High auto re-enrollment rates in the SBMs, revisited

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Sometimes, you can do worse

My last post flagged dramatically different rates of “active” health plan renewal and autorenewal in the 33 states using the federal ACA marketplace, Healthcare.gov, compared to the 18 states (including D.C.) that run their own marketplaces. This post take a second run at whether the high autorenewal rates in the state-based marketplaces (SBMs) are problematic.

In HealthCare.gov (the “FFM,” or federally facilitated marketplace), 72% of renewals in the Open Enrollment Period 2023 were active, meaning the enrollee logged into the marketplace, updated their personal information, and affirmatively chose either to remain in last year’s plan or choose a new one. In the SBMs, just 28% of renewals were active; 72% of returning consumers were auto re-enrolled.

Auto re-enrollment can be dangerous, because 1) enrollees’ personal circumstances that affect subsidies — their income and the family members seeking coverage in the exchange — may change; 2) an enrollee’s current plan’s premium may rise in the coming year; and 3) most unpredictably, the benchmark (second cheapest silver) plan against which subsidies are set can change. If the coming year’s benchmark plan has a lower premium than the current’ year’s, subsidies shrink, since enrollees pay a fixed percentage of income for the benchmark plan. If the enrollee’s premium rises and the benchmark falls, it’s a double whammy.

I therefore presented high auto re-enrollment rates as a troubling feature of the SBMs, and maybe in some cases they are. But there are also differences in SBM and FFM practice that may make auto re-enrollment more viable for more enrollees in the SBMs.

Enrollees get better information earlier in at least some SBMs

Most strikingly, independent health insurance broker Sheron Sidbury, who serves clients both in Maryland, which runs an SBM, and Virginia, which uses HealthCare.gov, explained in a lengthy Twitter exchange that in Maryland, plans and prices are posted on October 1, well in advance of the Nov. 1 kickoff of Open Enrollment. In Maryland, Sidbury explains:

Do the ACA's state-based marketplaces have an auto re-enrollment problem?

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Enrollment should be active

It has been clear since plan offerings were posted for the ACA marketplace’s second Open Enrollment Period (OEP) in fall 2014 that “auto re-enrollment” can be dangerous for enrollees.

If marketplace enrollees take no action during OEP — declining to log on and update their income and other information relevant to subsidy eligibility and subsidy size, and review available plans — HealthCare.gov or the relevant state-based marketplace will auto-enroll them in their prior year plans, tapping the IRS and other data sources to update income and other personal information. If that plan is no longer offered, the marketplace will “crosswalk” the enrollee into the nearest equivalent, e.g., a plan by the same insurer in the same metal level. If the marketplace determines that the enrollee is no longer subsidy eligible, it will enroll her with no subsidy, exposing her to hundreds of dollars per month in premiums (one month, if she fails to pay any premium in the new plan year). Disenrollment occurs only if the person logs on and initiates it — or fails to pay the monthly premium when the new plan year begins.

Even when the enrollee’s income and family composition are essentially unchanged, remaining in last year’s plan (or a substitute into which one is crosswalked) without examining this year’s options can lead to major new expense. The plan’s premium may rise significantly. Worse, if another insurer (often a new entrant into the local market) undersells last year’s benchmark plan — the second cheapest plan, against which subsides are set — subsidies may shrink, hitting an enrollee who stays in a plan with a rising premium with a double whammy. The media was full of such stories in the fall of 2014. I told one myself, about a family of 3 in Philadelphia whose premium for a silver plan would have gone from $0 to $196 per month if a navigator hadn’t provided guidance.

The problem is not new, and it hasn’t gotten any better. In fact it’s gotten worse, as narrow-network HMO plans have become prevalent at the lowest price points, and cut-rate new entrants sometime render plans with more robust networks more expensive.. Another aspect of the problem is also not new, but when when it was brought to my attention this week it rather shocked me, and it may have major policy implications.

ACA marketplace enrollment 2021-2023: Where the growth is and isn't

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The Open Enrollment Period for the ACA marketplace in 2023 was the second OEP in which the enhanced premium subsidies created by the American Rescue Plan Act (ARPA) in March 2021 were in effect. The table below shows enrollment patterns at different income levels and state groupings in what we can now call the post-ARPA era (extended through 2025 by the Inflation Reduction Act of 2022).

ARPA rendered benchmark silver coverage free at incomes up to 150% of the Federal Poverty Level; removed the previous 400% FPL income cap on subsidy eligibility, capping benchmark silver premiums at 8.5% of income above that threshold; and reduced the percentage of income required to buy a benchmark silver plan at income levels in between.

A data note before diving in: In the 18 state-based exchanges (SBEs), the data for enrollment at incomes above 400% FPL appears anomalous and probably erroneous, at least in 2022, as discussed at bottom. The far right column, which combines “income unknown” and reported incomes over 400% FPL (as well as income under 100% FPL, which was grouped with income above 400% FPL as “other” in CMS’s 2021 reporting) may give some idea of enrollment patterns at high incomes in the SBEs. Enrollment at income under 100% FPL, included by necessity, shouldn’t change much: it barely changed from 2022 to 2023, accounts for 1.4% of total enrollment and just shy of 10% of enrollment in the “<100%/>400% FPL/unknown category.”

Some takeaways from the data below:

The "upper coverage gap" in nonexpansion states has shrunk dramatically

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It has been gratifying if frustrating to watch the number of states that have refused to enact the ACA Medicaid expansion (after the Supreme Court rendered the expansion optional to states in 2012) dwindle from 26 in 2014 (when the ACA’s core coverage programs launched) to 10 today.*

Those ten remaining nonexpansion states include Texas and Florida — two population behemoths that between them account for more than 60% of the 1.9 million uninsured people estimated by the Kaiser Family Foundation (KFF) to be in the “coverage gap” — eligible neither for Medicaid (available in expansion states to adults with income up to 138% of the Federal Poverty Level) nor for subsidized marketplace coverage (for which eligibility begins at a minimum income of 100% FPL in nonexpansion states). The arc of Medicaid expansion history may be bending toward justice, but for the poor uninsured it’s far too long.

The American Rescue Plan Act (ARPA) included an enticement to nonexpansion states to enact the expansion — a temporary but lucrative increase in the federal share of Medicaid costs for nonexpansion enrollees in any state that enacts the expansion. So far, only North Carolina has (provisionally) taken advantage of that incentive.

The lingering coverage gap, in which nearly two million uninsured adults with income below the poverty line remain mired with no federal help toward health coverage, has led some advocates to resurface an old proposal: Allow states to expand Medicaid eligibility only to incomes up to 100% FPL, rather than the statutory 138% FPL threshold now in effect in 38 states (with two more states, South Dakota and North Carolina, slated to join within the year). Such an expansion would be cheaper for states, since the federal government funds 100% of marketplace premium subsidies, versus a mere 90% of costs for Medicaid expansion enrollees.