Is there any remaining "upper coverage gap" in nonexpansion states?

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What's left of the upper coverage gap?

For some years, the Kaiser Family Foundation (KFF) has published estimates of people in the “coverage gap” in states that have refused to enact the ACA Medicaid expansion — that is, uninsured people who would be eligible for Medicaid if the state enacted the expansion. (As of now, 10 “nonexpansion states” remain.) In some briefs, KFF has divided the estimate into two groups: uninsured below 100% FPL, who in most cases are ineligible for government-supported insurance in nonexpansion states, and uninsured in the “upper coverage gap” — those with income in the 100-138% FPL range, who are eligible for subsidized marketplace coverage.

KFF estimates of the uninsured are based on the Census Bureau’s American Community Survey, which generally lags ACA enrollment data by two years. In April 2021, I noted that marketplace enrollment at 100-138% FPL in nonexpansion states in 2020, laid beside KFF’s estimates of uninsured in that cohort as of 2019, indicated that a bit more than half of those eligible for marketplace coverage in this income bracket had enrolled in plans. In a followup post, I noted that enrollment gains in 2021 at 100-138% FPL (a 17% increase in the 12 nonexpansion states then remaining) should be making inroads on the uninsured population in the upper coverage gap.

At the time of that writing, the American Rescue Plan Act (ARPA) had just rendered benchmark silver coverage with Cost Sharing Reduction free at incomes up to 150% FPL, and an emergency Special Enrollment Period, which extended through August 15, 2021, was just gathering steam. Since then, enrollment at 100-138% FPL (85% of which is in the remaining nonexpansion states) has more than doubled, from 3.3 million as of the end of the Open Enrollment Period (OEP) for 2021 to 6.9 million in OEP 2024.

Just last month, KFF updated its estimates of the uninsured in the coverage gap, including the upper coverage gap (100-138% FPL). The estimate, again, is based on the American Community Survey and only goes through 2022. Since that point, enrollment gains the 100-138% FPL income bracket exceed — in fact, more than double — KFF’s 2022 estimate of uninsured in the bracket. Enrollment figures below are from the Marketplace Open Enrollment Period Public Use Files, 2022 and 2024.

ACA Enrollment assistance in 2024: A conversation with Shelli Quenga

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The enrollment doctor is in

Last week I caught up with Shelli Quenga of the South Carolina-based nonprofit Palmetto Project, who has been an ACA enrollment assistor and enrollment project director since the ACA marketplace’s first Open Enrollment Period (OEP) in fall 2013.

In the Obama years, the Palmetto Project was South Carolina’s chief grantee under in the federally funded Navigator enrollment assistance program. When the Trump administration gutted the program’s funding*, Palmetto Project converted its enrollment assistance program to a nonprofit brokerage in advance of OEP 2019. At that point, the program was operating on a shoestring, with five employees. Now, Quenga told me, they are up to 11 employees, with a couple of more hires planned.

After 11 years on the front lines of marketplace enrollment assistance, Quenga has a deep understanding of how people find their way to coverage through the ACA — or fail to. Her reflections shed light on the dynamic of the enrollment explosion of the pandemic years — particularly in the ten remaining states (including South Carolina) that have refused to enact the ACA Medicaid expansion. Enrollment overall is up 87% since OEP 2020, 147% in nonexpansion states, and 167% in South Carolina, from 214,040 in 2020 to 571,175 in 2024. In 2024, enrollment growth was concentrated at the lowest subsidy-eligible income levels, up 61% nationally in the 100-138% FPL bracket. In South Carolina, enrollment at 100-138% FPL almost doubled in OEP 2024, from 133,787 to 253,158.

Among the key points:

ACA Marketplace in 2024: low-income enrollment up, silver plan selection down

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CMS has published its 2024 Marketplace Open Enrollment Period Public Use Files, providing detailed breakouts of enrollment by income, metal level selection, demographics, etc.

We already knew that enrollment increased by 31% nationally this year, spurred in part by the Medicaid unwinding — that is, the resumption of Medicaid redeterminations and disenrollments after a three-year pandemic-induced moratorium. While there’s always much to explore in the PUFs, two facts jump off the page for me:

• Enrollment growth was heavily concentrated at low incomes — up 61% at 100-138% FPL and 54% in the slightly broader 100-150% FPL bracket. That’s perhaps not surprising, given that CMS announced that 2.4 million Medicaid disenrollees had enrolled in the 32 states using the federal platform, HealthCare.gov (and perhaps 2.9 million nationally, by Charles Gaba’s estimate). Year-round enrollment at incomes up to 150% FPL has likely also boosted enrollment in this bracket [added 3/23/24].

• The decline in silver plan selection at low incomes that I flagged last March has continued. That is, growing numbers of low-income enrollees are forgoing Cost Sharing Reduction, available only with silver plans. At incomes up to 200% FPL, CSR makes silver plans roughly equivalent to platinum. Since March 2021, at least two CSR-enhanced silver plans in each rating area, with an actuarial value of 94%, are available at zero premium to enrollees with income up to 150% FPL. In the 150-200% FPL bracket, the benchmark (second cheapest) silver plan costs 0-2% of income (topping out at about $45/month for a single person) and has an actuarial value of 87%. Yet silver plan selection in the 100-150% FPL bracket was just 76.4% in HealthCare.gov states, down from 84.9% in 2022 and 89.3% in 2017. In the 150-200% FPL bracket, silver crashed from 69.5% last year to 56.7% this year. It was 83.2% in 2017.

Let’s look first at enrollment growth by income.

Biden administration to ACA enrollment assistors: Please credit yourselves

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Please add my 13-digit ID

CMS is apparently working to redress the Trump administration’s attack on the effectiveness of the nonprofit enrollment assistors chartered by the ACA and partly funded by the federal government.

Earlier this week CMS sent this memo to enrollment assistors:

The memo spells out the rationale for ensuring that navigators, CACs and EAP, who have no direct financial incentive to credit themselves on marketplace enrollments they facilitate, do so anyway:

Including your assister ID will help the Centers for Medicare & Medicaid Services (CMS) to better understand the support that the assister community provides and continue to improve the consumer experience….

Understanding your reach as an assister is important to enhancing the support CMS provides you and the consumers you assist.

There is a long history behind this exhortation.