Friday, December 10, 2021

ACA enrollment gains in OE 2022 may just consolidate gains from the emergency SEP

CMS's Week 5 snapshot of ACA marketplace enrollment during the Open Enrollment season for 2022 shows an all-state enrollment increase of 8.5% over Week 5 for 2021, according to Charles Gaba's calculation. (Gaba adjusts the growth rate reported by CMS to account for the fact that this year's data reflects 34 days of enrollment, vs. 35 days at this point last year.)

While extrapolations in mid-OE are always dicey, that rate of increase has held fairly steady, and I'll venture to point out that gains in this range would basically consolidate the large enrollment increases effectuated during this year's emergency Special Enrollment Period, which ran from February 15 to August 15 on, the federal exchange, and for varying extended periods on 15 state-based exchanges. The emergency SEP was essentially a second Open Enrollment period.

The enrollment gains during the current OE, as during the emergency SEP and OE for 2021, are heavily concentrated in states that have not enacted the ACA Medicaid expansion and have a consequent "coverage gap" - -that is, no subsidized health insurance available for most adults with incomes below 100% of the Federal Poverty Level, the threshold for marketplace subsidy eligibility.  As reflected in the table below, 72% of net enrollment gains nationally from February through August of this year were in the nonexpansion states (excluding Wisconsin, which offers Medicaid to adults with incomes up to 100% FPL and so has no coverage gap). For that reason, I have focused on the nonexpansion states to compare apparent enrollment gains at present with those logged in the emergency SEP.  

In fact, 47% of all gains during the SEP were in Florida and Texas. Those two states appear also to be driving enrollment growth during the current OE.

It's consistent with past experience that Oklahoma and Missouri, which enacted the Medicaid expansion in July and October of this year respectively, are currently showing steep enrollment drops (marked in red below). About a third of pre-expansion marketplace enrollees in those states are now eligible for Medicaid.

The far right column shows the year-over-year change in daily average enrollment through Week 5, from OE 2021 to OE 2022, as calculated by Gaba.

Sources: Effectuated enrollment snapshot, Feb. 2021Final enrollment report, emergency SEP 20212022 OE Week 5 snapshot; Charles Gaba, Week 5 overview NOTE: the "all states" rate of growth from OE Week 5 2021 to 2022 is for 33 states only. NOTE 2: Wisconsin is excluded because it has no coverage gap. 

While the net increases for all states and all nonexpansion states in OE and the emergency SEP look strikingly similar, that may be coincidence -- there is considerable variation state-by-state. Also, the all-state growth rate for the year-over-year OE comparison is for the 33 states only, whereas the other all-state figures are for all 51 states (including D.C.). Still, in broad outline, the net enrollment gains during OE may look a lot like those in the SEP. Whether ramped-up advertising and enrollment assistance net OE year-over-year gains beyond those already effectuated in the SEP remains to be seen. The ultimate measure is average monthly enrollment, which is reported in June each year for the year prior.

As I have emphasized many times, ACA marketplace enrollment growth has been strong throughout the pandemic -- and before it -- in states that have not expanded Medicaid. Enrollment in nonexpansion states increased by 44% from August 2019 to August 2021. In those states, eligibility for subsidized marketplace coverage begins at an income of 100% FPL, as opposed to 138% FPL in expansion states, where Medicaid is available to adults below that threshold. 

Since the American Rescue Plan passed in March, benchmark silver coverage has been available for free at incomes up to 150% FPL -- that is, for about half of enrollees in nonexpansion states. In 2020, the generous supplemental unemployment insurance income allocated by the CARES Act probably pushed many low-income residents of nonexpansion states over the 100% FPL eligibility line for marketplace subsidies, and in 2021, anyone who received any UI income at all automatically qualified for free benchmark silver coverage. 

As eligibility for marketplace subsidies is based on estimates of future income, those who newly qualified may continue to exercise themselves to estimate enough income to stay enrolled (as they should). In short, the stimulus provided by the pandemic, to motive as well as to income, may be taking a not-insubstantial bite out of the coverage gap.

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