Wednesday, October 07, 2020

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, 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.

Special enrollment periods

We need also to consider those who enroll outside the annual Open Enrollment season via Special Enrollment Periods (SEPs), granted on an individual basis after loss of other insurance or other "life changes," such as divorce or the birth of a child. For SEPs, we have partial data. This past June, CMS issued a report on SEP enrollment during the pandemic -- and by way of comparison, included SEP enrollment totals from January through May for the years 2017-2020 in the states that use the federal exchange, (39 states did so from 2017 to 2019, and 38 this current year). Here is the tally:

SEP enrollments in this subset totaled 2,843,956. The time frame represents a bit less than half the annual SEP period in each year. states represent about three quarters of national enrollment. I suspect that SEP enrollment diminishes as the year wanes. Multiplying the Jan-May total by 1.6, and then adding 33% for the states that run their own exchanges, suggests about 6 million SEPs from 2017 through 2020.

The rules for obtaining SEPs -- verifying a qualifying "life change" -- were tightened in 2016. In 2015, 1.6 million SEPs were granted in states, suggesting 2.1 million nationally, according to an unpublished CMS presentation that Charles Gaba got hold of . For 2014 and 2016, I have no data. In total, a reasonable estimate is that 8-12 million people have effectuated coverage through SEPs.

Acknowledging some uncertainty it's fair to assume that 32-40 million people have accessed the ACA exchanges since 2014, or 14% of the nonelderly population. About 85% of on-exchange enrollees are subsidized, suggesting about 31 million subsidized enrollees.

Off-exchange new enrollment

ACA-compliant plans can also be purchased outside the ACA exchanges, directly from insurers or through brokers, including commercial online platforms. And off-exchange enrollment in ACA-compliant plans, which dropped sharply in response to sharp premium increases in 2017 and 2018, has ranged from 5.4 million in 2015 to 2.1 million in 2019, according to the Kaiser Family Foundation. Summing those totals, estimating 4 million for 2014 (where Kaiser does not break out off-exchange enrollment) and adding 2.1 million for 2020 (when premiums dropped slightly) comes to 23 million total off-exchange enrollees. 

Assuming that the same percentage of off-exchange enrollees from 2014-2020 are new enrollees as on-exchange (39%) suggests that 9-10 million people, or 3% of the nonelderly population have accessed ACA-compliant plans off-exchange.

The Kaiser Family Foundation's Krutika Amin suggested that I check the off-exchange estimates against a CMS report on trends in subsidized and unsubsidized enrollment that included yearly totals from 2014-2018 of unsubsidized enrollment, combined on- and off-exchange, on an average monthly enrollment basis. CMS effectuated enrollment snapshots provide data for 2016-2019 that make it possible to to get a hard count of average monthly unsubsidized enrollment on-exchange. Where available, I've subtracted those totals from the combined on- and off-exchange enrollment totals in the report.

Average monthly enrollment is less than peak effectuated enrollment each year. Using this chart of monthly effectuated enrollment, I've calculated that peak enrollment averages 110% of average monthly. Bottom line: the Kaiser estimates, derived in part from commercial sources, closely match the CMS tallies.

In the chart below, estimated totals are in green.  For 2014, 2015 and 2020, I derived unsubsidized on-exchange enrollment on the basis of the reported percentage of total average monthly enrollment that is subsidized. Off-exchange totals for 2019 and 2020 are based on Kaiser's estimate for 2019 and flat premiums in 2020. Since Kaiser's 2018 off-exchange estimate is essentially identical to the hard-number off-ex tally for 2018 derived from the CMS report, I did not adjust down for 2019 and 2020.

Unsubsidized "new" enrollment, 2014-2020

                                             Sources: CCIO: Trends in Subsidized and Unsubsidized Enrollment 
                                                                     CMS effectuated enrollment snapshots 2020, 2019, 2018, 2017                                      

By broad estimate, then, between 42 million and 50 million people have accessed ACA-compliant health insurance in the individual market since 2014.

My thanks to Cynthia Cox and Krutika Amin of the Kaiser Family Foundation for assistance with these estimates.

Again, the post discussing these findings is here at

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