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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.
Effectuated enrollment in nonexpansion states, 2019-2021
(click to enlarge - this is smaller than I'd like!)
Wisconsin excluded
Sources: CMS, Early Effectuated Enrollment Snapshot, 2020, 2021; SEP enrollment 7/14/21
In these 13 states, 51% of enrollees as of the end of Open Enrollment for 2021 had incomes in the 100-150% FPL range. About 85% of those in this income range likely had incomes below 138% FPL, which would qualify them for Medicaid in expansion states. During this year's emergency SEP, 50% of enrollees in these states are paying less than $10 per month for coverage (silver plans with Cost Sharing Reduction are free for enrollees up to 150% FPL). Most (not all) of these enrollees also are likely in the lowest subsidy-eligible income bracket.
Since benchmark silver coverage is now free at incomes up to 150% FPL (thanks to the American Rescue Plan, enacted in March, which boosted subsidies at all income levels), we must earnestly hope that close to none of the hundreds of thousands of new enrollees below that income threshold are selecting bronze plans. At incomes up to 150% FPL, Cost Sharing Reduction (CSR) reduces silver plan deductibles to a median of $0 and an average of $177, providing an actuarial value of 94% -- well above that of most employer-sponsored plans. Bronze plans have an AV of just 60%; deductibles average about $7,000. Out-of-pocket maximums are generally over $8,000*; for high-CSR silver, the average is $1100. In prior years, 85-90% of enrollees with incomes below 150% FPL selected silver; the percentage should be higher this year.
Wisconsin is excluded above because the state offers Medicaid to adults with incomes up to 100% FPL (as opposed to 138% FPL in expansion states). It therefore has no "coverage gap": those who are not eligible for marketplace subsidies, because their income is below the 100% FPL eligibility threshold, are eligible for Medicaid. (In other nonexpansion states, an estimated 2.2 million people as of 2019 qualified neither for Medicaid nor for marketplace subsidies.) So why exclude Wisconsin, you may ask. Eligibility for marketplace subsidies is the same in Wisconsin as in other nonexpansion states, beginning at 100% FPL, and offering free, high-CSR coverage to the many enrollees in the 100-150% FPL income bracket.
True. But Wisconsin offers indirect evidence, albeit with a sample size of just one, that during the pandemic, enrollment in nonexpansion states is fueled in part by people who previously found themselves shut out because they estimated incomes below 100% FPL. During OE 2021, enrollment in the 100-150% FPL income bracket in these 13 states increased by 17% compared to OE 2020; in Wisconsin, enrollment was down 5%. During this year's SEP period, enrollment in these 13 states was quadruple enrollment in the same period of 2019; in Wisconsin, SEP enrollment in 2021 (Feb. 15 - June 30) was less than double same-period 2019.
The Wisconsin exception may constitute evidence that in the nonexpansion states with a coverage gap, more people with incomes near the poverty line are estimating incomes above that threshold and so qualifying for subsidies -- stimulated, perhaps, by the pandemic; by the enhanced unemployment insurance provided in two pandemic relief bills (which counts as income); by the enhanced premiums enacted in March that make high-CSR coverage free at low incomes; by the emergency SEP; and by a $50 million advertising boost from the Biden administration. In May, CMS smoothed the path to estimating a qualifying income (over 100% FPL), though knowledge of that regulatory action is not widespread.
A bit about the assumptions behind my estimates of current effectuated enrollment in the chart above. Thanks to CMS's effectuated enrollment snapshots (see the source list below the chart), we have actual figures for enrollment in February for all three years, and for June in 2019 and 2020, as well as SEP enrollment since Feb. 15 in 2021. The wild card is monthly attrition: people disenroll every month. In 2020, elevated SEP enrollment (triggered by mass job loss, which qualifies an individual for a SEP in normal years) almost but not quite canceled out monthly disenrollments through June: in June, total enrollment was 58,000 below the February total. I therefore assumed that disenrollments from February through June (roughly) equaled SEP enrollments plus 58k. Since enrollment in February 2021 was 12.5% higher than in February 2020, I estimated 2021 disenrollments by multiplying the 2020 total by 1.125. Make sense? Time will tell: total enrollment for June 2021 (along with every other month of this year) will be published next June.
Update: it occurs to me that more SEP enrollments this year than last may also mean more disenrollments (beyond the 12.5% increase I estimated based on the larger pool as of February), simply because a portion of any new enrollee pool will disenroll in short space. Then again, new enrollees are paying so much less this year, thanks to the ARP subsidy boosts, that disenrollments among the new enrollees may be few. Time will tell.
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* An exception is bronze plans in the High Deductible category, which qualify the enrollee for a tax free Health Savings Account. The OOP max for such plans is limited by statute to $6900.
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