Rapid marketplace enrollment growth in nonexpansion states, revisited

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I don't know whether ACA marketplace observers have fully fathomed the extent to which the nonexpansion states drove the enrollment surge during the emergency Special Enrollment Period that ran from Feb. 15 to August 15 on HealthCare.gov -- and indeed, over the past two years.

Also not fully fathomed: the extent of total enrollment growth in all states during the pandemic.

When considering the nonexpansion states as a group, I exclude Wisconsin, which has no coverage gap, as it provides Medicaid eligibility to adults with incomes up to 100% FPL (the threshold for subsidy eligibility in the ACA marketplace). Perhaps "coverage gap" states would be a better term for the thirteen states considered as a body here. I include Oklahoma, which enacted the expansion effective July 1, and Missouri, which will begin processing applications on October 1.  As of October 1, there will be 11 coverage gap states.

Consider the following data points. Sources are the SEP final enrollment report and a CMS tally of effectuated enrollment in August 2019, 2020 and 2021

• During the SEP period, 55% of all new enrollment nationally was in the thirteen coverage gap states.  New enrollment in all states totaled  2,807,518. Enrollment in the coverage gap states was 1,547,981. These 13 states account for 49.7% of effectuated enrollment nationally, up from 43.3% in August 2019.
  
  
• Effectuated enrollment in these 13 states as of August 2021 was up 44% since August 2019. Forty four percent!   That's an increase of 1.8 million. More than 40% of enrollees in these states are in the 100-138% FPL income range that would qualify them for Medicaid had their states enacted the expansion (as Oklahoma has now done, and Missouri will do imminently). 
  
  
• The coverage gap states accounted for 74% of total marketplace enrollment growth during this two-year period.

• Let's also take in the fact that total enrollment nationally increased by 25.6%, or 2.5 million, from August 2019 to August 2021.  While Medicaid carried the main burden of covering the newly uninsured during the pandemic -- increasing enrollment by 11.6 million from February 2020 to April 2021 -- the marketplace also made a dent.
  
  
• Over 40% of SEP enrollment in these 13 states was by people with incomes between 100% FPL and 138% FPL -- that is, income that would qualify them for Medicaid in expansion states (and has since qualified them for Medicaid in Oklahoma, which launched the expansion in July, and Missouri, which will begin retroactive enrollment in October).* 

In a walk-the-dog pause, I reminded myself of my original reason for excluding Wisconsin in prior looks at the enrollment surge in nonexpansion states. Wisconsin does, after all, extend marketplace eligibility from 100% FPL, rather than 138% FPL as in the expansion states. It also had much more modest SEP enrollment than the other nonexpansion states. My suspicion is that various incentives may be pushing some people who were previously in the coverage gap -- estimating incomes below 100% FPL -- over the line into subsidized enrollment. These include the supplemental unemployment benefits provided by Congress in 2020 and 2021; the subsidy eligibility according to all applicants who received any unemployment insurance income in 2021; the subsidy boosts provided by ARPA, which make high-CSR silver coverage free at incomes up to 150% FPL; and the desire to be covered during the pandemic. 

I have a post up at healthinsurance.org taking a broader look at the marketplace enrollment surge triggered by the pandemic, the emergency SEP and the ARP subsidy boosts.

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* This estimate is based on HHS's report that 33% of 2,069,596 new enrollees in HealthCare.gov states, or 683,000, had income in the 100-138% FPL range. Since Medicaid eligibility begins at 138% FPL in expansion states,  all but a tiny fraction of these enrollees (e.g., legally present non-citizens in expansion states time-barred from Medicaid) are in the nonexpansion states (all of which use HealthCare.gov). About 6,000 of these enrollees were likely in Wisconsin. I am assuming that about 670,000 out of 1.55 million SEP enrollees in the twelve "coverage gap" states reported incomes in the 100-138% FPL range.

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