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%.

There are two elements of uncertainty here. First, there's no reporting for SEPs from Dec. 15 (end of OE) through Feb. 15. Second, CMS breaks out enrollment by income during OE, but not in the SEP reports.  In OE 2021, 51.3% of enrollees in these 13 states had incomes in the 100-150% FPL range, compared to 48.3% in 2020. To estimate SEPs at this income level, I took 51.3% of totals for each year, as the pandemic-induced enrollment spurs in effect during OE 2020 were likely already in effect in spring 2020. Since benchmark silver coverage with strong Cost Sharing Reduction is now free at incomes up to 150% FPL (thanks to the American Rescue Plan), the percentage of SEP enrollments below that income threshold in these states may be even higher.

Here's the whole calculation for 13 nonexpansion states:

Enrollment at 100-150% FPL, OE 2020      2,499,940  
Enrollment at 100-150% FPL, OE 2021      2,927,190
Year-over-year Increase, OE 2021                  427,250
Percentage increase YoY, OE 2021                       17.1%
SEP enrollment, Feb. 15--June 30, 2020         436,365 
SEP enrollment, Feb. 15--June 30, 2021      1,137,619
SEP enrollment at 100-150% FPL, 2020         223,855 (estimated @ 51.3% of total)
SEP enrollment at 100-150% FPL, 2021         583,599 (estimated @ 51.3% of total)
YOY SEP increase at 100-150% FPL, 2021    359,744 (estimated)
YOY OE + SEP increase, 2021                        786,994 (estimated) 

While I can't account for attrition rates in the two years discussed here, an increase of almost 800,000 enrollments at low incomes in the nonexpansion states From Nov. 1, 2020 to June 30, 2021 is quite something.  As I've noted before, about 85% of enrollment in the 100-150% FPL range is at incomes below 138% FPL -- i.e., people who would have been eligible for Medicaid had their state enacted the ACA Medicaid expansion. That indicates an increase of about 669,000 enrollees in that category (100-138% FPL) in OE 2021 and the current SEP over the same periods (Nov. 1 to June 30) in the prior  enrolment year.  

The Kaiser Family Foundation has estimated that as of 2019, 1,771,000 people in the 100-138% FPL income range in nonexpansion states (excluding Wisconsin) were uninsured. The enrollment surge at low incomes triggered first by the pandemic and then by the subsidy boosts enacted in the American Rescue Plan, in concert with the emergency Special Enrollment Period kicked off on Feb. 15, may have taken a significant bite out of that uninsured population.


* While Wisconsin has not enacted the ACA Medicaid expansion, the state provides Medicaid eligibility to adults with incomes up to 100% FPL (instead of 138% FPL as in expansion states) and thus has no coverage gap, as eligibility for marketplace subsidies begins at 100% FPL. 

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