jersey

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The New Jersey Senate and Assembly are holding hearings this afternoon on a bill, S2676/A4389, that would replace the national ACA tax on health insurers repealed by Congress late last year with a state tax that would raise some $300 million per year. The bill dedicates the funds to improving health insurance affordability, focusing mainly on low-income New Jerseyans.

The bulk of the money will likely be used to add state subsidies to federal subsidies for health plans sold in the ACA marketplace -- possibly as early as 2021 --  with a portion going to fund the existing reinsurance program that reduces individual market premiums for those who earn too much to qualify for subsidies.

BlueWaveNJ, of which I am a member, submitted the testimony below on behalf of the bill.

How to boost Medicaid enrollment in a pandemic: Kentucky's Cara Stewart has an idea or eight

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Let's zoom in once more on Kentucky, the state that appears to be having the most success enrolling the newly unemployed in Medicaid. From February to July, Medicaid enrollment in the state rose by 14.3%.  That's the sharpest increase in the nation, I believe, in the period of mass job loss triggered by the pandemic. [Update, 9/17: Medicaid enrollment in Kentucky is now up 19.7% since early March.]

That's not an accident. Kentucky has probably been the most proactive state in reaching out to the uninsured and helping them find subsidized coverage if eligible. Yet American standards are low: ignorance about Medicaid and the ACA marketplace is rife throughout the land. Cara Stewart, a longstanding advocate for increased healthcare access in Kentucky, and currently director of policy advocacy at Kentucky Voices for Health, believes the state could be doing more to reach out to the uninsured. We'll get to those ideas shortly. First, some benchmarks.

How many newly uninsured? Families USA and the feds paint different pictures

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Families USA released a report this week estimating that 5.4 million adults newly unemployed by the pandemic as of May are also becoming uninsured.

The estimate is based on data and analyses concerning  1) the number of people who have lost jobs (BLS), 2) the likely percentage of newly unemployed who have lost access to health insurance, and 3) the percentage of newly unemployed in the ACA era (2014-2018) who have found other insurance, including Medicaid and marketplace (Urban Institute).

The analysis boils down to a fairly simple equation: about a quarter of those who lose jobs do not find their way to job-based insurance through a family member, Medicaid, marketplace coverage or COBRA. Much higher percentages of the newly unemployed are estimated to become uninsured in states that have refused the ACA Medicaid expansion (42.5%) than in expansion states (22.6%).

5.4 million uninsured adults equates to about a 2.6 percentage point increase in the uninsured rates for Americans aged 18-64.  Based on the most recent National Health Interview Survey (Jan-June 2019), that would suggest an uninsured rate of about 16.3% for ages 18-64. As I've noted recently, more immediate survey data seems to indicate less severe increases in the uninsured population. A Commonwealth Fund survey of about 2300 adults conducted May 13 through June 2 seemed to indicate that a bit less than 2% of the population had recently become uninsured.

More strikingly, the experimental new Household Pulse Survey updated weekly by the CDC -- a joint project of the Census Bureau and National Center for Health Statistics -- shows comparatively little movement since its launch in the week of April 23, when it recorded a national uninsured rate of 12.6%  for ages 18-64 -- more than a percentage point lower than the 2019 NHIS estimate. The weekly updates have been quite volatile but on the whole have ticked upward, reaching 13.5% in the week of June 25 (there'll be another update tomorrow).  Estimates for individual states, shown below, average three percentage points higher in Pulse than in the FUSA study, and vary widely.

Medicaid enrollment in a pandemic: 18-state snapshot (expansion only)

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Update, 8/14: for all further updates please see the 26-state snapshot published August 12.

Update, 8/5/20:  Enrollment in Utah, which enacted full Medicaid expansion in Jan. 2020 following a partial expansion (for adults up to 100% FPL) launched in April 2019, increased 10.9% from February to June 2020. The population of enrollees rendered eligible by the expansion is up 25.5% in the same period. As the unemployed population in Utah was 45,000 higher in June than in February (largely recovered after a huge spike in April), the increase in Medicaid enrollees in the state since February (33,615) may exceed the increase in newly uninsured. 

Update, 8/4/20: Minnesota managed Medicaid/MinnesotaCare enrollment increased 1.5% July-August. It's now up 14.% since February. New York is up 9.5%, Feb-July; New Jersey is up 7.0% in the same period. Medicaid expansion population totals for Maine and Virginia are also update. 

Update, 8/2/20: I have updated the chart with July and/or June tallies for Illinois, Maryland, Oregon, and Washington. Noteworthy: a 3.1% surge in Illinois in June, and an Oregon update through July 27 that shows total enrollment up up 9.1% since February 3. Overall, enrollment in Medicaid programs charted by these 16 states (e.g., all Medicaid, managed Medicaid only, or ACA Medicaid expansion population only) was up 6.8% February through June. Colorado, newly added, was up 7.0%, Feb-June.

As mass unemployment appeared almost instantly in the wake of the pandemic-triggered shutdowns in March, and is likely to persist as the U.S. fails to contain the virus, I have focused almost all posts in recent weeks on increases in Medicaid enrollment in states that have enacted the ACA Medicaid expansion.

To repeat a baseline expectation, the Urban Institute forecast that if 15% unemployment lasts for "several months to a year," between 8.2 million and 14.3 million people would enroll in Medicaid, an increase of 11%--20% over total enrollment in early 2020, or 16%--28% over the total of enrollees under age 65.   While the current national unemployment rate has dipped officially to 11% (actually 12% when a categorization error acknowledged by BLS is added in), it's likely to spike again as our public health failures lead to renewed shutdowns and our legislative failures result in cutoffs or sharp reductions in relief benefits.

In Kentucky and Minnesota, Medicaid enrollment has already increased by double digits since February. In others, it's barely budged.  Myriad factors determine the rate of growth, including the extent of job losses in the state, the types of jobs lost, the mode/duration of layoff, and state per capita income.

I am more focused on factors within the states' control -- whether there is any effective outreach to inform the newly unemployed of their health insurance options and prompt them to apply -- for Medicaid (primarily) or marketplace insurance as appropriate.  Outreach can come via state-based ACA marketplaces (there are just 13; the federally administered HealthCare.gov serves the rest), advertising, governors' pandemic briefings, the state taxing authority (as in Maryland) or -- most promisingly, through the unemployment insurance division of state labor departments, as urged by Families USA and the Brookings Institute. As far as I know, Kentucky, where Medicaid enrollment is up 14%, is the only state that's fully exploiting this vital channel. Expanding presumptive eligibility (which Kentucky has also done) or accepting attestation of income can also have a strong impact.

Where is Medicaid enrollment surging? A June update

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7/9/20 -- see updates at bottom re strong July enrollment growth in Minnesota and Kentucky

A month ago, I spotlit a handful of states in which Medicaid enrollment was surging in response to the mass job losses triggered by the Covid-19 pandemic. Here, an update.

To review the context for enrollment growth recorded so far: the Urban Institute has forecast that if 15%* unemployment lasts for "several months to a year," between 8.2 million and 14.3 million people would enroll in Medicaid, an increase of 11%--20% over total enrollment in early 2020, or 16%--28% over the total of enrollees under age 65.  Joan Aiker and Tricia Brooks of Georgetown have tracked enrollment in 22 states that have reported through May and found an average increase of 5% over February.

Notes below track enrollment logged in June or as of July 1.  While the Georgetown scholars are tracking both expansion and nonexpansion states, I've limited myself to expansion states where growth is particularly strong.

As of the end of May, both Kentucky and Minnesota had reported increases exceeding 10% since February. I don't have an update yet for either. Among states with new data: