WSJ editorial board: Insuring low-income "able-bodied" adults is a waste of federal money

  Note: All xpostfactoid subscriptions are now through Substack alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit xpostfactoid on Substack and sign up.

Providing ideological cover for Republicans who seek to cut hundreds of billions of dollars out of federal Medicaid funding, the Wall Street Journal editorial board would have you believe that federal Medicaid spending is out of control, that rich states get more than their fair share of federal Medicaid funding, that cuts to the projected spending growth rate under current law are not cuts, and that Medicaid isn’t much worth having anyway. That’s all false of course.

Let’s look at these nostrums one by one.

Undue spending in Medicaid growth. The WSJ editorialists write:

Medicaid spending as a share of federal outlays rose to 10% from 7% between 2007 and 2023, while the share of Social Security and Medicare remained stable.

Well yes, of course. The ACA Medicaid expansion, rendered optional by the Supreme Court in 2012, offered Medicaid eligibility to all lawfully present U.S. adults with income up to 138% of the Federal Poverty Level, excepting those subject to a federal 5-year bar on new immigrants. As of the program’s full launch in 2014, 24 states had enacted the expansion, and as of now, 40 states plus D.C. have done so. Medicaid enrollment has accordingly grown by 38% since 2013 (and had swelled even higher as of 2023, the year cited by the Journal, as a result of the pandemic-induced three-year moratorium on disenrollments. Medicaid enrollment has dropped 17% since the 2023 peak.)

Democratic states grab more than their fair share of federal largesse. We are asked to believe:

Democratic-run states receive disproportionately more federal Medicaid dollars. New York received $3,046 for each state resident in 2023 based on the most recent federal data. Federal Medicaid dollars also subsidize California ($2,167 per resident) and Illinois ($1,715) much more than Florida ($991) and Texas ($1,239).

---

On gutting/not gutting Medicaid

 Note: All xpostfactoid subscriptions are now through Substack alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit xpostfactoid on Substack and sign up.

Van Drew promises to square a circle

I have not posted for the last couple of weeks because I’ve been engaged, as co-chair of the healthcare committee of Blue Wave New Jersey, in the effort to stop the savage cuts to Medicaid written into the House Republican budget resolution that passed on a strict party line vote on Tuesday night.

New Jersey has three Republican House members: Jeff Van Drew, a lapsed Democrat (NJ-2); Chris Smith, who voted against ACA repeal in 2017 (NJ-4); and Tom Kean, who represents one of the country’s most competitive districts (NJ-7).

Below is a version of a note that went to the Blue Wave healthcare committee that I think captures a couple of key points about where we’re at in the battle to prevent the gutting of Medicaid.

The ACA's 2025, projected

Note: All xpostfactoid subscriptions are now through Substack alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit xpostfactoid on Substack and sign up.

Project 2025ifying the ACA

On February 10, KFF (f.k.a. the Kaiser Family Foundation) hosted a webinar on the fate of the ACA under Republican rule (read the transcript). Moderated by Larry Levitt, who oversees all research at KFF — probably the chief nongovernmental source of data on U.S. healthcare coverage and usage — the discussion featured Cynthia Cox, director of KFF’s ACA-related research; Sarah Lueck, VP for Health Policy at the Center on Budget and Policy Priorities; and Brian Blase, president of the Paragon Institute, a conservative think tank, and former special assistant to Trump at the White House’s National Economic Counsel.

Blase is noteworthy as an inveterate enemy of the ACA marketplace, ACA Medicaid expansion, and really Medicaid generally, which he would shrink radically, as Republicans in Congress are now proposing. His Paragon Institute has put out position papers recommending that the enhanced premium subsidies enacted in 2021 in the American Rescue Plan Act (ARPA), which are funded only through 2025, not be extended, and that the federal funding mechanism for the ACA Medicaid expansion — a 90% federal match rate (or FMAP) — be phased out over ten years, along with further cutting the FMAP for “wealthy” states. The 90% FMAP phase-out appears to be envisioned in the Republican House budget resolution released this week.

Blase provides an ideological basis for Republicans to refuse to extend the ARPA subsidies — and in so doing, wields a political cudgel against Republican reps who would prefer not to uninsure tens of thousands of their constituents by letting the enhanced subsidies expire. So what he says is worth listening to for its likely practical effect.

Blase’s case against extending the ARPA subsidy increases is based mainly on allegations of pervasive fraud in ACA applications. These allegations, as Cox and Lueck acknowledged, have a basis in truth, as agent-induced fraud increased rapidly in 2023 and 2024. But as Lueck suggested, Blase exaggerates the extent of fraud and would needlessly disenroll millions to combat it. I responded to his arguments in detail in this post and added a TLDR in this one, pasted as a noted below.

What stood out to me in the roundtable was Blase’s concessions to those aiming to salvage as much of the marketplace status quo as possible under Trump. Those concessions reflect Trump’s grudging intimations in the campaign that he was not looking to repeal the ACA, which in public perception means the ACA marketplace — though Republicans are apparently aiming again to defund the ACA Medicaid expansion, which was always the submerged core issue. (Larry Levitt kept this discussion away from Medicaid.)

Here were the noteworthy concessions, if that is the right word:

---

Thanks for reading xpostfactoid! Subscribe for free:

No abolition: While Blase wants to stand up an ACA-noncompliant market as the Trump administration did in 2018 — that is, a market of medically underwritten plans not required to cover Essential Health Benefits or provide an out-of-pocket limit — he acknowledges that eradicating the ACA marketplace is not on the table. Below, he complains about the year-round enrollment for people with income below 150% FPL implemented by the Biden administration in early 2022. In that context, he concedes (my emphasis):

If you're going to have guaranteed issue and community rating... And I think we have decided that there's a political consensus to have a market that has guaranteed issue and community rating... You need to have an open enrollment period, otherwise you're going to have severe adverse selection forces that come in and disrupt that market.

The counterargument here is that year-round enrollment is appropriate at low incomes, where people’s situations change frequently and awareness about available programs is low. Medicaid enrollment is year-round, and the income bracket in which year-round enrollment is currently available in the marketplace is capped at a level — 150% FPL — only slightly above the ACA’s Medicaid eligibility level, 138% FPL (inoperative in nonexpansion states, where most marketplace enrollment below 150% FPL occurs). Moreover, year-round enrollment at 100-150% FPL has probably had an effect opposite to adverse selection, in that much of it is driven by year-round agent/broker marketing (some of it fraudulent), which is finding people who otherwise would not have enrolled and giving them something for free with relatively little friction.

But I digress. The point worth noting here is the alleged political consensus to more or less leave the ACA marketplace standing as it was pre-ARPA — albeit probably adulterated and confused by a more robust ACA-noncompliant parallel market than the one Trump 1.0 managed to stand up.

Preserving part of ARPA: Blase voices the conservative chestnut that people who get zero-premium health coverage (e.g., 79 million Americans on Medicaid?) don’t value it. (Lueck countered by citing positive feedback from low-income enrollees, and Cox alluded to usage data showing that they are getting needed care.) Blase regards the ARPA subsidy boosts at the low end of the income spectrum as wasteful — notwithstanding (or because) the ARPA subsidy boosts drove enrollment at the 100-150% FPL income level from 3.9 million in 2021 to 9.4 million in 2024,* with most of those gains coming in states that have refused to expand Medicaid. He alleges widespread fraud in the income estimates of people whose applications put them in this income bracket, untroubled by the fact that the 6-odd million enrollees who claim income in the 100-138% FPL range in the ten states that have not expanded Medicaid would be in Medicaid if their states accepted the expansion (which he also regards as wasteful spending).

On the other hand, the smaller contingent of those who gained coverage because ARPA removed the income cap on subsidy eligibility — about 1.5 million** — do gain his sympathy and willingness to help.

Cynthia Cox recounted that the pre-ARPA subsidy cliff did hurt a significant number of modestly affluent people, and that their predicament was a political cudgel against the law (as well as a genuine failure to live up to its promise of affordable coverage for all):

So this was a really vocal group. It's a relatively small number of people, but it was a group that was arguably harmed by the Affordable Care Act. Especially if they were relatively healthy before, they might've gotten a lower premium. And then with the protections that were put in place with the ACA that required that people with pre-existing conditions be able to get coverage, premium increases were probably fairly common for this group, and they didn't get a subsidy to offset it. So this was a really sympathetic group, especially in 2016 [sic] when we were talking about repealing and replacing the Affordable Care Act. It was often that news coverage would focus in on a really sympathetic group like a family, maybe a small business owner or a farmer or an entrepreneur who didn't get coverage through their job but did have a fairly good income, but it just wasn't enough to afford full-price insurance.

Blase agrees that something should be done about the pre-ARPA subsidy cliff (my emphasis):

We should have unsubsidized options for upper/middle income people to choose. I do think if I was going to keep any portion of the enhanced subsidies, I would look at the area just above 400% of the poverty line, at least until there's some broader ACA reforms. Because in some parts of the country, premiums are really expensive and I think there would be an abrupt cut at 400% of the poverty line, and you could think about keeping a portion of those subsidies. That's not my preferred policy. My preferred policy is to eliminate the enhanced subsidies entirely and pursue regulatory changes to the ACA. But if Congress was looking to keep a portion of them, I think that is where they should focus.

So there you have it. Whether the Republican-controlled Congress does anything to improve the marketplace’s pre-ACA subsidy schedule depends on whether Republicans can pass any budget legislation without Democratic votes — and if not, how much leverage Democrats can muster and to what extent they’ll concentrate it on healthcare generally or the marketplace in particular. The other wildcard, as with anything related to the federal government now, is Musk, DOGE, Russell Vought, as the possibility of unconstitutional executive branch meddling with financing and programs currently in place or altered by the current Congress.

Revolutionary fascist interference of the DOGE variety aside, Blase, whose work is cited twice in the Project 2025 blueprint (and who appeared in this webinar sporting a 2025 sweatshirt or sweater), is a major ideological influence on Republican healthcare policy. His own blueprint for health coverage policy — leave the pre-ARPA ACA marketplace more or less in place, possibly provide some relief for some prospective enrollees with income above 400% FPL, stand up a medically-underwritten, lightly regulated parallel market, and defund the Medicaid expansion — probably represents mainstream Republican policy. It remains possible that Democrats will be able to salvage some or even all of the ARPA subsidy schedule, perhaps with a short-term extension, and — more importantly — fend off major Medicaid cuts. It’s also possible that DOGE will slash and burn the programs as established by law, or that the team assembled by RFK Jr. will catastrophically mismanage all programs. But the policy course outlined here is worth noting.

- - -

Here is my TLDR re Blase’s attack on the post-ARPA marketplace (again, from this post on Vance’s October remarks about Trump’s ACA plans :

Republican opponents of ARPA subsidy expansion are leaning heavily on a paper by Brian Blase, formerly a special assistant to Trump’s National Economic Counsel, alleging rampant overpayment of subsidies in the ACA marketplace. Blase does have a legitimate complaint in the recent explosion of unauthorized enrollment and plan-switching by unscrupulous ACA brokers. That fraud was stimulated in part by ARPA’s zeroing out of premiums for benchmark coverage for enrollees with income under 150% FPL (currently $21,870 for an individual), in combination with an administrative rule enacted in early 2022 that allows not only year-round enrollment to people below that threshold, but also a monthly Special Enrollment Period (SEP), enabling endless plan-switching. While I agree with Blase that that monthly SEP should be eliminated, and that CMS needs to act aggressively to quell broker fraud (as it appears to be doing), Blase attacks the subsidy enhancements with more dubious claims fraud in ACA enrollees’ income estimates — that is, raising or lowering income estimates to maximize subsidies (or access them at all). To those claims, I responded in detail here. The TLDR:

1) Most of the Post-ARPA enrollment increase in the ACA marketplace, as well as most of the increase at incomes where Blase alleges fraud is concentrated, is in states that have refused to enact the ACA Medicaid expansion, where most adults who estimate their incomes below 100% FPL get no government help at all. If substantial numbers of enrollees do in fact have incomes below 100% FPL, the solution is to…enact the ACA Medicaid expansion. People with income below 100% FPL should not be left with no access to affordable coverage.

2) ACA subsidies are based on an estimate of future income, which is inherently uncertain, especially for people at low incomes, who often work uncertain hours, change jobs, are self-employed, or depend on tips. Mismatches between income reported to the IRS and income projected in ACA applications probably have as much to do with inaccuracies in tax reporting as with inaccurate income projections in the ACA application. As for mismatches between income data based on ACA enrollment and data from the Census Bureau’s consumer surveys, those, like mismatches between IRS data and survey data, are perpetual.

3) Blase misreads CMS figures regarding former Medicaid enrollees, disenrolled in the post-pandemic “Medicaid unwinding,” who enrolled in the ACA marketplace in 2024. In HealthCare.gov states, according to CMS tracking, about a third of Medicaid disenrollees enrolled in the marketplace — not 70%, as Blase claims.

CMS needs to stop the broker fraud; should probably end the monthly SEP (though not year-round first-time enrollment for those with income under 150% FPL); and perhaps ramp up income checks on enrollees who may be underestimating their income (as opposed to overestimating it to get over the 100 % FPL threshold). Killing the ARPA subsidies to quell broker fraud would be throwing the baby out with the bathwater. But of course that baby — affordable insurance for those who lack access to affordable employer-sponsored health insurance — is a perpetual target for Republicans. And killing the ARPA subsidy boosts would further another core Republican goal — undermining the ACA’s protections for people with pre-existing conditions.

- - -

* In 2024, 6.9 million marketplace enrollees reported income in the 100-138% FPL range. In the broader 100-150% FPL category, 9,407,463 enrolled in 2024. The 100-138% FPL bracket was not reported in 2021, the last pre-ARPA year. From 2021 to 2024, enrollment in the 100-150% FPL bracket increased from 3.8 million to 9.4 million. That’s an increase of 5.5 million, more than half of the total increase of 9.4 million from 2021 to 2024. See the Marketplace OEP Public Use Files. To compare all-state totals at 100-150% FPL for 2021 and 2024 I excluded Idaho, which did not provide income breakouts to CMS in 2021.

** In 2024, 1.5 million on-exchange enrollees nationwide reported income above 400% FPL, which would have rendered them ineligible for subsidies pre-ARPA. Another 856,000 did not report income at all, most of whom probably knew they were ineligible for subsidies even with the post-ARPA 8.5%-of-income cap on the premium for a benchmark silver plan.

Thanks for reading xpostfactoid! Subscribe for free:

Girding for healthcare battle at Families USA's Health Action 2025

  Note: All xpostfactoid subscriptions are now through Substack alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit xpostfactoid on Substack and sign up.

The Families USA conference convened in February 2017 felt a bit like the U.K. after the Dunkirk evacuation — an all-hands-on-deck mobilization to prevent Republicans from tearing down what many of those present* had worked for decades to build (the ACA, and Medicaid as it had evolved over decades).

It was my first Health Action conference, and I was heartened by the concentrated expertise and determination of the speakers — activists and advocates, healthcare scholars, former government officials — who shared a wealth of practical knowledge as to how to move elected officials and mobilize people with stories to tell.

Though I’m not a Lord of the Rings fan, I was reminded of a scene where the fellowship accompanying Frodo and his fellow hobbits on their quest to deep-six the ring of power is assaulted by a pack of super-wolves. As the wolves circle, there’s this exchange:

My heart’s right down in my toes, Mr. Pippin,’ said Sam. ‘But we aren’t etten yet, and there are some stout folk here with us. Whatever may be in store for old Gandalf, I’ll wager it isn’t a wolf’s belly.’

The dominant chord was struck by incoming FUSA executive director Frederick Isasi: "Our action should lead to inaction" — that is, failure to pass a repeal bill. That dictum proved prophetic.

At this year’s conference, the mood was grimmer but the determination was the same, as was the focus on grassroots action. As to the legislative prospects compared to 2017, both the stakes and the odds are hard to gauge — they appear both better and worse.**

ACA marketplace enrollment growth in 2025 reflects year-round enrollment

 Note: All xpostfactoid subscriptions are now through Substack alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit xpostfactoid on Substack and sign up.

Renewals tend to increase over the years (until they don't)

Writing about the ACA marketplace at this point has an elegiac feel (as does writing about almost any not-depraved or degraded aspect of American life). As of 2026, coverage is likely to be far less affordable, out of pocket costs will rise as more enrollees fall back on bronze plans, and enrollment is likely to drop precipitously. And that’s a near-best-case scenario, barring repeal or some kind of not fully imaginable regulatory assault (or judicial assault, e.g., on free preventive care).

That said, I’ve been mulling this year’s new peak in enrollment, driven primarily by a large number of renewals. That’s fueled not only by the 31% year-over-year enrollment surge in OEP 2024 but by continuous off-season enrollment for applicants with income under 150% FPL (in place since early 2022) and by off-season enrollment from those disenrolled from Medicaid during the unwinding, which was essentially done by last summer. (New enrollment dropped from 5.2 million in OEP 2024 to 3.9 million in OEP 2025.)

All that said, I wanted to look at year-round enrollment patterns through the Trump and Biden eras. I no longer refer to the January-to-December enrollment fluctuations as a question of “retention,” as there has been so much off-season enrollment since 2022; a slight drop or even increase from January to December does not give a clear picture of how long people are remaining enrolled. On the other hand, one perhaps-obvious fact that jumps out from the table below is that in all years, almost everyone who is enrolled as of December renews, actively or passively. And in the Biden years, thanks mainly to the ARPA subsidy boosts, fall-off from the end of OEP to “early effectuated enrollment in February is minimal - -that is, the auto-re-enrolled do not drop coverage in droves when the first premium payment (often $0, thanks to ARPA) is due (retention also improved through the Trump years, as cuts to outreach and marketing and a shortened OEP apparently culled more marginal enrollees).

ACA fulfills early forecasts

Note: All xpostfactoid subscriptions are now through Substack alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit xpostfactoid on Substack and sign up.

CBO inside

As we near the end of the ACA marketplace’s Open Enrollment Period (OEP) for 2025, CMS is out with a new enrollment snapshot showing 23.6 million plan selections. As OEP has another week to go in the 32 states using HealthCare.gov, and up to 23 days more in some state-based marketplaces, Charles Gaba estimates final enrollment at 24.2 million*, up about 13% over OEP 2024 — and just about double the 12.0 million total in OEP 2021. That was the last year before the Democratic Congress and the Biden administration changed the game by radically boosting premium subsidies and expanding eligibility for them as part of the American Rescue Plan Act (ARPA), enacted in March 2021 (and effective immediately during an emergency Special Enrollment Period that had started on February 15).

The ARPA subsidy increases made benchmark silver coverage with strong Cost Sharing Reduction free to enrollees with income up to 150% FPL; removed the 400% FPL cap on subsidy eligibility; and reduced the percentage of income required for the benchmark silver plan at all income brackets in between. Enacted as a pandemic measure lasting only through 2022, the enhanced subsidies were extended through 2025 by the Inflation Reduction Act, enacted in August 2022. If the Republican Congress declines to extend the ARPA subsidy boosts, OEP 2025 will stand as the marketplace’s high-water mark, and millions will drop coverage beginning in 2026 (7.2 million according to the Urban Institute’s estimate).

I have written more than once that the ARPA subsidy boosts brought the ACA within striking distance of fulfilling the mission expressed in its name (affordable coverage for all who lack access to pre-ACA sources of health insurance) and envisioned by its drafters — and by the Congressional Budget Office, e.g., in its final projection prior to enactment, on March 20, 2010. That is almost literally true now. Enrollment in the ACA’s core programs — the Medicaid expansion and the subsidized marketplace — is quite close to the 2010 CBO ten-year projections, albeit six years late (and just shy of four years after ARPA was enacted — when, in a sense, the clock restarted).

---

Top line, the CBO in 2010 was almost dead-on as to the ACA’s long-term effect on the uninsured rate, forecasting that 92% of the nonelderly U.S. population would be insured ten years in. That wasn’t true in 2019 (pre-pandemic, pre-ARPA), but it’s close to true now. The latest quarterly estimate from the National Health Interview Survey (NHIS), for Q2 2024, pegs the uninsured rate in the under-65 population at 9.1%. In 2010 CBO forecast 23 million uninsured as of 2019; the NHIS pegs the uninsured population (all ages) at 25.3 million in Q2 2024.**

I cannot locate the March 2010 CBO report on the ACA’s likely effects (updates from 2011 forward are readily available), so I’ll have to rely on an old printout. Forgive some old scribblings in the 2015 column.

Some notes as to the forecasts for 2019:

• CBO anticipated the marketplace approaching full capacity with 23 million enrollees in 2017, its fourth year of operation, edging up to 24 million in 2018 and remaining at that level in 2019. Current enrollment is…24 million. (Add 1.8 million in the Basic Health Programs established in three states, which CBO did not anticipate — see the first note at bottom.)

• CBO projected a net increase of 16 million in Medicaid enrollment from 2010 to 2019. There are a couple of ways to assess this projection. First, as of September 2019, total Medicaid enrollment was up 15.1 million from July-September 2013, the pre-ACA comparison point used by KFF.

• Viewed another way, the total number of Medicaid enrollees rendered “newly eligible” by ACA expansion criteria (that is, adults with income up to 138% FPL who would not have been eligible by other criteria) was 16.6 million*** in June 2024 — the last month for which numbers are available. By that point, the “Medicaid unwinding” — resumption of disenrollments in May 2024 after a three-year pandemic-induced moratorium — was mostly over.

• While getting the top line for increased Medicaid enrollment more or less right, CBO actually underestimated the ACA’s effects on Medicaid enrollment, as it expected the ACA expansion to be in effect in every state. In June 2012, the Supreme Court rendered the expansion optional for states, and initially only 24 enacted it. As of December 2019, 34 states had enacted the expansion; as of now, ten states, including Florida and Texas, still have not.

• The persistence of “nonexpansion states” has inflated marketplace enrollment. In the ten remaining nonexpansion states, 5.8 million marketplace enrollees reported income in the 100-138% FPL range, which would have placed them in Medicaid had all states enacted the expansion.

• In light of the points above, based on what it knew/assumed in 2010, CBO overestimated marketplace enrollment and underestimated Medicaid expansion (as about 6 million marketplace enrollees in nonexpansion states “ought” to be in Medicaid). Those misses more or less cancelled each other out as to the top line.

• Medicaid enrollment increased by more than 20 million during the three-year moratorium on involuntary disenrollments enacted in March 2020 as part of the Families First Act, a pandemic relief bill. The “unwinding” — resumption of redeterminations and disenrollments — that began in spring 2023 was clumsy and cruel in many states, and too many children lost coverage. When the dust settled, however, enrollment was still 7.7 million higher in September 2024 than in March 2020, the eve of the pandemic, and the uninsurance rate may prove not to have risen. After a year-plus of unwinding, enrollment among those rendered eligible by ACA expansion criteria was up was 5.4 million higher in June 2024 than on the eve of the pandemic in March 2020.

• CBO forecast a net drop in employer-sponsored insurance (ESI) of just 3 million over ten years. According the KFF’s annual survey based estimates, enrollment in employer-sponsored insurance was 3 million higher in 2010 (estimated at 157 million) than in 2024 (154 million). The labor force did increase by about 4.4 million from 2019 to 2024, perhaps suggesting a slight further shrinkage in ESI.

• CBO also forecast a drop of 5 million from 2010 to 2019 in off-exchange “nongroup” insurance combined with “other” insurance — an opaque catch-all category that includes disability Medicare (about 7 million at present), student health plans, care at correctional facilities, and some other odds and ends. The drop was forecast to occur chiefly in off-exchange nongroup enrollment, and that drop was probably steeper than forecast, driven by a) a sharp rise in unsubsidized premiums in 2017-18, b) a steady fade-out of pre-ACA “grandfathered” and “grandmothered” (don’t ask…) plans, and c) by ARPA’s removal of the income cap on subsidies, which prompted a lot of new enrollment in the 400-600% FPL range. CBO probably underestimated the drop in off-exchange nongroup enrollment. In a 2019 brief, KFF estimated nongroup enrollment in 2011 (pre-ACA) at 10 million. By the first quarter of 2015, per KFF, off-exchange nongroup enrollment in ACA-compliant and noncompliant plans combined had dropped only modestly to 8.8 million, but after steep premium increases in 2017-2018 it plummeted to an estimated 3.3 million by Q1 2019. CBO estimates from June 2024 peg nongroup coverage bought outside the marketplace at a similar 3.1 million in 2024. That looks like a drop of about 7 million in off-exchange nongroup enrollment from the pre-ACA period to 2019 and beyond — perhaps 2 million more than forecast, though a lot of moving parts are involved.

It may seem somewhat dicey to compare 2025 totals to CBO’s 2010 projections for 2019. But I believe the comparison is instructive. The 2010 10-year forecast encompassed just six years of operation of the ACA’s core programs, which kicked off in January 2014 (though a few states started the Medicaid expansion early). Marketplace and Medicaid enrollment stalled, and in fact went into modest reverse, during the Trump years, until the pandemic struck. The ARPA subsidy enhancements, which have been in effect through four OEPs (2022-2025), represented a new beginning — and the premise here is that the enhanced subsidies enabled the marketplace to fulfill the function envisioned at the level envisioned.

ARPA made that fulfillment possible. In late 2009, as the ACA was writhing through multiple iterations in the Senate, it was plain to progressive advocates that the emerging subsidy schedule was inadequate to the marketplace’s purpose. In his 2011 book about the battle to pass the ACA, Richard Kirsch, national campaign manager from 2008-12 for Health Care for America Now (HCAN), an umbrella group formed by unions and progressive nonprofits to advocate for universal health care, took the inadequacy of the subsidies as a given:

In the President’s September address to Congress, the President not only made a concession on the public option. He also said, “the plan I’m proposing will cost around $900 billion over ten years.” Yet $900 billion was not enough money to make health care truly affordable to the uninsured. Why did the President make another, preemptive concession to the bill’s opponents, one that would significantly damage his core goal? An article co-authored by Robert Pear and The New York Times White House correspondent Jackie Calmes summarized the impact nicely: “The number suggests a political and fiscal calculation to avoid the sticker shock of the trillion-dollar threshold. But it probably means that Mr. Obama could fall short of his goal of providing universal coverage for all Americans because the lower cost may force lawmakers to reduce the subsidies needed to help more uninsured individuals and small businesses seeking coverage for employees.”...

While the marketplace roughly met enrollment goals in its launch year, 2014, and enrollment increased substantially in 2015, CMS officials in the later Obama years knew that enrollment would not grow in line with CBO projections — and starting in OEP 2018, team Trump took steps to ensure that enrollment would not grow (e.g., gutting funding for enrollment assistance and outreach, shortening the OEP, and standing up an alternative market of ACA-noncompliant plans). Average monthly enrollment reached a peak in 2016 that would not be passed until the pandemic and resulting job layoffs stimulated off-season enrollment in 2020 (as highlighted in the Average Monthly Enrollment column below). In 2021, ARPA took over, and the rest is the history we’ve been examining.

Sources: Marketplace Open Enrollment Public Use Files and Full-Year and February Effectuated Enrollment tables, available via the 2024 Early Effectuated Enrollment Snapshot.

None of this is to suggest that the marketplace is an unproblematic program (and wait till team Trump 2.0 gets hold of it). I personally think that a market of private plans offered mostly by for-profit insurers paying modified commercial rates to providers and pushed by competition toward very narrow provider networks is a suboptimal way to offer health coverage to those who lack access to other sources of insurance. Out-of-pocket costs in the marketplace are way too high; networks are too narrow; and the proliferation of plan choices in each market, numbering over 100 on average in 2024, is nonproductive and bewildering. All that said, coverage is currently available and affordable to most of those who need it. That wasn’t true until ARPA, and it’s a BFD. It very likely won’t be true in 2026 or any time soon.

- - -

* Another 1.8 million people are enrolled in the Basic Health Programs offered in lieu of the ACA marketplace to low-income enrollees by New York, Minnesota and Oregon (1.6 million of them in New York*). BHPs, an alternative provided to states by the ACA statute, are standardized, Medicaid-like plans with low out-of-pocket costs. New York’s Essential Plan is technically no longer a BHP, as the state extended eligibility to enrollees with income up to 250% FPL in 2024. By statue, BHPs can only serve enrollees with income up to 200% FPL. New York reorganized the Essential Plan, preserving its federal funding, via an ACA Section 1332 “innovation waiver.”

** Since 2019, the population has grown by about 9.3 million, suggesting that if CBO’s estimate for that year had been on target and remained stable until now, another 760,000 people would be uninsured. So the modest gap between the CBO 2010 estimate and the current NHIS estimate of the absolute number of uninsured is roughly in line with the percentage gap.

*** CMS offers two measures of ACA expansion enrollment in Medicaid: those rendered eligible by ACA criteria (“Group VIII”), and those rendered newly eligible by those criteria. The distinction stems from a handful of states independently extending Medicaid eligibility to all adults with income up to a threshold of 100% FPL or higher; in those states, a number of Group VIII enrollees would presumably remain eligible if there were no ACA expansion. In June 2024, there were 20.9 million Group VIII enrollees, 16.7 million of them “newly eligible.”

- - -

Non sequitur: some writing from me in a different mode, for kids.

Thanks for reading xpostfactoid! Subscribe for free: