Friday, December 08, 2023

Still growing: OEP 2024 in the ACA marketplace

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CMS’s Week 5 snapshot for the 2024 Open Enrollment Period (OEP) in the ACA marketplace shows 7.3 million active enrollments (new enrollments and active re-enrollments) — a stunning 39% year-over-year increase, according to Charles Gaba’s swift compilation. The snapshot is through December 2 for 32 states using and through November 25 for 19 state-based marketplaces (SBMs). New enrollment is up 44%, and active re-enrollment is up 37%, per Gaba. (Passive auto re-enrollment is reported at different times by different exchanges, and some SBM auto re-enrollment tallies are included separately in the snapshot.)

For the year-over year comparison, Gaba has helpfully adjusted for an extra day included in the 2023 Week 5 snapshot. His breakdowns for different state groupings — states vs. SBMs, and states that have enacted the ACA Medicaid expansion — are below, in simplified format, and followed by a few observations.

    OEP Week 5: 2023 vs. 2024

Observations and speculations:

  1. While this is the third consecutive year of strong enrollment growth, still probably driven in part by the subsidy enhancements enacted in the American Rescue Plan Act (ARPA) in March 2021, this year’s growth needs to be viewed in the context of the Medicaid “unwinding” — that is the resumption in April 2023 of Medicaid “redeterminations” and disenrollments after a three-year pandemic-induced moratorium. As of August, about 800,000 of those disenrolled from Medicare had enrolled in QHPs. More broadly, CMS reported in the Week 3 snapshot, “Prior to the start of the 2024 OEP, approximately 1.5 million more people enrolled in Marketplace coverage nationwide from March to September 2023, compared to the same period in 2022.” Those new off-season enrollments have presumably swelled the pool of re-enrollees, while ongoing Medicaid disenrollments may be boosting new marketplace enrollments.

  2. The stark apparent difference in growth rates between states and SBM states, while continuing a post-pandemic trend, is somewhat skewed by a rocky debut for Virginia’s marketplace, which to this point is showing a 63% year-over-year decrease in active enrollment (from 88,405 to 32,951), though the state has also booked more than 300,000 auto re-enrollments. Discounting Virginia, the other SBMs are up 36.4% year-over-year — not wildly different from the average.

  3. One might think that the pool of Medicaid disenrollees eligible for marketplace enrollment would be larger in expansion states, since eligibility depends simply on an income threshold that many may have crossed after the rapid economic recovery from the initial pandemic shock. On the other hand, the SBM states are mostly Democrat-run and probably tend on balance to exercise more due diligence in Medicaid redeterminations than the nonexpansion states and many expansion states on The expansion states that use are more of a mixed bag politically, and their enrollment increase is closer to that of the nonexpansion states (39.7% vs. 42.8%).

  4. The SBM states are wealthier on balance. According to CMS’s Marketplace Medicaid Unwinding Report and SBM Medicaid Unwinding Report, a much lower percentage of Medicaid disenrollees who seek marketplace coverage in the SBM states end up enrolling. Only about a third of SBM applicants deemed subsidy-eligible enrolled in QHPs, for some reason, and only about 20% of those determined eligible for QHPs with or without subsidy. In states, in contrast, 71% of those deemed QHP-eligible did enroll. That is frankly a pretty baffling discrepancy. In nonexpansion states, which make up the majority of enrollment (and the majority of enrollment growth nationwide), a large percentage of marketplace applicants are eligible for free or very low-cost, high-CSR silver coverage.* On the other hand, nine SBM states offer supplemental subsidies on top of federal ACA marketplace subsidies.

    5. During the pandemic years, the nonexpansion states (a shrinking pool) have accounted for the vast bulk of marketplace enrollment growth. That’s true so far in this OEP, even though Florida and Texas, the behemoths driving enrollment growth in the post-ARPA era, are either below or right at the national average growth so far this OEP. Totals for the nonexpansion states (excluding North Carolina, which has expanded as of Dec. 1**) are below.

                  OEP Week 5: 2023 vs. 2024 - Nonexpansion states

    1. Four of the nine nonexpansion states are among the 12 states where, as Gaba notes, enrollment is more than 50% higher than the same point last year (with Alabama just below the threshold). Ten are on the federal exchange (TN, OH, WV, LA, IN, SC, AR, OK, GA, MO) and two are SBMs (DC and Rhode Island). See Gaba for a complete listing of state enrollment tallies.

      6. As I noted recently, the increased engagement of brokers in the marketplace, and brokers’ increased use of commercial Enhanced Direct Enrollment (EDE) platforms, may be facilitating enrollment growth. In 2023, more than 70% of active enrollments in states were broker-assisted. The dominant EDE, HealthSherpa, serving thousands of brokers and running a number of insurers’ direct enrollment platforms, claims as of December 4 to have executed 4 million enrollments in states, or well more than half of the 6.5 million in states tallied through December 4 (up from about 35% in 2023). It appears that more enrollments are processed through HealthSherpa than directly on — or any other exchange. To date, no SBMs enable EDE or its predecessor DE (Direct Enrollment, which required a trip through for subsidy processing), while more than 80% of broker-assisted enrollments on are via DE or EDE.

      7. Boosted by ARPA, the marketplace is approaching its intended purpose: covering most of those who lack access to other affordable insurance. It would be a real shame if the ARPA boosts were allowed to expire in 2026, as scheduled. It’s hard to see how they can be extended if Republicans retain the House or Senate, let alone the presidency.

    Postscript: Just for fun: if the ratio between the year-over-year increase in Week 5 and the YoY increase at the end of OEP this year is the same as last year (no real reason it should be - there are a lot of vagaries in the reporting), enrollment at the end of OEP for 2024 would be 20.9 million. Last year, Gaba reported the Week 5 YoY increase as 17.9%, but if he had adjusted for an extra day in OEP 2022 it would have been 21.6%, by my calculation. End-of-OEP enrollment was up 12.7%. If that ratio between Week 5 and end-of-OEP were to hold, enrollment this year would be up about 22.8% from 16,357,030 for OEP 2023.


    * In New York and Minnesota, low-income enrollees go to the states’ Basic Health Programs rather than to marketplace, and some 120,000 “unwinding” applicants have enrolled in the BHPs (vs. 181,000 in QHPs). The BHP enrollments don’t affect the reported percentages of QHP-eligibles who enroll.

    ** North Carolina will transfer marketplace enrollees with income below the 138% FPL Medicaid eligibility threshold to Medicaid.—-

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