In early 2021, the Kaiser Family Foundation published an updated analysis of the ACA coverage gap -- that is, the plight of low-income adults shut out of Medicaid in the twelve states that have refused to enact the ACA Medicaid expansion. While focused mainly on adults with income below 100% of the Federal Poverty Level -- those who qualify for no government help obtaining health insurance in nonexpansion states -- the analysis also included an estimate of the number of uninsured in the 100-138% FPL income range in each of these states.
That population, which would be eligible for Medicaid had these states enacted the expansion, is eligible for premium subsidies in the ACA marketplace. In this income range, silver plans are enhanced by Cost Sharing Reduction that raises the actuarial value of a silver plan to 94%. Until March 2021, a benchmark silver plan cost 2% of income for enrollees with income up to 138% FPL. Nonetheless, KFF estimates indicated that almost half of adults in this income range in nonexpansion states were uninsured as of the end of the 2020 Open Enrollment Period.
Enrollment in this income bracket in nonexpansion states has surged since OEP 2020, however. It* increased by 17% during OEP 2021, doubtless spurred by the pandemic and its disruptions to employment and income (including supplemental unemployment income that may have pushed many people over the 100% FPL eligibility threshold). It surged by another 24% in 2022, this time spurred in part by subsidy increases provided through 2022 by the American Rescue Plan, which made benchmark silver coverage free at this income level.
The upshot is that the uninsured population in this "upper coverage gap" (created by poor takeup of ACA coverage, not ineligibility) may have shrunk considerably since 2019. A major caveat is that more people in this income group in nonexpansion states may have needed marketplace coverage in 2021 and 2022, having lost or forgone employer-sponsored insurance.
With that caveat, below I've compared enrollment in 2020 and 2022 in the 100-138% FPL bracket in the 12 current nonexpansion states to illustrate the possible impact of the enrollment surge in those years on KFF's 2019 uninsured estimates.
The simplest way of looking at this: KFF estimated 1.8 million uninsured in this income bracket in these states as of 2019. Marketplace enrollment in this income bracket has increased by 900,000 thousand since then. While I wouldn't venture to say that the upper coverage gap has been cut in half, this comparison does give a sense of the scale and impact of the enrollment surge.
Other notes and caveats:
1. For the "Percent of potentially eligible enrolled in 2022," I added the KFF uninsured estimate and the 2020 enrollment total (enrolled as of Dec. 15, 2019) and divided 2022 enrollment by that total.
2. CMS has broken out the 100-138% FPL income category just twice, in 2016 and 2022. In other years (e.g., 2020), the nearest breakout is 100-150% FPL. To estimate the 100-138% FPL bracket in 2020, I used the percentage of 100-150% FPL enrollment that was in the narrower 100-138% FPL band in each state in 2016 (as explained in this post). That percentage for these twelve states collectively was 85.5% in 2016 and 83% in 2022.
3. These totals are as of the end of OEP, and so not all enrollments are effectuated. In past years, enrollment totals have shrunk between the end of OEP and the earliest "effectuated enrollment snapshot as of February or March by between 6% and 18%. Attrition shrank steadily during the Trump years, to 6% in 2021. It may rise this year, as a longer Open Enrollment Period and ramped-up outreach and enrollment assistance bring in more marginal enrollees. On the other hand, the increased subsidies may aid retention.
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* The enrollment increases cited in this paragraph are for the 100-150% FPL bracket, as enrollment for the narrower 100-138% FPL bracket was not provided in 2020 and 2021. The increases for the narrower category should be comparable, however.
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