Tuesday, October 19, 2021

New Mexico models a platinum benchmark for the ACA marketplace

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I'd like to delve a bit deeper into the metal level pricing in New Mexico's 2022 marketplace (discussed in the previous post), since it's a potential model for the whole country. Plans available for 2022 can now be previewed on New Mexico's new state-based exchange, bewellnm.

For 2022, the state's insurance department instructed insurers to price silver plans as if they have platinum value. That's because, for enrollees with incomes up to 200% FPL, silver plans do have platinum value, thanks to the Cost Sharing Reduction (CSR) subsidies available to low income enrollees, which attach to silver plans only. Most silver plan enrollees in New Mexico have incomes below 200% FPL, and the pricing instructions are meant to be a self-fulfilling prophecy: if gold plans cost less than silver, then no one with an income over 200% FPL will buy silver plans. Since premium subsidies are set to a silver benchmark, gold will be available below benchmark, i.e. below the level deemed affordable by ACA criteria.

Thursday, October 14, 2021

bewellnm launches with *really* cheap gold plans; some confusion at low incomes likely

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New Mexico's newly minted state-based ACA exchange, bewellnm, has launched plan preview shopping for 2022.

What's noteworthy: uniquely, the New Mexico Office of the Superintendent of Insurance has instructed insurers selling in the state individual market to price silver plans on the assumption that no one who does not qualify for strong Cost Sharing Reduction (CSR)-- that is, no one with an income above 200% of the Federal Poverty Level -- will buy silver.  In other words, silver plans must be priced more or less as if they're platinum* -- since they are in fact platinum-equivalent at incomes below 200% FPL.  Platinum plans (which are almost nonexistent) have an actuarial value (AV) of approximately 90%. CSR brings silver plan AV to 94% for enrollees with income up to 150% FPL, and 87% for those in the 150-200% FPL income range.

This is meant to be a self-fulfilling prophecy: if gold plans (approximately 80% AV) are priced below silver plans, no one who doesn't get the high CSR value should buy silver. Silver plans for enrollees who don't qualify for CSR (income above 250% FPL) have an AV of 70%; those who qualify for negligible CSR (income 200-250% FPL) get an AV of 73%.   Why buy silver if it offers a lower AV than gold -- -but costs more?

In Albuquerque in 2022 (zip code 87107), gold is priced well below silver, as planned. For a 40 year-old ineligible for subsidies (income $100,000**), the lowest-cost gold plan costs $288 per month; the lowest-cost silver plan is $320 per month. Six gold plans, with deductibles ranging from $750 to $2300, are cheaper than the cheapest silver plan, which has a deductible of $5450.  The second cheapest (benchmark) silver plan, at $337/month, has a deductible of $4250. Who would buy silver in these circumstances?

Tuesday, October 12, 2021

In which the Kaiser Family Foundation moves to quell a PhRMA disinformation campaign

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The Kaiser Family Foundation (KFF) appears to have taken steps prevent PhRMA from using its polling in a disinformation campaign. 

In response, PhRMA has accused KFF of politicizing its research. That's like Donald Trump accusing an opponent of lying to the public (or rigging the vote count).

What KFF did do -- amend its survey questions about empowering Medicare to negotiate prescription drug prices -- is interesting. Let's step back and review how KFF typically structures questions regarding public policy options.

In its questionnaires, KFF will ask whether a respondent favors an initiative -- say, subsidizing children's lemonade stands. 90% approve! It will follow up with a question that raises the possible negative effects -- say, increasing neighbors' likelihood of developing Diabetes from all that liquid sugar.  Approval will drop, a little or a lot.

Tuesday, October 05, 2021

Wonder of wonders: National balance billing protection for consumers that (probably) won't increase healthcare costs

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The federal government* delivered some rare good news on the healthcare cost control front with release last week of the second part of interim final rule governing implementation of the No Surprises Act, which will protect Americans from the most egregious forms of balance billing (excepting ground ambulances!) beginning on January 1, 2022. The No Surprises Act was part of the broad-based bipartisan budget deal signed into law by Trump in late December 2020.

The good news concerns the ground rules for arbitration of out-of-network bills, which either the provider or the insurer can initiate if they can't agree on a price within 30 days. As in New York, New Jersey and other states that have passed laws protecting patients from balance billing, it's "baseball arbitration," in which the arbitrator must rule in favor of one party's proposed price, rather than splitting the difference. What matters is the standard by which the arbitrator must judge the competing bids. A summary published by CMS provides the upshot:

Tuesday, September 28, 2021

Rapid marketplace enrollment growth in nonexpansion states, revisited

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I don't know whether ACA marketplace observers have fully fathomed the extent to which the nonexpansion states drove the enrollment surge during the emergency Special Enrollment Period that ran from Feb. 15 to August 15 on HealthCare.gov -- and indeed, over the past two years.

Also not fully fathomed: the extent of total enrollment growth in all states during the pandemic.

Friday, September 24, 2021

Even with balance-billing protection, a tiered network may cause tears

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My last post involved a close look at the severely tiered provider network in the silver plans sold in the ACA marketplace by Independence Blue Cross, the dominant insurer in Philadelphia and southeastern Pennsylvania.  On a second look, a thought occurred to me: tiered networks that place go-to hospitals in higher tiers put an asterisk of sorts on balance-billing protections for emergency care, including those due to come online nationally when the No Surprises Act takes effect on January 1.

Under the No Surprises Act, emergency care is billed at in-network rates whether or not the hospital or facility is within the provider network of the patient's health plan. But what exactly is an "in-network rate" in a tiered network? Depends on the tier.

Independence's HMO plans sold in the ACA marketplace have three tiers. Its second-cheapest silver offering on Pennie, Pennsylvania's ACA exchange, the Keystone HMO Silver Proactive plan, posts a deductible of $0. But that's in Tier 1 only. For enrollees with incomes too high to qualify for Cost Sharing Reduction (CSR),* Tiers 2 and 3 have a deductible of $6,000 for an individual and $12,000 for a family. 

Tuesday, September 21, 2021

Independence Blue Cross sells only 24-carat gold plans in Philadelphia and surrounding counties

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What is wrong with this picture?

These health plan quotes, taken from the health plan comparison tool provided on Pennie, Pennsylvania's online ACA marketplace, show the lowest-cost silver and gold plans offered in Philadelphia by southeastern Pennsylvania's dominant insurer to a 40 year-old with an income of $38,000.  (Premiums are net of a federal subsidy of $262 per month.) 

In the pricing of its lowest-cost gold plan, Independence Blue Cross, issuer of the Keystone health plans listed above, is an outlier, in that its lowest cost gold plan is priced well above its lowest cost silver plans. That's not how it's supposed to work in Pennsylvania.

Thursday, September 16, 2021

Notes from the SEP: On record marketplace enrollment in August 2021

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CMS today released a final enrollment report for the emergency Special Enrollment Period that ran in HealthCare.gov states from Feb. 15--Aug. 15 this year, and for mostly comparable lengths in the 15 state-based marketplaces. 

The top line: 2.8 million new enrollments nationally in that period. A few quick notes:

  1. Effectuated enrollment in August 2021, 12,199,393, is up 14.6% over 2020, the previous high (10,642,088*), and 22% over enrollment in August 2016, the peak prior to 2020.  Caveat: off-exchange enrollment in ACA-compliant plans dropped by about 3 million from 2016 to 2019, according to KFF estimates. On-exchange enrollment is about 2.2 million above the August 2016 total.

  2. While 2.8 million people newly enrolled in marketplace coverage during the SEP, total enrollment has risen by only 900,000 since February, when effectuated enrollment stood at 11.3 million.  That's steeper attrition than I anticipated when I estimated total enrollment at 12.7 million through July.

Friday, September 10, 2021

Dropping the Medicare age to 60 also requires...

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130 House Democrats have co-sponsored a bill introduced on September 3 by Pramila Jayapal, the Improving Medicare Coverage Act, that would drop the Medicare eligibility age to 60 -- simply and cleanly, with Medicare offered on the same terms at age 60 as it now is at age 65, within six months of enactment. That's the headline. But the bill does something else that's arguably more consequential. 

Without other changes to Medicare, dropping the eligibility age to 60 would be a mixed blessing at best. That's because for 60-64 year-olds with income below 200% of the Federal Poverty Level ($25,520 for an individual, $34,480 for a couple in 2021), Medicare in its current form would be considerably more expensive than ACA marketplace coverage (as enhanced through 2022 by the American Rescue Plan Act in enacted in March) -- excepting for those who are dually eligible for Medicaid and Medicare. While just over a quarter of the U.S. population is in households with incomes below 200% FPL, about half of the uninsured have incomes below that threshold.  

Jayapal's bill changes the equation by making all Medicare enrollees with income below 200% FPL eligible for a new Medicare Cost Assistance Program that would zero out premiums, coinsurance and deductibles for Medicare Parts A (hospital)  and B (physician and outpatient), and also subsidize Part D prescription drug coverage (covering the entire Part D premium and reducing prescription copays to single-digit dollar amounts).  The bill would also move administration of these benefits from state Medicaid programs to Medicare, with the federal government assuming 100% of costs now shared with states.

Saturday, September 04, 2021

Viewing the uninsured rate through foggy lenses

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Medicaid card

Snapshots of the health insurance status of the U.S. population are blurry.

When you look at the CMS tally of Medicaid enrollment increase since the pandemic struck, it seems, simply, that the increase swamps most estimates of the number of people that lost employer-sponsored insurance. Other factors are at work, of course. But the one large number is considerably larger than the other large number.

But official Medicaid enrollment totals may not be an entirely reliable measure of how many people are actually covered by Medicaid, and know themselves as such -- particularly during this pandemic, when disenrollments have been paused since March 2020. State Medicaid agencies are, to varying extents, blind beasts.

I know a young man who, during a year of transition, lived in two states and worked at three jobs, with a period of unemployment. At different points in the year he applied for Medicaid in two (blue) states and received rejection notices. From both of those states, months later (and months apart), while insured through his employer, he was sent managed Medicaid membership cards and informed that he'd be enrolled since shortly after his application was completed.  In both states, it took some doing and some time to get himself disenrolled.

Thursday, September 02, 2021

How will Medicare enhancement change the current public-private Medicare ecosystem?

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Democrats' aspirations to add dental, hearing and vision benefits to Medicare raises questions about the interactions between tradition, fee-for service (FFS) Medicare, Medicare Advantage (MA), and Medigap. These center on MA's growing market share, its funding mechanism, the gaps in FFS Medicare coverage that MA plans partially fill, and the value of Medigap for those who can afford it (or whose employers fund it).

Below, a brief outline (distilled mainly from KFF briefs) of how the three programs (FFS, MA and Medigap) interact/compete at present, followed by questions about how pending legislation may alter the ecosystem.

Tuesday, August 31, 2021

NHIS: No shift from private to public insurance?

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The annual early release estimates from the National Health Interview Survey (NHIS) came out today. The NHIS recorded a decrease in the uninsured rate for all ages from 2019 to 2020, from 10.3% to 9.7%, but deemed the change statistically insignificant. Among adults aged 18-64, the uninsured rate  dropped from 14.7% to 13.9% -- also deemed not significant. Similarly, the Urban Institute survey report that I wrote about last week found essentially no change in the uninsured rate from March 2019 to April 2021 -- but also recorded a statistically insignificant drop. 

Directionally, as I noted last week, most surveys, including the Census's experimental Household Pulse Survey, point to a modest drop in the uninsured population during the pandemic. Big picture: huge gains in Medicaid enrollment, driven largely by a pause in disenrollments effectively mandated by pandemic relief legislation, appear to have outstripped drops in access to employer-sponsored insurance (ESI), which according to various sources fell less than the massive job losses triggered by the pandemic might have led one to expect. But there are a lot of moving parts that may have canceled one another out. 

Thursday, August 26, 2021

Is the uninsured rate flat since 2019, or down a bit?

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See 8/31 update from NHIS survey at bottom

The Urban Institute, in an analysis of results from its own ongoing Heath Reform Monitoring Survey, found that the uninsured rate among adults aged 19-64 did not change significantly from March 2019 to April 2021. 

That's at least a backhanded tribute to the U.S.'s kludgy health insurance safety net as bolstered by the Affordable Care Act. Big picture: in Urban's estimate, as a result of the pandemic, employer-sponsored insurance  fell by 3 percentage points (from 65% to 62.3%) in the survey period, while insurance through public programs (mainly Medicaid) increased by 4 percentage points (from 13.6% to 17.5%). 

You could read these results as a paean to the ACA Medicaid expansion (which Republicans almost repealed in 2017). In states that have expanded Medicaid, Urban found that the uninsured rate actually dropped two percentage points for people with incomes below 138% FPL, the Medicaid eligibility threshold. According to CMS, total Medicaid enrollment (including children) increased by 11 million -- 15.6% -- from February 2020 to March 2021.  Enrollment among adults rendered eligible by the expansion increased by about double that rate.

Urban recorded a much more modest and ambiguous impact for the ACA marketplace -- though the huge enrollment surge during the emergency Special Enrollment Period open from February 15 through August 15 of this year, turbo-charged by subsidy increases enacted in the American Rescue Plan, which appeared on HealthCare.gov on April, was mainly missed by Urban's study period. I'll return to that in a bit.

I speculated in May that the U.S. uninsurance rate might be at an all-time low, powered by huge gains in Medicaid enrollment, significant gains in marketplace enrollment, and relatively modest losses in employer-sponsored insurance during the pandemic. My methods (and math) are far less sophisticated than Urban's, and this is not to question their results (no source ever has a really complete picture of insurance in the U.S.).  That said, a few comments and caveats below.

Thursday, August 19, 2021

What's the effect of a gold benchmark in the ACA marketplace? Three states tell a tale. And a platinum benchmark is coming.

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Bloomberg's Sara Hansard reports that six states have now taken action to require insurers in their ACA marketplaces to price plans in strict proportion to their actuarial value -- that is, to increase the effects of silver loading. (Actuarial value (AV) refers to the percentage of the average enrollees costs the plan is designed to cover, in percentages fixed by metal level.)

Maryland, Pennsylvania and Virginia required strict silver loading in 2021 (and some or all in years prior). New Mexico and Colorado have new regulations going into effect in 2022. Texas has passed a law requiring the state insurance commissioner to take the value of Cost Sharing Reduction (added to silver plans only) into account during rate review.

Silver loading as mandated in Maryland, Pennsylvania and Virginia makes gold plans at least marginally cheaper than silver plans, increasing value for enrollees with incomes above 200% of the Federal Poverty Level ($25,520 for an individual in 2021). Below that income threshold, Cost Sharing Reduction (CSR) raises the actuarial value of silver plans to a roughly platinum level.

Friday, August 13, 2021

On staying out of the coverage gap: expert advice

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I have a post up on healthinsurance.org addressing a subject near my heart: how to help more people avoid the "coverage gap" in states that have refused to enact the ACA Medicaid expansion.  That is, how to avoid being denied any help paying by estimating next year's income at a level below 100% of the Federal Poverty Level.

Eligibility for subsidized coverage (now free at incomes in the 100-150% FPL range, e.g., for anyone just over the eligibility threshold) is based on an estimate of next year's income. A lot of variables go into such estimates, especially for people with low incomes, who are often self-employed or work variable and unpredictable hours, or rely on tips, or do seasonal work. In this piece, brokers and enrollment counselors who have been at work since the ACA marketplace launched explain in detail how to maximize a good-faith estimate when necessary.

In many, many cases, failing to qualify for subsidized coverage is a matter of ignorance. The application does not tell you that there's a minimum income threshold you need to cross. Accordingly, the first step in helping low-income people seeking coverage is to spell out the minimum qualifying income:

This point can't be emphasized enough, according to Shelli Quenga Director of Programs at the Palmetto Project, a nonprofit health insurance brokerage in South Carolina.  "You need to know what amount you're shooting for," Quenga says. "You need to know where that line is. HealthCare.gov does not tell you."

Paradoxically, the application does recognize income uncertainty, and in fact positively invites applicants to take it into account:

Tuesday, August 10, 2021

Total marketplace enrollment likely approaches 13 million

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Axios reports that Vice President Harris will announce today that more than 2.5 million people have signed up for marketplace coverage during the emergency Special Enrollment Period that began on February 15 and ends on August 15. (Yesterday, Charles Gaba estimated 2.57 million total SEP enrollments as of July 31.) [Update: CMS's SEP report through July 31 is out and cites the 2.5 million total.]

Just for fun, let's take a stab on where total marketplace enrollment likely stands right now. 

We know that effectuated enrollment totaled 11,290,546 in February, and that about 2.5 million additional enrollees have been logged since then. The wild card is disenrollments during those months. To estimate them, our best hints come from monthly enrollment tallies in 2020, recorded in the effectuated enrollment snapshot for February 2021.

Thursday, August 05, 2021

Maximizing the ACA Innovation Waiver: Biosimilar silver loading, anyone?

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Ask, and it shall be given

The advocates for more affordable health insurance at Families USA are asking the Biden administration to loosen up the Catch-22 that confronts states seeking to take advantage of the ACA's section 1332 innovation waivers.

1332 waivers enable states to propose alterations to virtually every feature of the ACA marketplace in pursuit of more affordable and effective coverage. The alternative scheme must cover at least as many people at least as comprehensively as the existing marketplace, and must do so without increasing the federal deficit. 

As currently interpreted, the deficit-neutral requirement presents a Catch-22: if the state's alternative scheme ends up costing more because more people sign up, the state is responsible for the excess costs, even if the coverage costs less (or no more) per person than the exiting ACA marketplace. 

Monday, August 02, 2021

ACA enrollment under ARPA: The view from near 100% FPL (and San Antonio)

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The ACA's tragic coverage gap confronts poor people in the 12 states that have refused to date to enact the ACA Medicaid expansion with a cruel logical absurdity: they may earn too little to qualify for government-supported health coverage.  Adults in households with incomes below the Federal Poverty Level (100% FPL) do not qualify for subsidized coverage in the ACA marketplace.

A few weeks ago, I noted that on May 5 CMS put a modest patch on the coverage gap by rescinding a Trump era policy of demanding income verification from marketplace applicants in nonexpansion states if "trusted data sources" indicated that the applicant's income was likely below 100% FPL -- i.e., ineligible for subsidies -- and the applicant had estimated an income above that threshold. (Since HHS's computer systems can't be retooled instantly, CMS explained, the exchanges will continue to request documentation in these circumstances for some time -- but in followup communication, they will "notify those consumers that they need not provide the requested information.")

In effect, a low-income applicant can make a good faith estimate of a household income in the coming year above 100% FPL and qualify for subsidized coverage (now free through 2022, if income is below 150% FPL, thanks to the subsidy boosts in the American Rescue Plan enacted on March 11). Documentation will not be required (though awkwardly, it will be requested for some time).  If income for the year in question ultimately proves to fall below the 100% FPL threshold, there is no clawback of subsidies granted, unless the applicant's income estimate is made with "intentional or reckless disregard for the facts."* 

The opportunity for low-income applicants to estimate their way into free coverage is the sort of regulatory forbearance that inspires high moral dudgeon from conservative adversaries of the ACA. In fact, though, poor or near-poor people in nonexpansion states who get as far as applying for health coverage - many don't, as ignorance of ACA programs is pervasive -- are likelier to underestimate their income than overestimate it. 

Friday, July 23, 2021

A Wisconsin window on the ACA coverage gap in pandemic time

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To pick up a thread from deep in the prior post...

In Wisconsin, ACA marketplace enrollment as of June 30, 2021 had increased by less than two percentage since June 2019. In the other thirteen states that had not enacted the ACA Medicaid expansion as of June 30 of this year, enrollment increased by 41% over the same period.

What's the matter (or rather, what's right) with Wisconsin?

    Enrollment in nonexpansion states, 2019-2021

     Sources: CMS, Early Effectuated Enrollment Snapshot, 20202021SEP enrollment 7/14/21; KFF
     See the prior post for an explanation of how June 2021 enrollment is estimated.

A lot of factors affect marketplace enrollment, which varies widely by state. But the most salient factor would appear to be the fact that Wisconsin has no "coverage gap." 

Thursday, July 22, 2021

Obamacare enrollment in nonexpansion states is up 26% year-over-year and 41% since June 2019 (estimate)

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Not to indulge in monomania, I want to offer a clearer snapshot than previously of really major marketplace enrollment gains in the pandemic period in states that had not enacted the ACA Medicaid expansion as of June 30 of this year.  As the uninsured rate in the nonexpansion states was nearly double the rate in expansion states as of 2019 (15.5% vs. 8.3%),  particularly rapid enrollment growth in those states -- most of it at low incomes -- is having a significant impact where help is most needed.

Every June, CMS publishes "effectuated" (i.e., paid-up) enrollment in each state as of February of that year. Those reports also break out monthly enrollment by state in the year prior. This year, that information is supplemented by monthly reports on off-season enrollment, stimulated this year by an emergency Special Enrollment Period (SEP), running from February 15 through August 15 in the 36 states using HealthCare.gov, which is the functional equivalent of a second Open Enrollment Period (the 15 states that run their own exchanges have also opened emergency SEPs.) The SEP reports provide enough data, or so I assume below, to estimate effectuated enrollment through June 30 of this year.

By my estimate, enrollment in 13 nonexpansion states as of June 30 -- excluding Wisconsin, for reasons discussed below -- is up 26% year-over-year, and 41% since in June 2019. That's a two-year increase of 1.74 million.  Enrollment is up by more than 50% since June 2019 in Texas, Georgia and Mississippi. It's up by almost 500,000 in Texas and by more than 650,000 in Florida.

Saturday, July 17, 2021

A huge increase in low-income ACA marketplace enrollment in nonexpansion states

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This is a postscript to my last post tracking massive SEP enrollment in nonexpansion states from February 15-June 30 of this year.  

I want to try to take the full measure of the enrollment surge in nonexpansion states at the lowest subsidy-eligible income level -- first in Open Enrollment season for 2021, and then in the emergency Special Enrolment Period (SEP) launched by the Biden administration on Feb. 15. This week, CMS reported SEP enrollment through June 30.

(This post is all numbers; please see the last post (and its backlinks to past posts ) for context, definitions, explanations.)

By my estimate, enrollment at the 100-150% FPL income level in 13 nonexpansion states (Wisconsin excluded*) in OE 2021 and the SEP for the Feb. 15-June 30 period combined exceeded 2020 enrollment in those two periods by almost 800,000.  That would be an increase of about 29%.

Thursday, July 15, 2021

More than half of all ACA SEP enrollment is in nonexpansion states

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CMS announced yesterday that ACA marketplace enrollment during the emergency Special Enrollment Period (SEP) that began on February 15 had passed 2 million by June 30. That's more than triple the total enrolled in the same period of 2019, the last year unaffected by the pandemic. By that standard, the emergency SEP, coupled with the subsidy boosts in the American Rescue Plan (ARP), has produced more than a million excess off-season enrollments. Mid-year on-exchange enrollment is certainly at an all-time high.

Let's look again (as I did in June) at emergency SEP enrollment in states that as of June 30* had not  enacted the ACA Medicaid expansion. In those states, eligibility for marketplace subsidies begins at an income of 100% FPL (as opposed to 138% FPL in expansion states), and more than a third of enrollees in normal times have incomes below 150% FPL -- which, as of ARP passage in March, now qualifies them for a free benchmark silver plan with low cost-sharing. 

As in the prior SEP report on enrollment through May 31, SEP enrollment in 13 nonexpansion states (excluding Wisconsin, which has no coverage gap**) accounts for 75% of enrollment in the 36 states that use the federal exchange, HealthCare.gov. These 13 states account for more than half of SEP enrollment nationally.  SEP enrollment in these states is more than quadruple enrollment in the same period in 2019, exceeding that year's total by more than 860,000.

Monday, July 12, 2021

Democrat to voters: "Friend, this past year, we saw just how important Medicaid expansion was to hard-working..."

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Terry McAuliffe, once and would-be future governor of Virginia, is running on the ACA Medicaid expansion (which opponent Glenn Youngkin opposed) and building on the ACA.  Here's the lead in a weekend email to supporters: 

Friend, this past year, we saw just how important Medicaid expansion was to hard-working Virginians and to folks across the country. Before COVID-19 hit, 394,000 Virginians were enrolled in Medicaid. Now? It’s over 550,000.

That’s over 150,000 Virginians who had coverage during the worst global public health crisis in recent history because of Medicaid expansion. But our work is not over.

700,000 Virginians - including 100,000 children - don't have access to health insurance. We NEED to continue to expand coverage to make sure every single Virginian has great health care.

The language there is a little sloppy -- over 550,000 Virginians (562,530 if you're keeping score at home, up 43% since March 1, 2020)  were rendered eligible for Medicaid by the ACA expansion criteria.  In total, 1.86 million people in the state are enrolled in Medicaid, up from 1.54 million on March 1, 2020, an increase of 20%.  

That safety net performance at a time of mass (if partially temporary) unemployment and mortal danger to health is something for Democrats to be proud of, especially since they scripted the moratorium on Medicaid disenrollments (in the Families First Act of March 2020) that's largely enabled the increase. They should all run on it. Remember, Republicans came within a breath of repealing the ACA's core programs, chief among them the Medicaid expansion.

Saturday, July 03, 2021

Making the ACA work 2014-2016: Administrative roads not taken

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The Obama administration stood up the ACA's core programs in the face of a never-ending shitstorm of Republican defamation, disinformation, noncooperation on the state level, total litigation warfare, and fiscal sabotage. For that they deserve our undying thanks. 

By the time Obama left office, the ACA had cut the ranks of the uninsured by about 40 percent, mainly through Medicaid expansion. The marketplace and the expansion proved resilient through the Trump years and provided a vital safety net when the pandemic struck. Since February 2020, Medicaid enrollment by those rendered eligible by the expansion has increased by about 5 million, and marketplace enrollment (with a large push by the Biden administration) by close to two million.

In administering the ACA, however, the Obama administration operated under self-imposed restraints. Pre-Trump, and before Republicans passed their $2 trillion tax giveaway to the wealthy in 2017, Democrats had yet to recognize -- or rather, acknowledge --  the full extent of Republicans' economic fraudulence. Without new appropriations by Congress that they knew would not be forthcoming,  Obama and administration officials were reluctant to increase spending on ACA programs and so increase the deficit. They declined to take several measures that would make coverage more affordable or credible. These included the following.

Monday, June 28, 2021

Nudging people out of the coverage gap, cont.

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In my last post, I noted that on May 5 CMS finalized a rule that patches a bit of the coverage gap afflicting low-income people in 13 remaining states that have refused to implement the ACA Medicaid expansion.

In those states, eligibility for ACA premium subsidies begins at incomes above 100% of the Federal Poverty Level (FPL). State residents with incomes below that threshold who do not qualify for Medicaid under the states' restrictive criteria get no government help to pay for coverage. Some 2 million adults are in this gap.

Saturday, June 26, 2021

In May, CMS quietly moved to shrink the ACA's coverage gap in states that have refused to expand Medicaid

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One of the most intractable of the holes in the ACA's implicit promise of affordable care for all is the so-called "coverage gap" opened up when the Supreme Court made the ACA Medicaid expansion optional for states in 2012, two years prior to scheduled full implementation. 

As originally enacted, the ACA provided Medicaid eligibility to adults in households with incomes up to 138% of the Federal Poverty Level (FPL). In the wake of the Supreme Court decision, just 25 states implemented this expansion upon the 2014 launch of the ACA's core programs. To date, thirteen holdout states have not enacted it. In those states, eligibility for ACA marketplace subsidies begins at 100% FPL, and some 2 million adults with incomes below that level get no help obtaining insurance.

There's no easy way for Democrats to plug this hole, as KFF's Larry Levitt recently explained on Twitter. They could make people in nonexpansion states with incomes below 100% FPL eligible for premium subsidies. But that might tempt states that have enacted the Medicaid expansion to rescind it, since the federal government pays 100% of marketplace premium subsidies and "only" 90% of Medicaid costs for expansion enrollees. They could create a new federally administered public option operating in nonexpansion states, but that's a heavy administrative lift, and very likely beyond the political capabilities of a Democratic party with razor-thin majorities.

As I mulled Levitt's thread, a partial and kludgy administrative response occurred to me: CMS could allow any applicant in a nonexpansion state to attest to an income over 100% FPL, without requiring documentation. In 2020, supplemental unemployment insurance provided by the CARES Act pushed a lot of incomes over the 100% FPL threshold, and enrollment for 2021 at 100-150% FPL in nonexpansion states soared 17%. Marketplace subsidy eligibility is based on an estimate of next year's income, and low income is notoriously uncertain and fluctuating. Why not open the door further?

I took a look at the statute setting the terms for marketplace subsidy eligibility and verification (42 U.S. Code § 18081) and the 2022 Notice of Benefit and Payment Parameters (NBPP) published May 5, 2021, seeking a way that current rules might be modified. It turns out that new rulemaking is unnecessary. 

As of now (effective May 5), CMS is declining to require verification of an income claimed to be above 100% FPL even if data sources tapped by CMS indicate that the applicant's income is below that threshold. The change is announced in the NBPP:

Elsewhere: the ACA survives and thrives

 For BlueWaveNJ, I've overviewed the legal threats to the ACA -- just overcome and still pending; the subsidy boosts enacted in the American Rescue Plan and their effects so far; and likely and unlikely next steps.  I covered similar ground at healthinsurance.org, with more attention to the remaining subsidy-eligible uninsured and measures to smooth and encourage enrollment.

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Friday, June 25, 2021

In NJ Spotlight News: "Affordable Care or a Loan?"

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I have an op-ed in NJ Spotlight News in support of a pending bill, A1023/S885, that would end Medicaid Estate Recovery pursued against enrollees in NJ FamilyCare (the state Medicaid program) who do not receive long-term care. The problem:

Unfortunately, in New Jersey — as in 19 other states and Washington, D.C. — efforts to make affordable coverage available to all come with a giant asterisk.

Applicants seeking health coverage on GetCoveredNJ, the state ACA exchange launched last fall, are routed either to the private plan marketplace or, if their family income is below 138% of the FPL (federal poverty level) — which is $1,482 for an individual, $3,048 for a family of four — to NJ FamilyCare, the state Medicaid program. If income qualifies an applicant for the latter, she must sign off on this disclosure:

Wednesday, June 23, 2021

Obamacare enrollment at vaccination sites Part II: Navigators on their own, mostly

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A month ago, I posited that the impressive drive to vaccinate all U.S. adults is also a golden opportunity to insure the uninsured. 

Vaccinations are free to all, but in the vaccination process the uninsured must identify themselves as such. An estimated 11 million uninsured are eligible for marketplace subsidies (now often zeroing out premiums entirely), and another 7 million for Medicaid. The emergency Special Enrollment Period launched by the Biden administration on February 15, running through August 15, opens the enrollment door to anyone who's uninsured and lacks access to other coverage -- and coincides with the vaccination drive. 

As noted in the prior post, while some assister groups have done outreach at vaccination sites, and at least a couple of states have supported such efforts to some degree, the initiative has come mainly from the assisters themselves (generally operating on a shoestring through the lean Trump years), not government agencies, and efforts have been scattered.  

That is accurate. CMS confirmed to me that while the agency gives assister groups vaccine information to disseminate, "CMS...has not promoted or organized any official Marketplace outreach or enrollment events in conjunction with any COVID-19 vaccination site or event."

Tuesday, June 22, 2021

In 2021, will attrition in the ACA marketplace go negative?

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Until the pandemic struck, enrollment attrition throughout the coverage year in the ACA marketplace was an established norm. Every year, effectuated enrollment (i.e. paid-up enrollment) as of the first month after the end of Open Enrollment (OE) was between 6% and 15% lower than the "plan selection" total as of the end of OE. From February through December, enrollment would downtick by 600-800,000.

Attrition was reduced throughout the Trump years; possible causes are discussed here. (In brief, the Trump administration made it harder to enroll, weeding out less motivated enrollees, while silver loading made coverage much cheaper for a significant number of enrollees.) Last spring, as the pandemic triggered tens of millions of layoffs, 12 state exchanges opened emergency Special Enrollment Periods (SEPs) in which anyone who needed insurance could enroll with relatively little friction (varying somewhat by exchange).  The Trump administration declined to open an emergency SEP for the 36 states using HealthCare.gov, but did reduce red tape for those who sought individual SEPs due to a qualifying "life change," usually loss of employer insurance. 

The net result was a steady reduction in attrition from 2017-2019 and a sharp reduction last year. In 2016, the year of peak plan selections as of the end of OE, average monthly enrollment (AME) was 79% of end-of-OE "plan selections." In 2019, AME was 86% of initial plan selections. In 2020, AME reached 92% of the end-of-OE tally.

Saturday, June 19, 2021

ACA marketplace enrollment in 2020 exceeded the 2016 peak (on-exchange)

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Every June, the first "effectuated enrollment snapshot" of the ACA marketplace for February includes month-by-month and average monthly enrollment for the previous year.

Though I had been eagerly awaiting this year's snapshot, having inferred last December that marketplace enrollment in June 2020 was probably at all-time mid-year high, I missed its release on June 5. But it's out, and it's official: average monthly enrollment in 2020 was the highest ever, exceeding the 2016 peak by 5.2%. 

That's notwithstanding the fact that initial "plan selections" as of the end of Open Enrollment for 2016 exceeded the 2020 end-of-OE tally by almost 1.2 million (12,681,874 vs. 11,444,141). Here are the official average monthly enrollment tallies by year:

Average monthly enrollment: ACA marketplace, 2016-2020

2016     10,007,113
2017       9,763,076
2018       9,895,197
2019       9,810,613
2020     10,531,978

Although end-of-OE plan selections were 9.8% higher in 2016 than in 2020, average monthly enrollment was 5.2% higher in 2020 than in 2016 (and 7.4% higher than in 2019).  Why? 

Tuesday, June 15, 2021

Three quarters of recent SEP enrollment on HealthCare.gov is in nonexpansion states

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HHS announced yesterday that new enrollments in the emergency Special Enrollment Period that began on February 15 totaled 1.24 million through May 31 in the 36 states using HealthCare.gov. That's more than triple enrollments during the same time period in 2019, the last "normal" year in which enrollment was unaffected by the pandemic. Further, HHS pointed out that since the enhanced subsidies enacted in the American Rescue Plan appeared on HealthCare.gov on April 1, 43% of new enrollees selected plans for which they will pay $10 per month or less.

Charles Gaba pointed out yesterday that the single biggest determining factor of how much a state's SEP enrollment has increased over pre-COVID time is whether the state has enacted the ACA Medicaid expansion.  Say that again.

Of the 1.2 million new enrollees, three quarters were in 13 states that had not enacted the ACA Medicaid expansion as of May 31 -- excluding Wisconsin, which offers Medicaid to state residents with incomes up to 100% of the Federal Poverty Level.*

Friday, June 11, 2021

How do you spell "affordable care"? ARP!

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 I have an article up at healthinsurance.org that surveys how the American Rescue Plan changed ACA subsidies, the significant impact on enrollment so far, and ways to build on this progress by smoothing the enrollment process.

With regard to the subsidy boosts, a lot of holes have been plugged:

How affordable is affordable? According to KFF, 6 million uninsured people are eligible for free plans. It’s true that for most of these (4.7 million), the free plan would be Bronze, with deductibles averaging in the $7,000 range. But for many of those eligible for free Bronze plans, Silver – and in some cases Gold plans – are available at very low cost or even no cost at all.

Thursday, June 10, 2021

Obamacare mid-year enrollment is likely up 19% over past peak

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see 6/18/21 update at bottom

Charles Gaba estimates current enrollment in the ACA marketplace at 12.4 million. That's based on effectuated enrollment as of February of 11.3 million, plus about 1.6 million new enrollments during the emergency Special Enrollment Period (SEP) commenced on Feb. 15, minus an estimate of monthly attrition based on last year's monthly totals. Attrition may be a bit higher, but this is a good estimate.

A lot of people who pay attention to marketplace enrollment patterns have imprinted a number: 12.7 million. That was the (rounded) national total of signups for coverage as of the end of Open Enrollment  season (OE) in 2016 -- long understood to be the peak year for marketplace enrollment. Plan selections declined in subsequent years, probably due in part both to soaring premiums in 2017 and 2018 and Trump administration sabotage (which contributed to 2018 premium hikes though not to the correction of 2017).

Plan selections as of the end of OE is a very different metric, however, from effectuated enrollment, which measures people who are paid up on their premiums. Attrition was high in 2016: effectuated enrollment peaked at 10.8 million in March, and average monthly enrollment for the year was 10.0 million. Attrition fell in the Trump years, for reasons we'll touch on below, and fell further last year, as the pandemic triggered high SEP enrollment

This year, the emergency SEP, coupled with massive boosts to premium subsidies enacted in the American Rescue Plan, has triggered SEP enrollment that's 3.5 times higher than in 2019, the last pre-pandemic year. The SEP enrollments logged to date have almost certainly outpaced normal attrition as experienced in the pre-pandemic years.  The ARP subsidy boosts have likely reduced disenrollments as well as stimulating new enrollment.

Bottom line: marketplace enrollment growth is larger than meets the eye, at least for those who measure "12.4 million" against the 2016 end-of-OE peak. June enrollment as estimated by Gaba is 20% higher than June enrollment in 2016, and 19% higher than in June 2020, when SEPs triggered by the pandemic pushed mid-year enrollment to a new high. 

Wednesday, June 09, 2021

The second-biggest health insurance exchange in the U.S. is...

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Almost from the (extremely rocky) inception of the ACA marketplace in fall 2013, CMS encouraged the development of commercial Direct Enrollment (DE) platforms. These were websites hosted by commercial brokers and health insurers themselves that could collect income and other eligibility data and send it to the federal exchange, HealthCare.gov, which would determine subsidy eligibility and then send the application back to the private platform for completion of the enrollment process.  During Open Enrollment for 2019, CMS began approving brokers for Enhanced Direct Enrollment, EDE, which enabled commercial brokers to complete the whole transaction. At present there are 43 approved EDE platforms interfacing with HealthCare.gov, mostly hosted by health insurers.

The Trump administration encouraged DEs and EDEs, in keeping with its general enthusiasm for commercial brokers and hostility toward the federally established nonprofit Navigator program, for which it gutted funding -- not to say the government-run exchanges.  EDE promotion also dovetailed with the Trump CMS's development of a parallel ACA-noncompliant market of medically underwritten, lightly regulated "short-term limited development" (STLD) plans (which the administration rendered neither short-term nor of limited duration unless state governments make them so). Brokers that deploy DEs or EDEs can sell and promote STLD plans, though not on the DE/EDE platform per se. Development of the DE/EDE program had begun in the Obama administration, however.

Tuesday, June 01, 2021

HHS devotes $4.8 billion to COVID-test the uninsured. P.S. How about insuring them?

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HHS announced today that it is dedicating $4.8 billion in American Rescue Plan funds to reimburse providers for providing Covid-19 testing to the uninsured, at no cost to the uninsured patient. That's a continuation of a program initiated last spring. So far, $2.5 billion has been allocated by the Health Resources and Services Administration (HRSA) for such reimbursement.

Am I letting a current preoccupation distort my vision in seeing something of a lost opportunity (and irony) in this HHS statement?

There are approximately 29 million uninsured individuals living in the United States. While this administration has been focused on decreasing the uninsured rate, as evidenced by the more than 1 million people who have enrolled into quality health coverage through the Special Enrollment Period (SEP), much work remains. By ensuring programs like the HRSA COVID-19 Uninsured Program remains adequately funded, this administration is removing cost impediments so anyone exposed to COVID-19 may seek appropriate testing and care.

The funding announced today is dedicated to COVID-19 testing. HRSA also helps uninsured individuals’ access COVID-19 treatment and vaccinations through the COVID-19 Uninsured Program.  The program reimburses providers at national Medicare rates for providing these services.

Sunday, May 30, 2021

Putting the "Affordable" in the Affordable Care Act: A role for the IRS

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 After the boost to ACA marketplace subsidies enacted as part of the American Rescue Plan Act (ARPA), the largest remaining bar to affordable coverage for all but undocumented Americans (who are barred from any government help for coverage) may be the affordability threshold for employer-sponsored insurance. It's ridiculously high. The IRS can provide some relief now, without portentous rulemaking.

The ACA defines employer-sponsored insurance (ESI) as affordable if a plan providing Minimum Essential Coverage (MEC) as defined by the ACA costs less than 9.5% of income. That baseline is adjusted annually to account for inflation in premiums in excess of inflation in the consumer price index and currently stands at 9.83% of income.  MEC is equivalent to bronze-level coverage in the ACA marketplace, which typically means a single-person deductible in the $7,000 range. Those for whom an employer's offer of insurance is deemed affordable are ineligible for ACA marketplace subsidies (though not ineligible for Medicaid). KFF estimates that 3.5 million uninsured people are in this category.

Thursday, May 27, 2021

Obamacare enrollment at vaccination sites, part 1

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                                             Getting jabbed? Get covered too!

11 million uninsured Americans are eligible for ACA marketplace subsidies, according to KFF estimates. With the premium subsidy increases enacted in the American Rescue Plan Act (ARPA) in March, coverage can credibly be called "affordable" for most of them.  Another 7.3 million uninsured people are eligible for Medicaid, per KFF.

Ignorance of these offerings is rife. Less than a third of the public knows the ACA is still law, again according to KFF. Enrollment outreach, sabotaged by the Trump administration, has always been a challenge (as has the difficulty of navigating the application for some but not all enrollees).

While considering incremental ways to improve the ACA in my last post, it dawned on me that enrollment outreach at vaccination sites, or via email and texts connected with vaccination, was a golden opportunity to reach the uninsured.  Like most lightbulb thoughts, this one was far from unique.  It's occurred to many professional enrollment assisters -- probably hundreds. Some have acted on the thought.

Tuesday, May 25, 2021

The ACA as it should have been and may yet be: beyond premium subsidy boosts

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The Wall Street Journal's Stephanie Armour succinctly captures where Democrats seem to be at on the healthcare reform front:

Many progressive Democrats and President Biden are facing the political reality that far-reaching healthcare overhauls aren’t likely to succeed in the short term, which means their hopes may rest instead on building on recent Affordable Care Act changes and reducing prescription drug costs.

That is, make the premium subsidy boosts in the American Rescue Plan Act (ARPA) permanent, and maybe maybe maybe pay for it by getting some tangible form of prescription drug cost control past Democratic moderates. 

Pretty plainly left behind is the centerpiece of candidate Biden's healthcare plan, which also happens to be the continually submerged Ur-template for Democratic healthcare reform:

Thursday, May 20, 2021

One more note to subscribers: feedburner stopped

 Dear xpostfactoid subscribers: as I noted a couple of weeks ago, Google is discontinuing feedburner, the subscriber service that's delivered xpostfactoid this many a year, as of July.  I accordingly transferred subscriptions to follow.it, and as the new service seems to be functioning adequately, I just cut the cord with feedburner. If you've been annoyed by getting two emails for each post, apologies: that ends now.  And if you haven't subscribed via follow it, please do, via the box at right. Thanks for reading...

Wednesday, May 19, 2021

In New Jersey, silver plans are free or all but free up to 200% FPL

When New Jersey launched supplemental state premium subsidies along with the launch of its state-based ACA marketplace, GetCoveredNJ, in the fall of 2020, I was somewhat taken aback to note that the state subsidies were heavily weighted toward enrollees at higher incomes. 

The supplemental NJ subsidies ranged from $20/month at an income of 138% FPL ($17,609 for an individual) to $95/month, beginning at an income somewhere between 250% and 300% FPL (around $38,000 for 40 year-old individual, according to my price checks on GetCoveredNJ).

As I noted at the time,

The smaller subsidies at low incomes leave substantial premiums in place at incomes below 200% FPL for silver plans, which carry a strong CSR [Cost Sharing Reduction] benefit up to that income threshold.

For a 40 year-old with an income of $25,000 (just under 200% FPL), the lowest cost silver plan in most of the state will cost $86/month. The deductible is $800; the out-of-pocket maximum is $2,600. The lowest cost bronze plan is $17/month, with a deductible of $6,000 and an OOP max of $7,000. Last year, cheapest silver would have cost about $125/month. 

Well, the American Rescue Plan Act (ARPA), signed into law in March, with an extra boost from New Jersey, has solved that problem, at least through 2022 (and hopefully beyond, if Democrats make the new subsidy levels permanent as they intend).  New Jersey's income-weighted subsidies mesh quite well with the subsidy boosts provided by ARPA, which reduced premiums for a benchmark (second cheapest) silver plan with strong CSR to $0 at incomes up to 150% FPL and to 2% of income at 200% FPL.

The New Jersey supplemental subsidies all but wipe out premiums for a silver plan all the way to 200% FPL.  Here's what's available to a 40 year-old with an income of $25,500:

Monday, May 17, 2021

Emergency SEP enrollment, shrinking attrition boost ACA marketplace enrollment beyond yearly top lines

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In a report issued last September, Covered California, the golden state's ACA exchange, announced that effectuated enrollment in private health plans through the exchange had reached an all-time high of 1.53 million (1,527,730) as of June 2020.   That was in the midst of an emergency Special Enrollment Period (SEP), effectively a second open enrollment season, implemented by California in response to the Covid-19 pandemic.  (In normal years, SEPs are open only to individuals who can demonstrate a qualifying "life change," such as loss of job-based insurance.)

The emergency SEP ran from March 20 through August 31, 2020. According to the September report, SEP enrollment increased by more than 100% over the same period in 2019, to 289,460.  As the CoveredCA report stresses, that's in contrast to a mere 27% increase in SEP enrollment in the 38 states then using the federal exchange, HealthCare.gov, for which the Trump administration refused to open an emergency SEP.  In September, active membership enrolled through CoveredCA reached a new all-time high, 1,551,470.  

Driven largely by the boost in SEP enrollment, plan selections as of the end of OE 2021 in California finally surpassed their 2016 high point of 1,575,340, reaching 1,625,546. (The term "plan selections" acknowledges that not all those who "enroll" in plans during OE make a first payment and thus "effectuate" enrollment and become, in CoveredCA parlance, "active members").  

While plan selections as of the end of OE have always served as the headline number for ACA marketplace enrollment, they provide a somewhat misleading picture. Every year, an average of about 10% of those who "enroll" in plans during OE never pay their first premiums, and attrition continues throughout the year, as disenrollments exceed SEP enrollments -- at least through 2019, the last year for which monthly enrollment has been published.  But attrition has been shrinking beginning in 2018, perhaps because the silver loading that began that year sharply reduced net-of-subsidy premiums for many enrollees, including a substantial number who paid zero premium.  In 2016, national enrollment as of December was 28% below the end-of-OE total for plan selections. In 2019, December enrollment was just 20% below the end-of-OE tally.

Wednesday, May 12, 2021

One quarter of the U.S. population is on Medicaid

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Time for an estimate of Medicaid enrollment growth since the eve of the pandemic, February 2020.  Monthly enrollment growth may finally be slowing, though it probably will not stop until the pause in disenrollments mandated by the Family First Act (passed in March 2020) is ended. Then, watch out: many states will probably commence income/eligibility checks at short intervals with a vengeance. 

As noted my previous update, the cumulative growth rate recorded in my sample, which is based on available monthly reports issued by the states, generally exceeds CMS's official tally (which lags this tally by four months) by about half a percentage point (state reports differ from CMS's official count in numerous ways).  Based on that rule of thumb, I would venture that enrollment nationally is up 16% since February 2020 and now stands at about 82.6 million for all full-service Medicaid programs. That's exactly one quarter of the U.S population. Exclude the undocumented and also legally present noncitizens who are time-barred from Medicaid eligibility, and the percentage is higher still.
[Update, 8/16/21: This estimate was high. The final tally for February is 81.4 million; CMS's total reported increase from Feb. 2020 through March 2021 is 15.6%. So my 34-state estimate is now coming in nearly a full percentage point ahead of final CMS tallies. CMS's preliminary March total is 81.7 million; the final March total will probably come in a bit over 82 million.]


Thursday, May 06, 2021

ARPA should reduce underinsurance in the ACA marketplace

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  • While free bronze plans have been widely available to low income marketplace enrollees since 2018, the American Rescue Plan makes free or very low-cost silver plans with much lower out-of-pocket costs widely available.

  • Bronze plan enrollment at low incomes spiked during Open Enrollment for 2021

  • The American Rescue Plan may already be reversing the drift toward bronze at low incomes

The Urban Institute estimates that if the American Rescue Plan Act's increases to subsidies in the ACA marketplace are made permanent, enrollment will increase by 5.1 million, and the uninsured population will be reduced by 4.2 million. The enhanced subsidies are funded only through 2022 at present.

Urban foresees most of this enrollment increase -- about three quarters of it -- occurring at incomes over 200% of the Federal Poverty Level.  But ARPA should also reduce underinsurance, primarily at incomes below 200% FPL.

While ARPA does not reduce out-of-pocket costs at any metal level, it does make silver plans, which come with strong Cost Sharing Reduction (CSR) subsidies at incomes up to 200% FPL, much more affordable to low income enrollees. 

Wednesday, May 05, 2021

A note to subscribers

 Dear xpostfactoid subscribers: you may (or may not) have heard that Google is discontinuing feedburner, the age-old subscription service through which you've received xpostfactoid posts. I am in the process of transferring subscriptions to a new delivery channel, follow.it. You do not have to take any action to maintain the subscription, though you can of course unsubscribe. Thank you for staying with us and continuing to read!

Tuesday, May 04, 2021

How much will free benchmark silver plans boost ACA marketplace enrollment in nonexpansion states?

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An Urban Institute brief estimates that if the premium subsidy increases for the ACA marketplace enacted through 2022 in the American Rescue Plan are made permanent, marketplace enrollment will increase by 5.1 million, and the uninsured population will decrease by 4.2 million.

That's somewhat higher than the increase of 3 million that KFF's Cynthia Cox floated to me as a soft estimate. A lot depends on the effectiveness of outreach and possible future improvements to the enrollment process, Cox stressed. Both estimates are pretty modest, given the magnitude of the subsidy boost, outlined below. By KFF's estimate, about 10.6 million uninsured are eligible for subsidies under the new schedule.

Here I want to focus on the category* in which Urban foresees minimal change: enrollment at 100-138% FPL in states that have refused the ACA Medicaid expansion. In those states, eligibility for marketplace subsidies begins at 100% FPL, whereas in expansion states, adults** with incomes up to 138% FPL are eligible for Medicaid. Under ARPA, benchmark silver coverage is free at this income level, and in fact up to 150% FPL. And up to that threshold, Cost Sharing Reduction boosts the actuarial value of the free silver plan to 94%, well above the average for employer-sponsored coverage. According to CMS, the average deductible for silver plans at this income level is just $69 in HealthCare.gov states (e.g., all nonexpansion states). While even modest out-of-pocket costs appear to be a barrier at near-poor incomes -- Medicaid logs higher satisfaction ratings than high-CSR marketplace coverage in surveys -- this is a very valuable free benefit.

The Urban Institute analysis estimates that ARPA will reduce the uninsured population at incomes below 138% FPL by only 312,000. The authors do not provide an estimate of the subsidy-eligible population at 100-138% FPL -- but as I noted in early April, the Kaiser Family Foundation does provide such estimates for 12 nonexpansion states.*** In those 12 states together, 1.8 million people with incomes in the 100-138% FPL range were uninsured in 2019, according to KFF's estimate.