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, 2020, 2021; SEP 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." 

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.

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%.

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.

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.

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.