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| zero premium is quite the adhesive |
In era where, thanks to the subsidy enhancements enacted in the American Rescue Plan Act in March 2021, almost half of all enrollees are eligible for free benchmark silver coverage, the percentage of those who select plans during OEP but never effectuate coverage (e.g., by paying a premium, if one is due) continues to drop. Of those who selected plans during the Open Enrollment Period for 2024, 97% had effectuated coverage as of February.
And in an era where, as of early 2022, prospective enrollees who report income below 150% of the Federal Poverty Level (46% of enrollees in OEP 2024) can enroll year-round, Average Monthly Enrollment as a percentage of initial enrollment during OEP continues to rise. In 2016 — the year of peak OEP enrollment before the ARPA subsidies kicked in for OEP 2022 — enrollment in December was 84.2% of enrollment as of March, the first month after OEP ended that year. In 2020, the last year before mass enrollment was enabled after OEP (thanks to a pandemic emergency Special Enrollment Period in 2021), December enrollment was 94.3% of enrollment in February the first month after OEP. In 2023, December enrollment was 113.5% of enrollment in February.
The upshot: enrollment growth in the post-ARPA era is far higher when measured in terms of Average Monthly Enrollment or Early Effectuated Enrollment as opposed to OEP plan selections. The two tables below illustrate. I’ve emphasized enrollment growth since 2016, the peak year for OEP on-exchange enrollment until 2022.
Sources: Marketplace Open Enrollment Public Use Files and Full-Year and February Effectuated Enrollment tables*, available via the 2024 Early Effectuated Enrollment Snapshot (links at FN 2).
Notes (some repeated, with editing, from my look at effectuated enrollment in 2023):
Effectuated enrollment in February 2024 is almost double the total in March 2016, that year’s peak. Average monthly enrollment in 2024 will almost surely be more than double the 2016 total.
On-exchange enrollment gains since ARPA enactment need to be considered in light of a collapse in off-exchange ACA enrollment that occurred in the wake of steep premium increases in 2017 and 2018. Off-exchange enrollment dropped from 5.1 million in Q1 2016 to 2.0 million in Q1 2019, according to Kaiser Family Foundation estimates. According to KFF estimates, total individual market enrollment in OEP 2022, a year of 21% enrollment growth, still had not surpassed total enrollment in 2015, the peak year for the individual market (though the 2015 total included 3.3 million enrollments in ACA-noncompliant plans). 2024, however, is unquestionably an individual market peak.
Rapid enrollment growth remains mainly a nonexpansion state phenomenon. Almost three quarters of all enrollment growth since 2020 — 7.3 million out of a total increase of 9.9 million — is in the ten states that had refused to enact the ACA Medicaid expansion as of the beginning of OEP 2024 (North Carolina launched its expansion in December 2024, but that does not seem to affected low-income marketplace enrollment). Enrollment growth was also concentrated at low incomes, especially in the nonexpansion states. In the ten nonexpansion states, 5.8 million enrollees in OEP 2024 reported incomes (100-138% FPL**) that would put almost all of them in Medicaid in expansion states. That’s about 28% of all marketplace enrollees.
Viewed in terms of average monthly enrollment, the perceived drop in marketplace enrollment during the Trump years all but vanishes and in fact reverses in 2020 (probably with some prompting from the pandemic, as the path to off-season enrollment was somewhat smoothed by emergency measures in 2020).
Retention improved steadily through the Trump years — probably because reduced advertising and outreach, coupled with a shortened OEP, filtered out more marginal enrollees — as did, perhaps, the zeroing out of the individual mandate penalty in 2019.
Also contributing to retention from 2018 forward: Silver loading — the pricing of the value of Cost Sharing Reduction (CSR) subsidies directly into silver plans, which began in 2018 after Trump cut off separate reimbursement of insurers for CSR in October 2017. Silver loading sharply increased the number of enrollees paying zero premium, which received a more dramatic boost from ARPA in 2021. To drop a zero-premium plan, you have to take positive action.
The Medicaid unwinding (the resumption of eligibility checks after a 3-year pandemic-induced moratorium) accounted for much of the enrollment growth in OEP 2024. According to CMS tracking, about 3.7 million marketplace enrollees as of January 2024 had been disenrolled from Medicaid. High overall retention rates as of February indicate that those transferees have not dropped marketplace coverage in large numbers.
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* Somewhat confusingly, CMS publishes two measures of “effectuated enrollment” in February of each year. The February report itself includes anyone who was enrolled at any point in February, whereas the full-year effectuated enrollment tables, which include enrollment in each month, count total member months and divide by twelve, resulting in slightly smaller totals (the difference is usually about 100,000-200,000). A small number of enrollees, e.g. newborns whose enrollment is backdated to birth, may be enrolled for part of a month, and in some states, people can terminate a plan at a date other than the end of the month. Thanks to Louise Norris for enumerating those exceptions for me.
* *Another 70,000 enrollees in nonexpansion states (and 384,000 nationally) reported incomes below 100% FPL. Legally present noncitizens subject to the federal “5-year bar” for Medicaid eligibility (and longer bars in a few states) are eligible for marketplace subsidies at incomes starting at $0.
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