The "upper coverage gap" in nonexpansion states has likely shrunk dramatically since 2019

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In early 2021, the Kaiser Family Foundation published an updated analysis of the ACA coverage gap -- that is, the plight of low-income adults shut out of Medicaid in the twelve states that have refused to enact the ACA Medicaid expansion. While focused mainly on adults with income below 100% of the Federal Poverty Level -- those who qualify for no government help obtaining health insurance in nonexpansion states -- the analysis also included an estimate of the number of uninsured in the 100-138% FPL income range in each of these states. 

That population, which would be eligible for Medicaid had these states enacted the expansion, is eligible for premium subsidies in the ACA marketplace. In this income range, silver plans are enhanced by Cost Sharing Reduction that raises the actuarial value of a silver plan to 94%. Until March 2021, a benchmark silver plan cost 2% of income for enrollees with income up to 138% FPL. Nonetheless, KFF estimates indicated that almost half of adults in this income range in nonexpansion states were uninsured as of the end of the 2020 Open Enrollment Period.

Enrollment in this income bracket in nonexpansion states has surged since OEP 2020, however. It* increased by 17% during OEP 2021, doubtless spurred by the pandemic and its disruptions to employment and income (including supplemental unemployment income that may have pushed many people over the 100% FPL eligibility threshold).  It surged by another 24% in 2022, this time spurred in part by subsidy increases provided through 2022 by the American Rescue Plan, which made benchmark silver coverage free at this income level.

At healthinsurance.org: Closeup of the ACA enrollment surge of 2021-2022

At healthinsurance.org, I have a post up this morning reviewing the surge in ACA marketplace enrollment  triggered by the pandemic and further spurred by the major boost to premium subsidies provided through 2022 in  the American Rescue Plan Act enacted last March.  

Long story short: from mid-December 2019 to mid-December 2021, plan selections during the annual Open Enrollment Period increased by 29% in the 33 states currently using HealthCare.gov, and most likely by about 25% for all states (final enrollment figures for the OEP are usually released in March). 

• Two thirds of the enrollment gains are in states that have refused to enact the ACA Medicaid expansion.
• Some new enrollees in those states may have climbed over the 100% FPL minimum income threshold for ACA subsidy eligibility. 
• Many new enrollees are getting free silver plans with strong Cost Sharing Reduction 
• Enrollment increases in the current OEP build on and extend the gains during the emergency Special Enrollment Period that ran from Feb. 15 through August 15 in HealthCare.gov states.
• The strong enrollment gains should compel Democrats to extend the ARPA subsidy boosts, which expire after this year.

I hope you'll give it a read.

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The ACA today: A mid-pandemic assessment

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High-CSR coverage in Nebraska (top) vs. unsubsidized coverage in Alaska (bottom)

Enrollment in ACA marketplace plans totaled 12.7 million at the end of Open Enrollment 2016 and 11.4 million at the end of OE 2020.  Enrollment as of the end of OE has shrunk in every year since the 2016 peak.

Those top-line fact tend to shape basic perceptions of how the marketplace has fared. But in itself the top line is almost meaningless. The marketplace, and the U.S. healthcare system more generally, have undergone an array of changes, some of which mitigate the impression of modest, steady erosion, and some of which reinforce or even intensify it. Among the OTOHs:

• Collapse in unsubsidized enrollment.  Enrollment in ACA-compliant health insurance plans by people who did not qualify for ACA premium subsidies stood at 6.7 million in the first quarter of 2016 and at 3.4 million in Q1 2019. * Huge premium increases in 2017 (triggered by a genuine market correction) and 2018 (in response to Republican attempts to repeal the ACA and sabotage the marketplace) appear to have driven half of unsubsidized enrollees out. The ACA's failure to provide affordable insurance to a large percentage of those who don't qualify for subsidies stands out as one of its core failures -- offset though it may be by the law's provision of subsidized insurance (mostly Medicaid) to some 20 million people who would otherwise have remained uninsured.

Fewer Americans qualify for ACA marketplace subsidies

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Regardless of whether ACA marketplace enrollment for 2020 is lagging 2019 totals, one persistent marketplace headwind that should get more attention is the long economic recovery. In an article by Bloomberg's Sara Hansard, Andrew Strohman of the American Action Forum puts one finger to this wind:

Unemployment is now about 3.6%, compared with 4% in January. “You could see some more people taking up employer-sponsored insurance rather than enrolling in the individual market,” Strohman said.

Regardless of whether more people are in jobs that offer affordable insurance, the population with incomes in ACA subsidy range (100-400% of the Federal Poverty Level in states that have refused the Medicaid expansion, 138-400% FPL in states that have implemented it) has shrunk since the ACA marketplace launched in 2014. At the same time, the population with incomes above 400% FPL (and so ineligible for ACA subsidies) has swelled.

Why 2019 ACA enrollment drops were concentrated in Medicaid expansion states on HealthCare.gov, Take 4

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In December and January, I took several whacks at explaining why 2019 enrollment losses in the 39 HealthCare.gov states were concentrated in the states that had expanded Medicaid. In those 21 states, plan selections as of the end of Open Enrollment were down 7% from 2018, compared to a 1% drop in 16 states that have refused to expand Medicaid. (I excluded Virginia and Maine, which expanded Medicaid in 2019, affecting enrollment options and results.)

First hypothesis was that the heavy concentration of enrollees in non-expansion states with incomes that would have qualified them for Medicaid in expansion states is especially "sticky." People in this income group (100-138% of the Federal Poverty Level) pay just 2% of income for a benchmark silver plan that comes with the highest level of Cost Sharing Reduction (CSR), raising the actuarial value of a silver plan to 94%, which usually translates to a deductible in the $0-500 range.  About a third of enrollees in nonexpansion states are in this income category. While about 15% of enrollees in expansion states have incomes in the 138-150% FPL range, which qualifies them for the 94% AV silver, they pay 3-4% of income for the benchmark.

Second hypothesis was that silver loading effects are stronger in nonexpansion states, because all those low income enrollees raise the average actuarial value of silver plans (which varies with income). In Florida, the blended AV of all silver plan enrollees is 91.5% in 2019.  (If you're unfamiliar with silver loading, see the note at bottom.)

Recently a third possible factor occurred to me: expansion states have a higher percentage of enrollees with incomes too high to qualify for subsidies, and enrollment losses among the unsubsidized were much steeper in the market as a whole than among the subsidized. This factor did play a role, but it was partly offset by the fact that in this category losses were steeper in nonexpansion states. The higher concentration of unsubsidized enrollees in expansion states cancelled out that advantage, however, so that losses in unsubsidized enrollment took basically equal bites out of total enrollment in both groups.

Surprise! ACA marketplace sabotage hit the most vulnerable hard

I fear I buried the lead somewhat in yesterday's look at how ACA enrollment losses were distributed among income groups in states that refused the ACA Medicaid expansion.

The distribution in the 18 nonexpansion states that use HealthCare.gov looked a lot like the distribution in all 39 HealthCare.gov states -- not surprising, since 69% of HealthCare.gov enrollees are concentrated in those states -- a fact kind of astonishing in itself. But enrollment is inflated in nonexpansion states because, thanks to a lucky ACA drafting error, eligibility for subsidies in those states begins at 100% of the Federal Poverty Level (FPL), whereas in expansion states it begins at 138% FPL. Those below that threshold in expansion states are eligible for Medicaid.

As I did note in the prior post, fully 36%* of enrollees in nonexpansion states, about 2.2 million as of the end of Open Enrollment, have incomes that would qualify them for Medicaid if their states accepted the expansion (as Virginia has for 2019, and as Maine has, though still blocked by Governor LePage's obstruction). Within that population, or rather, within the somewhat wider 100-150% FPL band broken out by CMS, enrollment dropped 6% in those states in 2018. That's a loss mainly among people who should be in Medicaid, and who are likely to be uninsured if they pass up marketplace enrollment, and for whom the marketplace is a relatively affordable deal -- premiums capped at 2% of income for CSR-enhanced plans with a 94% actuarial value. (Ironically, the Medicaid work requirements imposed by some expansion states will likely uninsure more people than the cuts in enrollment assistance and outreach in the marketplace.)

More broadly, the relatively modest top line of ACA on-exchange enrollment loss in 2018 -- about 4% -- shouldn't blind us to the fact that the loss was close to double that among people with incomes in the 100-200% FPL range (7.5% in HealthCare.gov as a whole). For that population, the core marketplace offering hasn't changed much, although fixed actuarial values mean a bit more out-of-pocket expense every year, and reduced competition may reduce quality of choice in many markets.

No, CMS, ACA marketplace enrollment isn't up this year, and doesn't justify navigator funding cuts

To justify gutting funding for the navigators who help low income people enroll in health insurance subsidized by the ACA (Medicaid as well as marketplace), CMS is turning a bogus talking point it concocted last year inside out. Here's the current claim, as reported by KHN's Phil Galewitz:

CMS also notes that after last year’s navigator funding was reduced, the overall enrollment in Obamacare plans increased slightly (when counting people who paid their first month’s premiums) to 10.6 million people.

Comparing 2017 and 2018 totals at the end of open enrollment  (before many enrollees have paid their first premium), total ACA marketplace enrollment was down 4% this year. CMS's comparison above uses the totals from the "effectuated enrollment snapshots" from 2017 and 2018, which tracked how many people were enrolled (and had paid their first premiums) as of February in each year. The reported total at that point was 10.3 million in 2017, vs. 10.6 million this year.

As Charles Gaba pointed out last year (and revisits here), however, the 2017 "snapshot" exaggerated early attrition by failing to take into account the fact that those who enrolled between 1/15 and 1/31 (the final day of OE in 2017) did not have payments due until March 1.  There were 539,352* enrollees in that time frame.  None of them could effectuated their coverage for February, which is the population counted in the "snapshot." If those enrollees effectuated coverage at the same rate as enrollees before 1/15 (88.5%), there were 10.8 million who had effectuated or would soon effectuate as of the time of CMS's tally. That total outstrips this year's by 2% .**

Christmas for ACA advocates

Healthcare Twitter was on edge today, as final open enrollment figures for HealthCare.gov were running a day late:

Maybe no one will notice how good the numbers are if they’re dumped on the Friday before Christmas...

— Lori Lodes (@loril) December 21, 2017

That triggered a bout of galloping Twitter procrastination on my part:

Twas the Friday before Christmas
and atop CMS
a late enrollment surge
was causing distress.

MEWAs were hung
on the chimney with care,
and Santa'd made the mandate
vanish in thin air.

And Seema in her kerchief,
and Price in his cap,
had worked to bend enrollment
until it would snap.

When all of a sudden I heard such a clatter
I sprang to my screen to see what was the matter.

Could the ACA help the Democrats take Florida?

The latest battleground state polls show Trump trailing Clinton by a narrow margin in Florida, a must-win state for him. One factor tilting the Florida field against Trump is surging voter registration among Latinos.  As flagged by Greg Sargent, Politico's Marc Caputo reports:

Since the 2012 presidential election, Florida’s voter rolls have grown by 436,000 — and only 24 percent of that increase is from non-Hispanic white voters while non-whites grew by 76 percent, according to new voter registration numbers released in advance of the Aug. 30 primary.

The number of Hispanic voters leaped by 242,000, which was 55 percent of the increase. Latinos are now 15.4 percent of the voter rolls, up from 13.9 percent overall in 2012, when President Barack Obama narrowly carried Florida thanks to the outsized backing of minority voters.

Recent Florida polls show Trump is losing the Hispanic vote by historic margins to Hillary Clinton after the Republican’s incendiary comments about illegal immigrants, which offended a broad array of Latino leaders, including many in his own party.

Latino voters have no shortage of reasons to reject Trump.  But what about positive motives to come out for Clinton and the Democrats generally? The Affordable Care Act -- generally a political loser for Democrats to date -- could be a factor. Latinos in particular, and minorities generally, have benefited hugely from the ACA in Florida. Here are the salient enrollment facts:

Fun with Kaiser!

The Kaiser Family Foundation today published its updated state-by-state estimate of "Percent of Potential Marketplace Population Who Have Selected a Marketplace Plan."   Kaiser's Larry Levitt tweeted thusly about Florida, the state with the highest marketplace enrollment:

Two-thirds of potential ACA enrollees in Florida have now signed up for health insurance. Top state in the country.https://t.co/bsKI2e1jdl

— Larry Levitt (@larry_levitt) March 15, 2016

Two thirds is very high indeed, since Kaiser's "potential population" includes those who earn too much to qualify for subsidies, and most of them buy their coverage off-exchange. So I went back to Kaiser's last estimate of each state's potential subsidy-eligible marketplace population and compared the estimate for Florida to the number of 2016 Florida enrollees (as of the end of open enrollment) who obtained premium subsidies. Lo, the results:

Potentially subsidy-eligible:                          1,556,000 (Kaiser, Sept. 30, 2015)
Enrolled with premium subsidy for 2016*:   1,585,965   (HHS final enrollment report, 2016)
Percent of potentially subsidy-eligible pop:  102%

Yup -- more Floridians are enrolled with subsidies, or were as of the end of open enrollment on Feb. 1, than Kaiser estimated to be eligible for subsidies last fall. That's amusing. Let's keep in mind:

So, ACA marketplace, how're you doin so far? [Updated 10/14]

[Update, 10/14/15: This week Kaiser estimated that about 7.1 million uninsured people are currently eligible for private plan subsidies in the ACA marketplace. As of June, the marketplace had 8.3 million active subsidized enrollees. Thus the marketplace has reached about 54% capacity among the subsidized, if Kaiser's estimate of the uninsured population is on point. The Kaiser estimate, like a recent HHS estimate of the 2016 target market, indicates that CBO's projections of what will constitute full marketplace capacity may be too high. ]
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A dispiriting backdrop for those assessing the progress of the ACA private plan marketplace is the Kaiser Family Foundation's estimate that state marketplaces have enrolled just 35%  of the "potential marketplace population." 28 million are eligible; 9.9 million have enrolled.

That stat is easy to misinterpret, though, in that the "potential eligible population" encompasses those who earn too much to qualify for subsidies -- including those who buy plans off-exchange. Taking off-exchange buyers into account*, probably about 17 million of Kaiser's 28 million "potential" enrollees are currently insured in the individual market.

Subtracting about 2.5 million who are in "grandfathered" or "grandmothered" pre-ACA plans, perhaps 14.5 million are in the unified risk pools that insurers who participate in the state marketplaces must establish for all their customers in each state who are enrolled in ACA-compliant plans.

Spotlight on the subsidy-eligible

What about the percentage of potentially subsidizable marketplace customers reached thus far? They're the real target market of the marketplaces. If you earn too much to qualify for ACA subsidies, there's little reason** to buy your plan via an exchange.