Enrollment in the ACA marketplace increased by 21% in the Open Enrollment Period for 2022, compared to OEP 2021. The main cause was almost surely the boost to premium subsidies provided through 2022 by the American Rescue Plan Act, which reduced the percentage of income required to buy a benchmark silver plan in every income category and removed the income cap on subsidy eligibility, formerly 400% of the Federal Poverty Level (FPL).
My last post focused on the income distribution of the enrollment increases. In percentage terms, increases were concentrated at high incomes, though the raw number of new enrollees in the 100-150% FPL, by far the largest income bracket, was far higher than in higher brackets. In this post, we'll add the distribution in the twelve states that still have not enacted the ACA Medicaid expansion, where half of enrollees have incomes in the 100-150% FPL range. Those twelve states account for slightly more than half of ACA marketplace enrollment, as some 40% of their marketplace enrollees would be in Medicaid had these states enacted the expansion.
Below are the totals for 33 HealthCare.gov states, 12 current nonexpansion states (all using HealthCare.gov), 18 state-based exchanges (SBEs), and all states. A reminder (from the last post) that the far right column, which combines those who did not report income (and so are unsubsidized) and those with income outside the 100-400% FPL range (the subsidy-eligible range pre-ARPA), is relevant mainly (really only) for the SBEs, where those categories seem to have got scrambled.
Enrollment by income bracket, 2021-2022
The nonexpansion states included are as of November 2021 (unchanged as of now). As of OEP 2021, Missouri and Oklahoma also had not enacted the expansion. For other adjustments made to account for changes from 2021 to 2022 in both record-keeping and market conditions (and for differences between HealthCare.gov states and SBEs), see the prior post.
As the 12 nonexpansion states account for 71% of enrollment in the 33 HealthCare.gov states, patterns in the nonexpansion states largely shape the numbers for all of HealthCare.gov. It's perhaps noteworthy that increases in nonexpansion states were steeper than in all HealthCare.gov states in a middle income range (150-400% FPL), as well as overall, but not at incomes above 400% FPL -- which were subsidy-ineligible before this year. (Enrollment at income below 100% FPL is rolled into this category, because that's how CMS structured the brackets through 2021, but it accounts for just 1.6% of enrollment). The nonexpansion states are lower-income on average than expansion states, and so may have had proportionately smaller pools of residents above 400% FPL who lacked access to other insurance.
That said, the increase in enrollment at incomes above 400% FPL (the former cap for subsidy eligibility) is striking -- exceeding even in absolute terms the enrollment growth in the 150-200% FPL bracket in HealthCare.gov states, and coming close in the nonexpansion states. Unfortunately, in the SBEs, the totals at incomes above 400% FPL and in the "income unknown" category seem scrambled.
The table below shows enrollment changes by income bracket from 2021 to 2022 in each of the twelve current nonexpansion states.
Enrollment by income bracket, 2021-2022 -- nonexpansion states
Thanks, Andrew, for reporting the increased enrollments broken down by MAG (hopefully that's what the statisticians used) income.
ReplyDeleteMy initial guess would have had highest enrollment above 400% FPL, differing from your initial guess (prior blog), because the change in net cost of coverage can be so large in that above 400% group. (With the still-temporary "subsidy enhancements".)
The subsidy enhancements are always reported blurringly in the press with that term and little else, but the reduction in net-premium for people to 400% FPL is relatively small at something at most around 1% of income, while above the 400% FPL "subsidy cliff" it can be much, much larger--going easily from a 30% or 35% of income down to 8.5%. (Based on: it's not uncommon to have older-adult lowest-available premiums as high as $18,000 a year per person -- you can see even 50% of income with the cliff for couples for older couples just over that cliff.)
Anyway, as I am sure you have pointed out in a recent column, the subsidy cliff has a high likelihood of coming back. The removal of the cliff was for 2 years only in COVID-associated legislation. In BBB, they initially had attempted a permanent removal of the subsidy cliff, but I think it's down to 3 years in the current version, and BBB is, of course, stalled and may be gone.
Meanwhile, as a focus of yours is fixing the remaining substantial problems in the ACA, I'll bet you were excited to hear about the executive order attempt by Biden to get rid of one of the major remaining problems--the "family glitch". (I use "attempt": it's a no brainer that Republicans will challenge this in court, and it might be 10 or twenty years before it gets resolved.)
You probably saw it already, but let me mention Katie Keith's sharp, sharp, sharp reporting and analysis on that in the Health Affairs "Following the ACA blog".
It really got down to the important details, including that if an employee alone had affordable available employer coverage, but it could not be extended to the family affordably, then the employee alone had to use the employer coverage, and only the rest of the family would get the subsidy. (Along with other details around this issue, and implications for the finances of employers offering coverage, and Federal finances.)
---
With such sharp analysis in the "Following the ACA" blog, I continue to be stunned that that blog has not mentioned the existence of the Medicaid-estate-recovery on expanded Medicaid (and other non-LTSS Medicaids) for people 55+ in a pile of Medicaid expansion states. It's certainly a puzzlement that they haven't categorized it is one of the five or so major problems, that, like the "family glitch" and "subsidy cliff", needs to be fixed.
I learned the new term "gaslighting" recently, and all I can think of is that, for some unknown and cruel reason, they are trying to gaslight both you and me. I know about the issue, and consider it major, and so do you. (https://xpostfactoid.blogspot.com/2019/06/aca-medicaid-expansion-lien-on-me.html ,
https://www.njspotlightnews.org/2021/06/medicaid-premiums-subject-to-estate-recovery-after-death-catch-in-affordable-care-end-now/ .)
Why are they trying to make us feel, by completely ignoring the issue, that we are crazy? Some kind of frisson? Human nature is strange.
(I will refrain from my usual references on Medicaid estate recovery for ACA "coverage" here. They do appear on the Health Affairs linked post.)
The cost of all the subsidy enhancements in the 2020 bill is estimated at $30 billion a year.
ReplyDeleteThis is a rounding error in federal health spending. Do you know how fast Republicans have been in approving $30 billion extra for Medicare Advantage? Republicans are desperate to prevent the ACA from being a long-term success. They think they are doing the Lord's work by defeating anything like socialism.