Thursday, December 30, 2021

The ACA as pandemic safety net, Chapter 2 (2021)

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As xpostfactoid is devoted mainly to tracking the implementation and metamorphosis of the Affordable Care Act, for the past two years I've focused mainly on ACA programs' performance as a safety net during the pandemic, as millions of people lost job-based health coverage for varying lengths of time. 

In 2020, the uninsured rate appears to have remained basically flat, though pandemic-related surveying challenges rendered Census and NHIS findings somewhat tentative. In 2021, the uninsured rate may actually prove to have downticked a bit, once the data is in. By kludgy American standards, the health insurance safety net -- Medicaid and the ACA marketplace -- have performed well, bolstered by several doses of emergency legislation and administrative action:

  • The Families First Act, which added six percentage points to the federal government's share of Medicaid costs -- contingent on states pausing Medicaid "redeterminations" and disenrollments for the duration of the COVID-19 emergency (still in effect).
  • Belated ACA Medicaid expansions that went live in Idaho, Utah and Nebraska in 2020 and in Oklahoma and Missouri in 2021.
  • The CARES Act, which provided $600/week supplementary unemployment income for up to ten weeks. Subsequent smaller emergency UI extensions ran through September of this year.
  • The emergency Special Enrollment Period launched by the Biden administration on Feb. 15, 2021 in 36 states using -- essentially a second Open Enrollment Period that ran through Aug. 15. The 15 state-based marketplaces also opened emergency SEPs, running for various lengths of time.
  • The American Rescue Plan Act, which provided a major boost to ACA premium subsidies through 2022, and provided free coverage in 2021 alone to anyone who received any unemployment insurance. ARPA also provided a 100% COBRA subsidy from April 1 - Sept. 30, 2021.
  • The Biden administration's reversal of the Trump administration's gutting of funding for the ACA Navigator program in states using Navigator organizations in each state are the nerve center of nonprofit, government-certified enrollment assistance. From an Obama administration high of $63 million, the Trump administration cut funding to $10 million annually. Biden bumped it up to $82 million in OEP for 2022, funding about 1500 assistors.
In 2020, the story was mostly Medicaid, as enrollment increased by 10 million from February 2020 to January 2021. This year the story is...still Medicaid, as the pause in disenrollments continues to swell the rolls by several hundred thousand each month. Medicaid enrollment in June 2021, reached 83 million, up 12.5 million since February 2020, and perhaps is around 85 million by now. But this year, too, the ACA marketplace has been transformed by ARPA, and the enrollment increase of about 2 million represents a real sea change.

The Medicaid and marketplace stories intersect in the states that have refused to enact the ACA Medicaid expansion -- and there, too, the stories of 2020 and 2021 intersect, as marketplace enrollment has grown a staggering 37% -- an increase of 1.8 million -- from mid-December 2019 to mid-December 2021 in the remaining twelve nonexpansion states (38% if you exclude Wisconsin, which has no coverage gap and has seen very limited enrollment growth).  That's about two thirds of enrollment growth in all 51 states (including DC) in that two-year period. Florida and Texas alone increased enrollment by almost 1.3 million in the past two years.

The main story line in this blog this year tracks how the marketplace has likely partially (very partially) compensated for the coverage gap in nonexpansion states, which offer most adults with incomes below the federal poverty level no help obtaining coverage. (Wisconsin, which offers Medicaid to adults with incomes up to 100% FPL, is an exception.)  About half of all enrollment in nonexpansion states is at incomes below 150% FPL -- where high-CSR benchmark silver coverage is now free.  Various factors may have helped some low-income people in these states cross the 100% FPL eligibility threshold for marketplace subsidies: pressure of need in the pandemic, extra UI income, some regulatory easing,  and increased federal funding for enrollment assistance. Oh, and one more, some helpful signposting of the minimum income required for marketplace subsidies on HealthSherpa, which processes almost a quarter of enrollments, and possibly an even higher percentage in nonexpansion states. 

Here are several posts (including a couple at that tell parts of this tale:

Even before ARPA, enrollment in nonexpansion states rose 17% at incomes below 150% FPL in OEP for 2021

Marketplace subsidy eligibility is based on an income estimate -- and CMS does not penalize a little optimism

An enrollment assistor in San Antonio, TX, recounts applicants' incredulity when told they don't qualify for aid because they earn too little -- and details how to help enrollees get over the 100% FPL threshold

Being denied subsidized coverage because you earn too little is a moral travesty. Why let it happen?

Most enrollment growth during the emergency SEP was in nonexpansion states at low incomes

Since OE for 2019, the dominant commercial web broker has been providing vital information to low-income applicants in nonexpansion states

Guess where most of the enrollment growth is?

Photo by Lagos Techie on Unsplash

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