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.

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As originally enacted, the ACA provided Medicaid eligibility to adults in households with incomes up to 138% of the Federal Poverty Level (FPL).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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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:

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."

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.

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? 

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.*

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.

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. 

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.

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.