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. [Update, 4/5/21: CMS's preliminary November total does indeed show an increase of 11.6% 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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See June 2021 update below the first chart.

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.