ACA marketplace enrollment may be up 45% in the pandemic era

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CMS announced yesterday that enrollment through December 15 in ACA marketplace plans on HealthCare.gov, the federal exchange serving 33 states, is up 18% year-over year. That’s on top of a 27% year-over-year increase in HealthCare.gov states last year.

Enrollment growth in the pandemic era has been slower in the 18 states (including D.C.) that run their own state-based exchanges (SBEs). Last year, SBE enrollment growth was about 8%, and the all-state total increase (HealthCare.gov + SBEs) was 21%. If the 18% growth rate for HealthCare.gov states holds through the end of the Open Enrollment Period, and the ratio of SBE growth to HealthCare.gov growth matches last year’s, then total enrollment growth as of the end of OEP 2023 will come in at about 13.7%.

That would peg total enrollment as of the end of OEP at about 16.5 million. Charles Gaba, who’s been tracking SBE enrollment tallies as they come in (they lag HealthCare.gov’s), projects a range of 16.4-16.9 million (plus 1.1 million in New York and Minnesota’s Basic Health Programs).

A few notes about this continued strong enrollment growth:

1. If total enrollment as of the end of OEP 2023 does reach 16.5 million, that would represent a 45% increase over enrollment as of the end of OEP 2020, the last year unaffected by the pandemic (OEP 2020 ran from Nov. 1 - Dec. 15 in 38 HealthCare.gov states, longer in some SBEs). Total enrollment was up 5% in OEP 2021, 21% in OEP 2022, and perhaps 14% this year.
   

2. Enrollment growth has plainly been turbo-charged not only by the obvious need for insurance in a pandemic but by the massive boosts to ACA premium subsidies provided by the American Rescue Plan Act, enacted in March 2021 while an emergency Special Enrollment Period was in effect. ARPA reduced the percentage of income required to pay for a benchmark silver plan at every income level, removed the income cap on subsidy eligibility (400% FPL, currently $54,360 for a single person, $111,000 for a family of four), and rendered benchmark silver coverage free at incomes up to 150 % FPL (currently $20,385/year for a single person, and $41,625 for a family of four). Enrollment increased by a net 900,000 during the emergency SEP of 2021 and those gains were consolidated and extended in OEP 2022.
   

3. Enrollment growth in the pandemic years has been concentrated in HealthCare.gov states because all states that have to date refused to enact the ACA Medicaid expansion use HealthCare.gov. In nonexpansion states, eligibility for ACA marketplaces subsidies begins at 100% FPL, as opposed to 138% FPL, the Medicaid eligibility threshold, in expansion states. Benchmark silver coverage is free up to 150% FPL, and about half of enrollees in nonexpansion states have incomes below that threshold (more than 40% would be eligible for Medicaid had these states expanded eligibility). Accordingly, enrollment in 12 nonexpansion states (including South Dakota, which will enact expansion in July 2023) increased by 31% year-over-year in OEP 2022. Enrollment in those 12 states accounted for half of all enrollment nationally. Enrollment in Florida and Texas alone accounted for 31% of national enrollment.
   

4. If enrollment growth in nonexpansion states outpaces growth in all HealthCare.gov states to the same degree this year as last, and the 18% growth in HealthCare.gov states holds through the end of OEP, enrollment in 12 nonexpansion states, at about 8.8 million, will be 75% above enrollment in those states in OEP 2020. Enrollment in those states will have increased by about 3.8 million from OEP 2020 to OEP 2023.
   

5. Enrollment in Texas this year may get a boost from the state’s implementation of strict silver loading for 2023, which has placed many gold plan premiums well below those of benchmark silver. (See point #2 in this post.) How Texas — Texas! — came to take positive action to improve affordability in its ACA — ACA! — marketplace is a story that I’ve relayed in the American Prospect.
   

6. Along with the enrollment increases during OEP in recent years, marketplace enrollment attrition, at the point of first payment and throughout the year, has been reduced in recent years. Two recent/upcoming developments (besides the improved affordability provided by the ARPA subsidy boosts) should extend that trend: First, the enactment this year of continuous enrollment for applicants with income below 150% FPL, and second, the upcoming end in April 2023 of the moratorium on Medicaid disenrollments, enacted in March 2020 as a pandemic emergency measure. CMS is pushing states to steer those Medicaid enrollees whose income now exceeds the Medicaid eligibility threshold toward the ACA marketplace, if they lack access to employer-sponsored insurance.
   

7. In OEP 2022, enrollment growth was strongest at incomes above 400% FPL, the pre-ARPA limit for subsidy eligibility. Whether that trend continues in OEP 2023 is something to watch when CMS publishes detailed statistical breakouts next spring. Whether much or even most of what remains of the off-exchange market for ACA-compliant plans migrates online is an open question.

Update, 4:50 p.m.: GetCoveredNJ, New Jersey’s SBE, just provided a Week 5 snapshot of enrollment, and it’s up 3.7% over last year’s Week 5 tally. That’s a modest increase not atypical of SBEs, but last year NJ enrollment surged 21%. As discussed here, New Jersey offers state-based "wraparound" subsidies that all but zero out premiums for benchmark silver coverage at incomes in the 150-200% FPL, and that add as much as $200/month in subsidy for family coverage for enrollees in the 250-400% FPL range.

Photo by Kampus Production