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

Subscribe (free) to xpostfactoid

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.

At healthinsurance.org: Closeup of the ACA enrollment surge of 2021-2022

At healthinsurance.org, I have a post up this morning reviewing the surge in ACA marketplace enrollment  triggered by the pandemic and further spurred by the major boost to premium subsidies provided through 2022 in  the American Rescue Plan Act enacted last March.  

Long story short: from mid-December 2019 to mid-December 2021, plan selections during the annual Open Enrollment Period increased by 29% in the 33 states currently using HealthCare.gov, and most likely by about 25% for all states (final enrollment figures for the OEP are usually released in March). 

• Two thirds of the enrollment gains are in states that have refused to enact the ACA Medicaid expansion.
• Some new enrollees in those states may have climbed over the 100% FPL minimum income threshold for ACA subsidy eligibility. 
• Many new enrollees are getting free silver plans with strong Cost Sharing Reduction 
• Enrollment increases in the current OEP build on and extend the gains during the emergency Special Enrollment Period that ran from Feb. 15 through August 15 in HealthCare.gov states.
• The strong enrollment gains should compel Democrats to extend the ARPA subsidy boosts, which expire after this year.

I hope you'll give it a read.

Subscribe (free) to xpostfactoid

Two thirds of ACA enrollment growth is in 11 nonexpansion states. Nearly half is in Florida and Texas

CMS announced today that plan selections for 2022 in the ACA marketplace have reached an all-time high of 13.6 million. That's up from 12.0 million as of the end of Open Enrollment (OE) for 2021, a 13% increase so far. [Update: Per Charles Gaba, the total as of Dec. 15 last year was 11.6 million, as most of the 15 SBEs' Open Enrollment seasons did not end on Dec. 15. See note at bottom]

As in last year's OE and this year's emergency SEP, enrollment growth was overwhelmingly concentrated in states that have refused to enact the ACA Medicaid expansion. Enrollment increased by 1.7 million in 33 states using HealthCare.gov, the federal exchange -- and 1.3 million of that increase was in the 11 remaining holdout states (excluding Wisconsin, which has no coverage gap), a 25% year-over-year increase in those states. Enrollment in Florida and Texas increased by 900,000.  

Over two years, from OE for 2020 to OE through Dec. 15 for 2022, enrollment in these 11 states has increased by 1.8 million, or 38%.

Is enrollment surge on GetCoveredNJ driven by off-exchange migration? Maybe not.

Subscribe (free) to xpostfactoid

Liberty State Park, Jersey City, NJ

New Jersey's Department of Banking and Insurance (DOBI) reports that enrollment in health plans on GetCoveredNJ, the state's ACA exchange, was up more than 25% as of December 5 compared to the same time last year. That may be the largest one-state year-over-year surge during an Open Enrollment season in which enrollment was up about 9% nationally as of Dec. 8. 

New Jersey has a large off-exchange individual market, which in 2020 accounted for 30% of enrollment in ACA-compliant plans (94,885 out of 316,580 total enrollments as of Q1 2020). The surge in on-exchange enrollment may provide a hint as to the extent of migration from off-exchange to on-exchange driven by the American Rescue Plan Act's removal of the income cap on subsidy eligibility. Since April of this year, premiums for the benchmark (second cheapest) silver plan have been capped at 8.5% of income, regardless of how high the income is. New Jersey, moreover, layers its own supplemental subsidy on top of the federal APTC. At high incomes, NJ kicks in $100/month per person, up to an income of 600% FPL. This subsidy, like the federal one, is only available on-exchange.

Subscribe (free) to xpostfactoid

If BBB remains blocked and ARPA subsidies go poof, what can CMS do to mitigate the damage?

Subscribe (free) to xpostfactoid

In the wake of Manchin's weekend declaration that he won't vote for the Build Back Better bill,  I am sure I'm not alone in choosing to hope that this is not game over, that some fragments of Biden's domestic agenda will become law. Still, it's time to face the strong possibility that the major temporary subsidy boosts in the ACA marketplace enacted in the American Rescue Plan Act will expire, and that the marketplace will revert to its under-subsidized pre-ARPA state in 2023.

It's time, then, to recall the various ways the administration can boost affordability in the marketplace without legislation, leaving coverage less affordable than it is now, but more affordable than it was before March 2021, when ARPA was enacted. 

Swinging benchmarks, meaningful difference, market stability and market chaos

Subscribe (free) to xpostfactoid

My last post focused on the steep premium hikes that can hit ACA marketplace enrollees if they passively let themselves be auto-reenrolled in their current plan for the year following. In brief: if the benchmark (second cheapest silver) premium shrinks (say, because a new discount insurer enters the market), so does the subsidy. If the enrollee's current plan premium in turn increases, it's a double whammy. 

The major increase in ACA marketplace subsidies enacted when the American Rescue Plan Act (ARPA) passed in March 2021 does not alter this dynamic. If the benchmark silver plan is available to you for free -- as it is now for some two million enrollees -- and your silver plan premium exceeds the benchmark by $139 per month, you'll pay... $139 per month. Louise Norris shows an even more extreme example of a one-year premium increase for a subsidized enrollee.

In fact, large benchmark swings may be more common this year than in years past. Insurer participation in the ACA marketplace has surged this year, probably prompted by the ARPA subsidy boosts, which followed several years of price stability and profitability. CMS reports that the average enrollee has between 6 and 7 insurers to choose from in 2022, compared to between 4 and 5 in 2021 -- an increase of 44% if you take the midpoint (6.5 vs. 4.5).  Among the insurers expanding their footprint in 2022 are discounters Bright, Centene, Friday, and Molina. The average benchmark premium dropped 3% nationally, according to the Kaiser Family Foundation.

A parallel problem, adding to the confusion inherent in marketplace structure for those who do check out their options, is an overabundance of plan choice. In 2022, the number of plans available to the average marketplace enrollee soared from 61 to 108 -- a 77% increase. In Dallas, 164 plans are available on-exchange. In Miami, 263.

Longer Open Enrollment period in ACA marketplace provides a fail-safe for enrollment errors

Subscribe (free) to xpostfactoid

Health insurance broker Jenny Chumbley Hogue, based near Dallas, highlights one good thing about the longer Open Enrollment Period for the ACA marketplace enacted by the Biden administration (OE is now running through January 15 rather than December 15):

Thank goodness OEP extended to 1/15 so we can correct the issues. @charles_gaba @LouiseNorris @AlekaGurel @xpostfactoid @SheronESidbury

— Jenny Chumbley Hogue (@kgmom219) December 13, 2021

That is: Marketplace enrollees who passively let themselves be auto-re-enrolled for 2022 in their current plan, and get shocked in January by a sliding benchmark that raises their premiums (sometimes dramatically), can now choose a cheaper plan before January 15 and suffer only one month at the higher premium, rather than being locked in for twelve months.

At an income of $25,000 for a couple -- just under 150% FPL -- the benchmark (second cheapest) silver plan is free in 2021 and 2022, thanks to the subsidy boosts created by the American Rescue Plan Act, enacted in March 2021 (the ARPA Jenny Hogue refers to in the tweet). That is, at least two silver plans are free for any individual or family with an income up to 150% FPL. 

This year, the cheapest silver plan in Dallas was the Blue Cross plan shown below. But see what happens to a pair of 63 year-olds in Dallas who renew that plan in 2022:

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 HealthCare.gov, 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.  

Few Medicare enrollees pay huge prescription drug costs out of pocket

Subscribe to xpostfactoid

The scaled-back prescription drug cost control measures belatedly added to the Build Back Better bill include a $2,000 annual cap on out-of-pocket costs for enrollees in Medicare Part D.

That's a vital reform, since Medicare enrollees' exposure to drug costs is currently open-ended, and can run to many thousands for the most expensive drugs, e.g., for cancer or rare diseases. 

But the complex Part D payment formula can leave some observers with the impression that more enrollees are paying astronomical costs than is the case. Specifically, references to amounts paid by all payers in each of the first three coverage phases often give the impression that those total costs are paid by enrollees. Such confusion appears to have recently reached the White House:

Talk to me if you became self-employed during the pandemic

Last week I noted that the subsidy increases in the ACA marketplace provided last spring by the American Rescue Plan Act (ARPA) were well-timed to catch a surge in self-employment and small business formation triggered by the pandemic.

Thanks to the subsidy boosts, the ACA marketplace is much closer than ever before to fulfilling the ACA's foundational promise of freeing Americans from "job lock" -- dependence on employers for health insurance. 

I would like to speak to people who have become self-employed or started businesses since the pandemic struck and looked to the ACA marketplace (or Medicaid) for health insurance -- successfully or unsuccessfully. I would also welcome hearing from people who were already insured through the marketplace and experienced changes once the ARPA subsidies were enacted in April/May 2021 (or July, for those who qualified for free silver plans because they had received unemployment insurance income this year).

If you'd like to tell me your experience, please email me: adsprung at gmail. Please refer anyone whose experience you think might be relevant. Thanks!

Subscribe to xpostfactoid 

Pointing low-income ACA marketplace shoppers toward Cost Sharing Reduction

As I noted in my last post, the American Rescue Plan Act's boosts to ACA marketplace subsidies seem to have reversed a years-long slide in "CSR takeup" among low-income enrollees. That is, during the emergency Special Enrollment Period that ended this past August 15, about 90% of enrollees with incomes below 200% of the Federal Poverty Level selected silver plans and accessed strong Cost Sharing Reduction (CSR), up from about 77% in the last Open Enrollment period. CSR is available with silver plans only. At incomes up to 200% FPL, it raises the value of a silver plan to the rough equivalent of platinum at no extra cost to the enrollee.

The surge in silver selection at low incomes this spring and summer was only logical, since ARPA made a benchmark silver plan free at incomes up to 150% FPL, and available for no more than 2% of income at incomes up to 200% FPL ($25,520 for a single person in 2021).  At incomes below 200% FPL, CSR reduces deductibles and out-of-pocket maximums to a small fraction of those prevalent in bronze plans (the median deductible obtained by 2.1 million enrollees on HealthCare.gov during the SEP was $50; bronze deductibles average nearly $7,000).  Free bronze plans used to be a serious temptation at incomes between 150-200% FPL in particular; now, not so much.

Since bronze plans are now almost always "dominated" by silver plans at incomes up to 150% FPL, and almost always a poor choice up to  200% FPL, I thought I'd check the degree to which the ACA exchanges - -HealthCare.gov, now serving 33 states, and 18 state-based exchanges (including D.C.'s) steer low-income enrollees toward silver plans. 

ARPA subsidy boosts in ACA marketplace reduced underinsurance, reversing a 'slide to bronze' at low incomes

Subscribe to xpostfactoid 

When the premium subsidy enhancements for the ACA marketplace that became law when the American Rescue Plan passed were first published in early February of this year, my first thought was that no one with an income below 200% FPL should ever buy a bronze plan again:

If the subsidy enhancements become law while the emergency SEP [Special Enrollment Period, running from Feb. 15 to Aug. 15 on HealthCare.gov] is still open, bronze plan enrollment at incomes under 200% FPL should go to zero. At incomes up to 150% FPL ($19,140 for a single person), silver coverage will be free. At 200% FPL ($25,520 for a single person), benchmark silver will cost $43 per month. That expense doesn't feel like nothing at that income, but the average deductible for silver at that income level ($800) is about one ninth of the average bronze deductible ($6,921). The out-of-pocket maximum for bronze plans is usually close to the highest allowable, $8,550 for a single adult.  For silver at incomes up to 200% FPL, it's $2,850, and usually well below that, averaging $1,189 at incomes up to 150% FPL and $2,528 at 150-200% FPL. 

Well, those subsidy boosts did go into effect during the emergency SEP, helping to drive a major surge in off-season enrollment. Nationally, 2.8 million people newly enrolled in ACA marketplace plans from Feb. 15 to Aug. 15, 2.1 million of them in the 36 states using the federal exchange, HealthCare.gov. And while selection of plans at metal levels other than silver at low incomes did not go zero during the SEP, it did go way down, reversing a troubling trend.  The ARPA subsidies are reducing underinsurance.

Is the ACA marketplace catching a surge in entrepreneurship?

Subscribe to xpostfactoid

The Wall Street Journal's Josh Mitchell and Kathryn Dill report that the pandemic has triggered a surge in self-employment and small business formation:

The number of unincorporated self-employed workers has risen by 500,000 since the start of the pandemic, Labor Department data show, to 9.44 million....Entrepreneurs applied for federal tax-identification numbers to register 4.54 million new businesses from January through October this year, up 56% from the same period of 2019, Census Bureau data show.

That surge underscores the value and good timing of the boosts to premium subsidies for plans sold in the ACA Health Insurance Marketplace provided by the American Rescue Plan Act, enacted in March 2021. Those subsidy increases brought the ACA much closer to fulfilling its promise of providing affordable insurance to those who lose or leave their jobs and so lose access to employer-sponsored plans, which insure the majority of working age Americans.

From verb to noun, on the rebound

Subscribe to xpostfactoid

Some time early in our relationship, my wife set down a plate or cup in front of me and said with indulgent and somewhat satiric glee, "you sit down an have an enjoy."

I thought that was hysterical for some reason, and it's been a watchword in our house for 40 years. I often try to fathom why it seems so funny, and get a grip on the intuition that led Cindy to manufacture a noun, enjoy, by accenting the first syllable of a common verb. My lingering association is with "escape" in Arlo Guthrie's Alice's Restaurant, below (reproducing Guthrie's pronunciation):

Almost a quarter of all emergency SEP enrollees in ACA marketplace should have been in Medicaid

Subscribe to xpostfactoid

For years, we have had to infer what percentage of ACA marketplace enrollees in states that have refused to enact the ACA Medicaid expansion have incomes below 138% FPL -- the Medicaid eligibility threshold in expansion states. It's a very large percentage, but as CMS's enrollment reports usually break out income in increments of 50 FPL percentage points, e.g., 100-150% FPL, it has to be inferred.

Just once, in 2016, CMS did provide enrollment results by state for the 100-138% FPL income range as well as for the broader 100-150% FPL bracket. In nonexpansion states, the former was about 85% of the latter. For years since, I've used 85% as a benchmark to estimate down from 100-150% FPL for the "should-have-been-in-Medicaid" cohort.

The final enrollment report for the 2021 emergency Special Enrollment Period, which ran from Feb. 15 to Aug. 15 in the 36 HealthCare.gov states, provides a tantalizing hint: 33% of all enrollment in those states was in the 100-138% FPL bracket. (All nonexpansion states use HealthCare.gov.) But what percentage of those were in the 13 states that had not expanded Medicaid as of the SEP period? (I'm including Oklahoma, which opened the Medicaid expansion gate on July 1 of this year.) 

Signposting likely Medicaid eligibility without muddling the message

Subscribe to xpostfactoid

The Missouri Medicaid expansion  -- mandated by referendum, denied funding by the state legislature, and enacted only after the Missouri Supreme Court so ordered -- is off to a slow start, with the administration of Republican Governor Mike Parson declining to do much outreach. Enrollment of those rendered newly eligible by ACA expansion criteria began on October 1.

News of the slow start led me to check whether HealthCare.gov has been retooled to tell Missouri visitors who use the site's see plans and prices tool that they're likely eligible for Medicaid if they input an income below the eligibility threshold. HealthCare.gov is not the primary means by which people enroll in Medicaid, but it's a "no wrong door" channel.

Yes, HealthCare.gov has has been updated. That's not surprising -- it's had to absorb about a dozen late Medicaid expansions.  But the check underscored to me that messaging on the site for those likely eligible for Medicaid (in all expansion states) could be clearer.  

Here's what you see if you input an income below the eligibility threshold (here, $17,000 for a solo applicant in zip code 63111 in St. Louis): 

The broker's tale: Louise Norris on skewed incentives in the ACA marketplace

Subscribe to xpostfactoid

As noted in last week's post, the ACA exchanges rely heavily on health insurance brokers and agents to help people sort their options and enroll in ACA-compliant individual market plans. Almost half of enrollments on the federal exchange, HealthCare.gov, which currently serves 33 states, are enrolled by brokers and agents. The same is true for Covered California, the largest state-based exchange -- which, unlike HealthCare.gov,* has maintained a consistent commitment to making the marketplace work as designed since its launch in fall 2013.

The reliance on brokers was inevitable, given the complexity of marketplace offerings (check out the 221 plans on sale in Miami, the nation's largest ACA marketplace, in 2022) and the pre-existing pool of expertise, commercially funded, that brokers constituted prior to ACA launch.  And while brokers have played a vital role,** the ACA failed to align their incentives in such a way as to ensure that their participation would be an unmixed blessing. Among the problems:

• Not all insurers that participate in the ACA exchanges pay commissions to brokers. Commissions have fluctuated quite a bit over the seven years of the marketplace's existence, as well as by state, region, and individual insurer.
  
  
• The lightly regulated market for so-called Short Term Limited Duration plans fostered by the Trump administration (which rendered them neither short-term nor of limited duration, if there's a difference) pays much higher commissions than the ACA-compliant market, but serves few enrollees' best interests. STLD plans are medically underwritten, riddled with exclusions and coverage gaps, prone to balance billing, and pay as little as half of premium revenue to cover enrollees' medical claims. ACA-compliant plans are required to maintain a minimum "medical loss ratio" (MLR) of 80% -- that is, pay out at least 80% of premium revenue in claims.

How do ethical brokers deal with these conditions, and how could incentives be better aligned? To address those questions I queried Louise Norris, co-owner with her husband Jay Norris of a health insurance brokerage serving individual market customers in Colorado.

Happy day(s) are here again?

Subscribe to xpostfactoid

As Biden's poll numbers sag, complaints are rife in my liberal Twitter bubble that the media casts current economic news in a bad light, with inflation trumpeted ahead of other pretty good fundamentals on the employment and growth front. 

We all think the refs are biased against us, and maybe they are. But with those complaints furnishing some corner of my mind, I just happened on a Wall Street Journal home page, which, if only momentarily, snapshots some pretty good economic (and geopolitical) news on balance. Take it for what it's worth. (Flashback: "green shoots" of spring 2009, oy gevalt...)

Under Biden, HealthCare.gov maintains its Trump era tilt toward commercial insurance brokers

Subscribe to xpostfactoid

11/19: See update at bottom:  Healthcare.gov put out an email today that leads with nonprofit assisters

Obtaining health insurance from publicly supported programs in the U.S. is a complex process, necessarily supported by a variegated ecosystem of enrollment assisters.  For people under age 65, nearly 50,000 commercial health insurance brokers and agents are registered (as of 2020), along with about 30,000 nonprofit enrollment assisters (as of 2016), many of the latter supported by federal or state funding.

Enrollment of the under-65 population that lacks access to employer-sponsored insurance depends on both commercial and nonprofit assisters, who have different and to some extent complementary strengths and weaknesses. 

HealthSherpa shows how to shrink the coverage gap

Subscribe to xpostfactoid

As I have noted repeatedly (1, 2, 3) the ACA's notorious coverage gap -- the unavailability of subsidized insurance for adults with incomes below 100% FPL in states that have refused to enact the ACA Medicaid expansion -- is exacerbated by ignorance. 

Few low income applicants in the 11 remaining "gap" states* know that they must estimate a minimum income for the coming year to qualify for coverage. HealthCare.gov, the application venue for all applicants potentially subject to the gap, does not spell out in the application or in the plan preview tool that a minimum income is required. People who are told that they do not qualify for aid because their income is too low are rightly incredulous.

Since fall 2018, however (during Open Enrollment for 2019), HealthSherpa, a commercial online health insurance brokerage used by thousands of brokers, has spelled out that vital information. 

Premiums down, out-of-pocket costs up up up: The post-ARPA case for maximal silver loading

Subscribe to xpostfactoid

I have repeatedly made the case that CMS should follow the lead of several states and mandate strict silver loading* in the ACA marketplace-- that is, require insurers to consistently price gold plans below silver plans, since the average actuarial value of silver plans is higher than the mandated AV for gold plans (80% -- i.e., the plan is designed to cover 80% of the average enrollee's costs). 

In recent posts, I have spotlighted New Mexico's maximized mandatory silver loading: in 2022, the state required insurers to price silver plans as platinum-equivalent, since silver plans are platinum-equivalent for enrollees with incomes below 200% FPL ($25,7600 for an individual in 2022).  The regulation is designed to be a self-fulfilling prophecy: if gold plans are priced well below silver, no one with an income over 200% FPL should buy silver plans.  In 2022, gold plans are in fact priced well below silver plans throughout New Mexico.

Since silver loading began in 2018, the main case for maximizing it has simply been that the ACA marketplace has always been under-subsidized, and a state or CMS can alleviate high enrollee costs without help from Congress. That case may appear less urgent after the American Rescue Plan Act (ARPA), enacted this past March, sharply increased premium subsidies. The draft Build Back Better bill would extend those subsidy boosts through 2025.

But the case for strict silver loading remains strong. While ARPA reduced premiums, it did not reduce out-of-pocket costs, and these have risen relentlessly at each metal level, driven by medical inflation, which is always higher in the commercial market.  Strict silver loading is a way to roll back that rise for enrollees with incomes above 200% FPL; it's a kind of back-door CSR for enrollees above that income level. (Moreover, the BBB bill is not a done deal, 2025 is not the end of time, and strict silver loading would mitigate a far-from-unlikely expiration of the subsidy boost.)

Open enrollment 2022! Marketplace loaded for bear, but bear traps remain

Subscribe to xpostfactoid

Open enrollment in the ACA marketplace begins tomorrow. This will be the first OE season - -and hopefully, not the last - -in which the enhanced subsidies created by the American Rescue Plan (ARPA) are in place. It's a season of hope -- and also worry. Some thoughts below.

1. All systems go? The marketplace, which never reached half the enrollment projected by CBO in 2010, is in some senses loaded for bear this fall. Thanks to ARPA, silver plans with strong Cost Sharing Reduction (CSR) are now free for people with incomes up to 150% FPL ($19,320 for an individual); cost no more than 2% of income at incomes up to 200% FPL; and cost no more than 8.5% of income (without CSR) for any enrollee who lacks access to other affordable insurance. 

Navigator organizations, which operated on a shoestring (if at all) during the Trump years, their federal funding cut from $63 million in 2016 to $10 million in 2018 and years following, have been granted $80 million for 2022. Florida's chief navigator organization, Florida Covering Kids and Families, started with 120 navigators in 2013 but was down to 50 in OE for 2020, with just 25 in the off-season. This OE, they've got 200 navigators in place. (Federal navigator funding, derived from user fees charged to insurers selling in the marketplace, only applies to the 33 states still using HealthCare.gov, the federal exchange. State exchanges fund their own outreach through user fees they retain.)

Albuquerque vs. Miami, or platinum vs. silver benchmark in the ACA marketplace

Subscribe to xpostfactoid

A week ago, I put a spotlight on ACA marketplace plan offerings for 2022 in New Mexico, which has essentially implemented a platinum benchmark. That is, regulators have instructed insurers to price silver plans as if all enrollees have incomes below 200% of the Federal Poverty Level. Below that threshold, silver plans, enhanced by Cost Sharing Reduction (CSR) do have actuarial values comparable to those of platinum plans. Under these new pricing guidelines, some half-dozen gold plans are priced well below the benchmark (second cheapest) silver plan, and no one with an income above 200% FPL should buy silver.

While New Mexico is a very small market, this pricing scheme could and should be implemented nationwide. That possibility has implications -- or should have implications -- for Democrats' negotiations over the healthcare provisions to be included in the Build Back Better bill. 

Today, then, I want to compare what's available to buyers with incomes above 200% FPL in Albuquerque and in a market with a more typical pricing structure. Miami fits that bill. There, the lowest-cost gold plan is priced 8% above the benchmark silver plan. That's right at the average spread between lowest-cost gold and benchmark silver nationally during the silver loading era (2018-2021), according to KFF.

If Democrats fail to enhance the ACA or remove the coverage gap, what can the Biden administration do?

Subscribe to xpostfactoid

As the extent to which Senators Manchin, Sinema, and other corporate Democrats will eviscerate the original outline of the Build Back Better bill sinks in, it's time to consider the once-unthinkable: what if Democrats fail to extend the enhanced ACA marketplace subsidies enacted in the American Rescue Plan Act (ARPA) in March?  And what if -- which was always uncertain -- they fail to plug the coverage gap in states that have refused to expand Medicaid?

New Mexico models a platinum benchmark for the ACA marketplace

Subscribe to xpostfactoid

I'd like to delve a bit deeper into the metal level pricing in New Mexico's 2022 marketplace (discussed in the previous post), since it's a potential model for the whole country. Plans available for 2022 can now be previewed on New Mexico's new state-based exchange, bewellnm.

For 2022, the state's insurance department instructed insurers to price silver plans as if they have platinum value. That's because, for enrollees with incomes up to 200% FPL, silver plans do have platinum value, thanks to the Cost Sharing Reduction (CSR) subsidies available to low income enrollees, which attach to silver plans only. Most silver plan enrollees in New Mexico have incomes below 200% FPL, and the pricing instructions are meant to be a self-fulfilling prophecy: if gold plans cost less than silver, then no one with an income over 200% FPL will buy silver plans. Since premium subsidies are set to a silver benchmark, gold will be available below benchmark, i.e. below the level deemed affordable by ACA criteria.

bewellnm launches with *really* cheap gold plans; some confusion at low incomes likely

Subscribe to xpostfactoid

New Mexico's newly minted state-based ACA exchange, bewellnm, has launched plan preview shopping for 2022.

What's noteworthy: uniquely, the New Mexico Office of the Superintendent of Insurance has instructed insurers selling in the state individual market to price silver plans on the assumption that no one who does not qualify for strong Cost Sharing Reduction (CSR)-- that is, no one with an income above 200% of the Federal Poverty Level -- will buy silver.  In other words, silver plans must be priced more or less as if they're platinum* -- since they are in fact platinum-equivalent at incomes below 200% FPL.  Platinum plans (which are almost nonexistent) have an actuarial value (AV) of approximately 90%. CSR brings silver plan AV to 94% for enrollees with income up to 150% FPL, and 87% for those in the 150-200% FPL income range.

This is meant to be a self-fulfilling prophecy: if gold plans (approximately 80% AV) are priced below silver plans, no one who doesn't get the high CSR value should buy silver. Silver plans for enrollees who don't qualify for CSR (income above 250% FPL) have an AV of 70%; those who qualify for negligible CSR (income 200-250% FPL) get an AV of 73%.   Why buy silver if it offers a lower AV than gold -- -but costs more?

In Albuquerque in 2022 (zip code 87107), gold is priced well below silver, as planned. For a 40 year-old ineligible for subsidies (income $100,000**), the lowest-cost gold plan costs $288 per month; the lowest-cost silver plan is $320 per month. Six gold plans, with deductibles ranging from $750 to $2300, are cheaper than the cheapest silver plan, which has a deductible of $5450.  The second cheapest (benchmark) silver plan, at $337/month, has a deductible of $4250. Who would buy silver in these circumstances?

In which the Kaiser Family Foundation moves to quell a PhRMA disinformation campaign

Subscribe to xpostfactoid

The Kaiser Family Foundation (KFF) appears to have taken steps prevent PhRMA from using its polling in a disinformation campaign. 

In response, PhRMA has accused KFF of politicizing its research. That's like Donald Trump accusing an opponent of lying to the public (or rigging the vote count).

What KFF did do -- amend its survey questions about empowering Medicare to negotiate prescription drug prices -- is interesting. Let's step back and review how KFF typically structures questions regarding public policy options.

In its questionnaires, KFF will ask whether a respondent favors an initiative -- say, subsidizing children's lemonade stands. 90% approve! It will follow up with a question that raises the possible negative effects -- say, increasing neighbors' likelihood of developing Diabetes from all that liquid sugar.  Approval will drop, a little or a lot.

Wonder of wonders: National balance billing protection for consumers that (probably) won't increase healthcare costs

Subscribe to xpostfactoid

The federal government* delivered some rare good news on the healthcare cost control front with release last week of the second part of interim final rule governing implementation of the No Surprises Act, which will protect Americans from the most egregious forms of balance billing (excepting ground ambulances!) beginning on January 1, 2022. The No Surprises Act was part of the broad-based bipartisan budget deal signed into law by Trump in late December 2020.

The good news concerns the ground rules for arbitration of out-of-network bills, which either the provider or the insurer can initiate if they can't agree on a price within 30 days. As in New York, New Jersey and other states that have passed laws protecting patients from balance billing, it's "baseball arbitration," in which the arbitrator must rule in favor of one party's proposed price, rather than splitting the difference. What matters is the standard by which the arbitrator must judge the competing bids. A summary published by CMS provides the upshot:

Rapid marketplace enrollment growth in nonexpansion states, revisited

Subscribe to xpostfactoid

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.

Even with balance-billing protection, a tiered network may cause tears

Subscribe to xpostfactoid

My last post involved a close look at the severely tiered provider network in the silver plans sold in the ACA marketplace by Independence Blue Cross, the dominant insurer in Philadelphia and southeastern Pennsylvania.  On a second look, a thought occurred to me: tiered networks that place go-to hospitals in higher tiers put an asterisk of sorts on balance-billing protections for emergency care, including those due to come online nationally when the No Surprises Act takes effect on January 1.

Under the No Surprises Act, emergency care is billed at in-network rates whether or not the hospital or facility is within the provider network of the patient's health plan. But what exactly is an "in-network rate" in a tiered network? Depends on the tier.

Independence's HMO plans sold in the ACA marketplace have three tiers. Its second-cheapest silver offering on Pennie, Pennsylvania's ACA exchange, the Keystone HMO Silver Proactive plan, posts a deductible of $0. But that's in Tier 1 only. For enrollees with incomes too high to qualify for Cost Sharing Reduction (CSR),* Tiers 2 and 3 have a deductible of $6,000 for an individual and $12,000 for a family. 

Independence Blue Cross sells only 24-carat gold plans in Philadelphia and surrounding counties

Subscribe to xpostfactoid

What is wrong with this picture?

These health plan quotes, taken from the health plan comparison tool provided on Pennie, Pennsylvania's online ACA marketplace, show the lowest-cost silver and gold plans offered in Philadelphia by southeastern Pennsylvania's dominant insurer to a 40 year-old with an income of $38,000.  (Premiums are net of a federal subsidy of $262 per month.) 

In the pricing of its lowest-cost gold plan, Independence Blue Cross, issuer of the Keystone health plans listed above, is an outlier, in that its lowest cost gold plan is priced well above its lowest cost silver plans. That's not how it's supposed to work in Pennsylvania.

Notes from the SEP: On record marketplace enrollment in August 2021

Subscribe to xpostfactoid

CMS today released a final enrollment report for the emergency Special Enrollment Period that ran in HealthCare.gov states from Feb. 15--Aug. 15 this year, and for mostly comparable lengths in the 15 state-based marketplaces. 

The top line: 2.8 million new enrollments nationally in that period. A few quick notes:

1. Effectuated enrollment in August 2021, 12,199,393, is up 14.6% over 2020, the previous high (10,642,088*), and 22% over enrollment in August 2016, the peak prior to 2020.  Caveat: off-exchange enrollment in ACA-compliant plans dropped by about 3 million from 2016 to 2019, according to KFF estimates. On-exchange enrollment is about 2.2 million above the August 2016 total.
   
   
2. While 2.8 million people newly enrolled in marketplace coverage during the SEP, total enrollment has risen by only 900,000 since February, when effectuated enrollment stood at 11.3 million.  That's steeper attrition than I anticipated when I estimated total enrollment at 12.7 million through July.
   
   

Dropping the Medicare age to 60 also requires...

Subscribe to xpostfactoid

130 House Democrats have co-sponsored a bill introduced on September 3 by Pramila Jayapal, the Improving Medicare Coverage Act, that would drop the Medicare eligibility age to 60 -- simply and cleanly, with Medicare offered on the same terms at age 60 as it now is at age 65, within six months of enactment. That's the headline. But the bill does something else that's arguably more consequential. 

Without other changes to Medicare, dropping the eligibility age to 60 would be a mixed blessing at best. That's because for 60-64 year-olds with income below 200% of the Federal Poverty Level ($25,520 for an individual, $34,480 for a couple in 2021), Medicare in its current form would be considerably more expensive than ACA marketplace coverage (as enhanced through 2022 by the American Rescue Plan Act in enacted in March) -- excepting for those who are dually eligible for Medicaid and Medicare. While just over a quarter of the U.S. population is in households with incomes below 200% FPL, about half of the uninsured have incomes below that threshold.  

Jayapal's bill changes the equation by making all Medicare enrollees with income below 200% FPL eligible for a new Medicare Cost Assistance Program that would zero out premiums, coinsurance and deductibles for Medicare Parts A (hospital)  and B (physician and outpatient), and also subsidize Part D prescription drug coverage (covering the entire Part D premium and reducing prescription copays to single-digit dollar amounts).  The bill would also move administration of these benefits from state Medicaid programs to Medicare, with the federal government assuming 100% of costs now shared with states.

Viewing the uninsured rate through foggy lenses

Subscribe to xpostfactoid

Snapshots of the health insurance status of the U.S. population are blurry.

When you look at the CMS tally of Medicaid enrollment increase since the pandemic struck, it seems, simply, that the increase swamps most estimates of the number of people that lost employer-sponsored insurance. Other factors are at work, of course. But the one large number is considerably larger than the other large number.

But official Medicaid enrollment totals may not be an entirely reliable measure of how many people are actually covered by Medicaid, and know themselves as such -- particularly during this pandemic, when disenrollments have been paused since March 2020. State Medicaid agencies are, to varying extents, blind beasts.

I know a young man who, during a year of transition, lived in two states and worked at three jobs, with a period of unemployment. At different points in the year he applied for Medicaid in two (blue) states and received rejection notices. From both of those states, months later (and months apart), while insured through a new employer, he was sent managed Medicaid membership cards and informed that he'd be enrolled since shortly after his application was completed.  In both states, it took some doing and some time to get himself disenrolled.

How will Medicare enhancement change the current public-private Medicare ecosystem?

Subscribe to xpostfactoid

Democrats' aspirations to add dental, hearing and vision benefits to Medicare raises questions about the interactions between tradition, fee-for service (FFS) Medicare, Medicare Advantage (MA), and Medigap. These center on MA's growing market share, its funding mechanism, the gaps in FFS Medicare coverage that MA plans partially fill, and the value of Medigap for those who can afford it (or whose employers fund it).

Below, a brief outline (distilled mainly from KFF briefs) of how the three programs (FFS, MA and Medigap) interact/compete at present, followed by questions about how pending legislation may alter the ecosystem.

NHIS: No shift from private to public insurance?

Subscribe to xpostfactoid

The annual early release estimates from the National Health Interview Survey (NHIS) came out today. The NHIS recorded a decrease in the uninsured rate for all ages from 2019 to 2020, from 10.3% to 9.7%, but deemed the change statistically insignificant. Among adults aged 18-64, the uninsured rate  dropped from 14.7% to 13.9% -- also deemed not significant. Similarly, the Urban Institute survey report that I wrote about last week found essentially no change in the uninsured rate from March 2019 to April 2021 -- but also recorded a statistically insignificant drop. 

Directionally, as I noted last week, most surveys, including the Census's experimental Household Pulse Survey, point to a modest drop in the uninsured population during the pandemic. Big picture: huge gains in Medicaid enrollment, driven largely by a pause in disenrollments effectively mandated by pandemic relief legislation, appear to have outstripped drops in access to employer-sponsored insurance (ESI), which according to various sources fell less than the massive job losses triggered by the pandemic might have led one to expect. But there are a lot of moving parts that may have canceled one another out. 

Is the uninsured rate flat since 2019, or down a bit?

Subscribe to xpostfactoid

See 8/31 update from NHIS survey at bottom

The Urban Institute, in an analysis of results from its own ongoing Heath Reform Monitoring Survey, found that the uninsured rate among adults aged 19-64 did not change significantly from March 2019 to April 2021. 

That's at least a backhanded tribute to the U.S.'s kludgy health insurance safety net as bolstered by the Affordable Care Act. Big picture: in Urban's estimate, as a result of the pandemic, employer-sponsored insurance  fell by 3 percentage points (from 65% to 62.3%) in the survey period, while insurance through public programs (mainly Medicaid) increased by 4 percentage points (from 13.6% to 17.5%). 

You could read these results as a paean to the ACA Medicaid expansion (which Republicans almost repealed in 2017). In states that have expanded Medicaid, Urban found that the uninsured rate actually dropped two percentage points for people with incomes below 138% FPL, the Medicaid eligibility threshold. According to CMS, total Medicaid enrollment (including children) increased by 11 million -- 15.6% -- from February 2020 to March 2021.  Enrollment among adults rendered eligible by the expansion increased by about double that rate.

Urban recorded a much more modest and ambiguous impact for the ACA marketplace -- though the huge enrollment surge during the emergency Special Enrollment Period open from February 15 through August 15 of this year, turbo-charged by subsidy increases enacted in the American Rescue Plan, which appeared on HealthCare.gov on April, was mainly missed by Urban's study period. I'll return to that in a bit.

I speculated in May that the U.S. uninsurance rate might be at an all-time low, powered by huge gains in Medicaid enrollment, significant gains in marketplace enrollment, and relatively modest losses in employer-sponsored insurance during the pandemic. My methods (and math) are far less sophisticated than Urban's, and this is not to question their results (no source ever has a really complete picture of insurance in the U.S.).  That said, a few comments and caveats below.

What's the effect of a gold benchmark in the ACA marketplace? Three states tell a tale. And a platinum benchmark is coming.

Subscribe to xpostfactoid

Bloomberg's Sara Hansard reports that six states have now taken action to require insurers in their ACA marketplaces to price plans in strict proportion to their actuarial value -- that is, to increase the effects of silver loading. (Actuarial value (AV) refers to the percentage of the average enrollees costs the plan is designed to cover, in percentages fixed by metal level.)

Maryland, Pennsylvania and Virginia required strict silver loading in 2021 (and some or all in years prior). New Mexico and Colorado have new regulations going into effect in 2022. Texas has passed a law requiring the state insurance commissioner to take the value of Cost Sharing Reduction (added to silver plans only) into account during rate review.

Silver loading as mandated in Maryland, Pennsylvania and Virginia makes gold plans at least marginally cheaper than silver plans, increasing value for enrollees with incomes above 200% of the Federal Poverty Level ($25,520 for an individual in 2021). Below that income threshold, Cost Sharing Reduction (CSR) raises the actuarial value of silver plans to a roughly platinum level.

On staying out of the coverage gap: expert advice

Subscribe to xpostfactoid

I have a post up on healthinsurance.org addressing a subject near my heart: how to help more people avoid the "coverage gap" in states that have refused to enact the ACA Medicaid expansion.  That is, how to avoid being denied any help paying by estimating next year's income at a level below 100% of the Federal Poverty Level.

Eligibility for subsidized coverage (now free at incomes in the 100-150% FPL range, e.g., for anyone just over the eligibility threshold) is based on an estimate of next year's income. A lot of variables go into such estimates, especially for people with low incomes, who are often self-employed or work variable and unpredictable hours, or rely on tips, or do seasonal work. In this piece, brokers and enrollment counselors who have been at work since the ACA marketplace launched explain in detail how to maximize a good-faith estimate when necessary.

In many, many cases, failing to qualify for subsidized coverage is a matter of ignorance. The application does not tell you that there's a minimum income threshold you need to cross. Accordingly, the first step in helping low-income people seeking coverage is to spell out the minimum qualifying income:

This point can't be emphasized enough, according to Shelli Quenga Director of Programs at the Palmetto Project, a nonprofit health insurance brokerage in South Carolina.  "You need to know what amount you're shooting for," Quenga says. "You need to know where that line is. HealthCare.gov does not tell you."

Paradoxically, the application does recognize income uncertainty, and in fact positively invites applicants to take it into account:

Total marketplace enrollment likely approaches 13 million

Subscribe to xpostfactoid

Axios reports that Vice President Harris will announce today that more than 2.5 million people have signed up for marketplace coverage during the emergency Special Enrollment Period that began on February 15 and ends on August 15. (Yesterday, Charles Gaba estimated 2.57 million total SEP enrollments as of July 31.) [Update: CMS's SEP report through July 31 is out and cites the 2.5 million total.]

Just for fun, let's take a stab on where total marketplace enrollment likely stands right now. 

We know that effectuated enrollment totaled 11,290,546 in February, and that about 2.5 million additional enrollees have been logged since then. The wild card is disenrollments during those months. To estimate them, our best hints come from monthly enrollment tallies in 2020, recorded in the effectuated enrollment snapshot for February 2021.

Maximizing the ACA Innovation Waiver: Biosimilar silver loading, anyone?

Subscribe to xpostfactoid

Ask, and it shall be given

The advocates for more affordable health insurance at Families USA are asking the Biden administration to loosen up the Catch-22 that confronts states seeking to take advantage of the ACA's section 1332 innovation waivers.

1332 waivers enable states to propose alterations to virtually every feature of the ACA marketplace in pursuit of more affordable and effective coverage. The alternative scheme must cover at least as many people at least as comprehensively as the existing marketplace, and must do so without increasing the federal deficit. 

As currently interpreted, the deficit-neutral requirement presents a Catch-22: if the state's alternative scheme ends up costing more because more people sign up, the state is responsible for the excess costs, even if the coverage costs less (or no more) per person than the exiting ACA marketplace. 

ACA enrollment under ARPA: The view from near 100% FPL (and San Antonio)

Subscribe to xpostfactoid

The ACA's tragic coverage gap confronts poor people in the 12 states that have refused to date to enact the ACA Medicaid expansion with a cruel logical absurdity: they may earn too little to qualify for government-supported health coverage.  Adults in households with incomes below the Federal Poverty Level (100% FPL) do not qualify for subsidized coverage in the ACA marketplace.

A few weeks ago, I noted that on May 5 CMS put a modest patch on the coverage gap by rescinding a Trump era policy of demanding income verification from marketplace applicants in nonexpansion states if "trusted data sources" indicated that the applicant's income was likely below 100% FPL -- i.e., ineligible for subsidies -- and the applicant had estimated an income above that threshold. (Since HHS's computer systems can't be retooled instantly, CMS explained, the exchanges will continue to request documentation in these circumstances for some time -- but in followup communication, they will "notify those consumers that they need not provide the requested information.")

In effect, a low-income applicant can make a good faith estimate of a household income in the coming year above 100% FPL and qualify for subsidized coverage (now free through 2022, if income is below 150% FPL, thanks to the subsidy boosts in the American Rescue Plan enacted on March 11). Documentation will not be required (though awkwardly, it will be requested for some time).  If income for the year in question ultimately proves to fall below the 100% FPL threshold, there is no clawback of subsidies granted, unless the applicant's income estimate is made with "intentional or reckless disregard for the facts."* 

The opportunity for low-income applicants to estimate their way into free coverage is the sort of regulatory forbearance that inspires high moral dudgeon from conservative adversaries of the ACA. In fact, though, poor or near-poor people in nonexpansion states who get as far as applying for health coverage - many don't, as ignorance of ACA programs is pervasive -- are likelier to underestimate their income than overestimate it. 

A Wisconsin window on the ACA coverage gap in pandemic time

Subscribe to xpostfactoid

To pick up a thread from deep in the prior post...

In Wisconsin, ACA marketplace enrollment as of June 30, 2021 had increased by less than two percentage since June 2019. In the other thirteen states that had not enacted the ACA Medicaid expansion as of June 30 of this year, enrollment increased by 41% over the same period.

What's the matter (or rather, what's right) with Wisconsin?

    Enrollment in nonexpansion states, 2019-2021

     Sources: CMS, Early Effectuated Enrollment Snapshot, 2020, 2021; SEP enrollment 7/14/21; KFF
     See the prior post for an explanation of how June 2021 enrollment is estimated.

A lot of factors affect marketplace enrollment, which varies widely by state. But the most salient factor would appear to be the fact that Wisconsin has no "coverage gap." 

Obamacare enrollment in nonexpansion states is up 26% year-over-year and 41% since June 2019 (estimate)

Subscribe to xpostfactoid

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.

A huge increase in low-income ACA marketplace enrollment in nonexpansion states

Subscribe to xpostfactoid

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%.

More than half of all ACA SEP enrollment is in nonexpansion states

Subscribe to xpostfactoid

CMS announced yesterday that ACA marketplace enrollment during the emergency Special Enrollment Period (SEP) that began on February 15 had passed 2 million by June 30. That's more than triple the total enrolled in the same period of 2019, the last year unaffected by the pandemic. By that standard, the emergency SEP, coupled with the subsidy boosts in the American Rescue Plan (ARP), has produced more than a million excess off-season enrollments. Mid-year on-exchange enrollment is certainly at an all-time high.

Let's look again (as I did in June) at emergency SEP enrollment in states that as of June 30* had not  enacted the ACA Medicaid expansion. In those states, eligibility for marketplace subsidies begins at an income of 100% FPL (as opposed to 138% FPL in expansion states), and more than a third of enrollees in normal times have incomes below 150% FPL -- which, as of ARP passage in March, now qualifies them for a free benchmark silver plan with low cost-sharing. 

As in the prior SEP report on enrollment through May 31, SEP enrollment in 13 nonexpansion states (excluding Wisconsin, which has no coverage gap**) accounts for 75% of enrollment in the 36 states that use the federal exchange, HealthCare.gov. These 13 states account for more than half of SEP enrollment nationally.  SEP enrollment in these states is more than quadruple enrollment in the same period in 2019, exceeding that year's total by more than 860,000.

Democrat to voters: "Friend, this past year, we saw just how important Medicaid expansion was to hard-working..."

Subscribe to xpostfactoid

Terry McAuliffe, once and would-be future governor of Virginia, is running on the ACA Medicaid expansion (which opponent Glenn Youngkin opposed) and building on the ACA.  Here's the lead in a weekend email to supporters: 

Friend, this past year, we saw just how important Medicaid expansion was to hard-working Virginians and to folks across the country. Before COVID-19 hit, 394,000 Virginians were enrolled in Medicaid. Now? It’s over 550,000.

That’s over 150,000 Virginians who had coverage during the worst global public health crisis in recent history because of Medicaid expansion. But our work is not over.

700,000 Virginians - including 100,000 children - don't have access to health insurance. We NEED to continue to expand coverage to make sure every single Virginian has great health care.

The language there is a little sloppy -- over 550,000 Virginians (562,530 if you're keeping score at home, up 43% since March 1, 2020)  were rendered eligible for Medicaid by the ACA expansion criteria.  In total, 1.86 million people in the state are enrolled in Medicaid, up from 1.54 million on March 1, 2020, an increase of 20%.  

That safety net performance at a time of mass (if partially temporary) unemployment and mortal danger to health is something for Democrats to be proud of, especially since they scripted the moratorium on Medicaid disenrollments (in the Families First Act of March 2020) that's largely enabled the increase. They should all run on it. Remember, Republicans came within a breath of repealing the ACA's core programs, chief among them the Medicaid expansion.