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.

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.

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:

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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:

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.

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.]

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. 

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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.  

UI effect? ACA marketplace enrollment soared at low incomes in nonexpansion states in 2021

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Back in March 2020,  you may have read here that the emergency supplemental unemployment insurance provided by the CARES Act -- $600 per week for up to 4 months -- would likely lift some uninsured people in states that had refused to expand Medicaid out of the so-called "coverage gap." That is, the extra UI income would raise some low income people over the income threshold for marketplace subsidy eligibility in nonexpansion states: 100% of the Federal Poverty Level (FPL).

Back in December, you may have read here that as of the end of Open Enrollment for 2021, marketplace enrollment was indeed up 10% over 2020 levels in nonexpansion states, but flat in expansion states.

This month, you may have read here that takeup of marketplace coverage at incomes just over the subsidy eligibility threshold in nonexpansion states -- 100-138% FPL -- has historically been weak -- under 50% in of these states states.

More detailed data about 2021 enrollment was released by CMS on April 21. I don't think it's an exaggeration to say that enrollment at the lowest subsidy-eligible income levels in nonexpansion states exploded this year.