Everything you always wanted to know about ACA marketplace enrollment 2018

Narrow focus curse: I've sliced 2018 ACA marketplace enrollment  so many ways I've lost track myself and too often go rooting around this blog for some half-remembered breakout. For my own sake, then, here is an index, omitting some redundant or not particularly illuminating posts.

The main takeaway for this year is pretty obvious: huge premium hikes, largely induced by Republican sabotage, sharply reduced unsubsidized enrollment while leaving subsidized enrollment relatively stable.

A second important takeaway that I've spotlighted more than once is less obvious: among the subsidized, enrollment dropped pretty sharply for those with incomes in the 100-200% FPL range; stayed more or less flat at 200-300% FPL, and rose sharply at 300-400% FPL.  A post I co-wrote with David Anderson, running in Health Affairs today, tells that story and draws conclusions about the crosswinds created by various Republican actions.

13* Ways of looking at enrollment 2018

* Okay, a few more than 13. Poetic license and all that.

National enrollment

Small enrollment shifts are not so small - 8/25/18
For example, a 1% shift in the percentage of all enrollees on hc.gov who are unsubsidized masks a 10% drop in enrollment among the unsubsidized -- exacerbated by heavy attrition in February.

GAO highlights the silver load offset to HHS sabotage - 8/24/18
The GAO report on HHS actions that depressed marketplace enrollment also shows a key effect of silver loading: average premiums at each metal level. This post matches that with shifts in metal level choice at different income levels, e.g. a massive shift out of silver at 200-400% FPL.

Silver loading vs. sabotage in non-expansion states - 8/14/18
Compares 2018 enrollment gains and losses by income group in states that refused to expand Medicaid with those recorded for healthcare.gov as a whole and in California

Unsubsidized on-exchange enrollment is also shrinking fast - 8/8/18
An unsurprising effect of massive premium hikes

Unsubsidized, but in subsidy range, in the ACA marketplace - 8/5/18
85% of enrollees via healthcare.gov were subsidized, but 90% have incomes in the 100-400% FPL range. Why the gap?

Silver loading vs. sabotage in non-expansion states

This post continues the story of how, where and to what extent silver loading offset all the factors pushing ACA marketplace enrollment down in 2018: the shortened enrollment period, massive cuts to advertising and enrollment assistance, Trump screaming the ACA is dead, huge premium spikes turbo-charged by CSR cutoff and yearlong uncertainty, etc. etc.

In previous posts I noted that silver loading, which created discounts in bronze and gold plans for subsidized buyers (see note at bottom), seems to have boosted enrollment by about 8 percentage points in the 200-400% FPL income range, both in 39 HealthCare.gov states and in California.

Enrollment losses were concentrated first and foremost among the unsubsidized, off- and on-exchange, and next among those at the lower income range of subsidy eligibility (100-200% FPL), where the CSR benefit still outweighed the bronze and gold discounts. They were partly offset at 200-400% FPL, where negligible or no CSR is available, and where in many locations, the discounts created by silver loading meant more value for less money was on offer than in previous years.

Here we'll take a look at the 18 states using HealthCare.gov that had not accepted the ACA Medicaid expansion as of 2018* (one more expansion state, Idaho, has a state-based exchange, and the enrollment breakouts we're looking at here are not available there).

ACA sabotage boomerang, type 3

Recently, I tallied the various ways that Republican sabotage of ACA programs has either backfired entirely or created means of mitigating the intended damage.

Very briefly, sabotage jacks up individual market premiums, which creates inflated federal subsidies, which can be leveraged both by individuals (via discounted bronze and gold plans) and states (via federally funded reinsurance or other innovation waiver programs). Two states, New Jersey and Vermont, have also turned effective repeal of the federal individual mandate to their advantage by creating state mandates, capturing a revenue stream while holding premiums down.

Late last week, the Washington Post's James Hohmann highlighted another form of sabotage that may also at least partially boomerang: Work requirements attached to Medicaid for "able-bodied" adults. It would be hard to find a policy more universally denounced by anyone with any professional experience or scholarly purview of Medicaid. The programs are cruel,wasteful and counterproductive; they will likely  reduce both coverage and employment. And yet...

As President Trump steps up efforts to undermine the law, from repealing the individual mandate to watering down requirements for what needs to be covered in "association health plans," the administration’s willingness to let states impose work requirements on Medicaid recipients has paradoxically given a rationale for Republicans to flip-flop on an issue where they had dug in their heels.

New Jersey takes strong action against ACA sabotage: A look-back

As Republican repeal of the ACA's individual mandate loomed last fall, potential remedies for states became self-evident, notwithstanding many political roadblocks. No one had ever challenged a state's authority to impose an individual mandate. And state reinsurance programs had already proved their worth and obtained federal funding.

New Jersey, with strong Democratic majorities in both houses of the legislature and a newly elected progressive governor, was one likely proving ground -- notwithstanding the mandate's unpopularity and the state's fiscal woes. Progressives committed to a working individual market and resumed progress expanding healthcare access were eager to see these remedies tried -- under the tight schedule imposed by insurers' June 20 deadline to file rate requests. The legislature came through, passing mandate and reinsurance bills on April 12. After a long and rather conspicuous silence, Governor Murphy signed them yesterday.

Below is a compendium of my posts and articles on this front, as well as outside efforts with BlueWaveNJ and the NJ for Health Care Coalition that I've been involved in. They address the fiscal challenges as well as the case for the bills.

Sabotage judo: States can turn individual mandate repeal to their advantage (12/14/18)
Impose a mandate and use the revenue to help fund reinsurance

How Gov. Murphy can protect NJ from Obamacare sabotage (NJ Spotlight, 1/17/18)
Specifics for New Jersey -- e.g. death spirals past

In New Jersey, ACA reinsurance or....?

Here in Jersey, progressives are urging Governor Murphy to sign two bills designed to fend off Republican sabotage of the ACA. The first would establish a state individual mandate to replace the effectively repealed federal mandate. The second would seek federal funding for a reinsurance program for the individual market for health insurance, designed to reduce premiums by 10-20%.

If the two bills are enacted and the ensuing waiver application seeking federal funding for reinsurance is approved, the two measures should reduce premiums by 20-30%, compared to where they'd be if no action is taken. For more detail, see this writeup.

Governor Murphy is likely to sign the mandate bill, but there are indications that he may seek changes to the reinsurance bill. The problem is cost.

Rough projections are that revenue from the mandate would cover a third to half of the reinsurance program's costs, while the federal government picks up half or a bit more than half. The state could be on the hook for an additional $30-40 million per year. New Jersey is in dire financial shape;  Murphy has a lot of spending priorities, and a looming fight on his hand to raise new revenue.

State Senator Joseph Vitale is confident that if the program proves to need more funding by FY 2021, when the first bill to insurers comes due, a revenue source can be developed -- probably via an assessment on insurers. Murphy might seek to get that in writing, in the bill -- as it was in an early version.  He would do so by issuing a conditional veto, after which the legislature would have to vote on an amended bill by June 7.

I found myself mulling this evening: If the bid to stand up a reinsurance program fails, how else might the mandate revenue, projected at about $90-100 million per year, be deployed to boost healthcare access in the state? One answer might be simply to return the mandate revenue to those hurt most directly by rising premiums: enrollees in the individual market who don't qualify for federal subsidies (subsidized enrollees pay a fixed percentage of income for a benchmark plan and so are not directly affected by premium hikes). These are mostly people above the income eligibility threshold, 400% of the Federal Poverty Level (FPL). They also include people who are ineligible for subsidies because of an offer of insurance from an employer.

Four ways states can leverage ACA sabotage

Sabotage of the ACA by the Trump administration and the Republican Congress will partially reverse the ACA's coverage gains, causing hardship to millions. But it differs from Republicans' failed legislative repeal in a fundamental way: The ACA's funding streams and mechanisms remain in place.

Not only can states that retain the will to make the ACA work continue to tap federal funding -- if they're willing to be creative, they can tap revenue streams created and inflated by the sabotage. Each form of sabotage has created new opportunities. There are at least four ways that states can not only fight off sabotage, but leverage funding opportunities that sabotage has created.

Halfway back to the future in the individual market for health insurance

The ACA-compliant individual market for health insurance is at a mid-point between Trump sabotage that's been executed and Trump sabotage that's threatened. At present, the market remains viable for most subsidized prospective enrollees -- and even accidentally improved for a good number of them via discounts for bronze and gold plans. It's largely dysfunctional for the unsubsidized, however, after two years of average premium hikes in excess of 20%.

The main (though by no means only) act of sabotage in 2017 was Trump's long-running threat -- executed in October -- to cut off federal reimbursement that the federal government is legally obligated to pay insurers for providing Cost Sharing Reduction (CSR) payments to qualifying enrollees. Stiffed by Trump, insurers had to boost premiums to cover the cost of CSR. That in itself accounted for nearly half of this year's 29% average premium hike, according to Charles Gaba.

The next sabotage threat is individual mandate repeal, coupled with pending administrative action to empower a non-ACA-compliant market of medically underwritten, loosely regulated plans. -- which currently do not satisfy the mandate. Those measures in combination will trigger a fresh wave of premium hikes in the ACA-compliant market by draining its risk pool. Many if not most of the 6-7 million current unsubsidized enrollees in ACA-compliant plans will probably be driven perforce into the unregulated market if this next round of sabotage is fully implemented.

We are already halfway there, I suspect.  Recently I spotlighted the choice facing a 58 year-old in Pottsville, PA who's ineligible for subsidies -- that is, with an income over $47,520 for an individual or $64,080 for a couple. For this person

The ACA is London after the Blitz

Trump administration sabotage of the ACA has done serious damage and will likely do more. Uncertainty over CSR reimbursement and enforcement of the individual mandate have themselves driven premiums up by over 20% in 2018 (Gaba's estimate) and driven many insurers out of the individual market.

Those premium hikes will probably knock several million unsubsidized buyers out of the individual market.  Weakened mandate enforcement, real or perceived, will probably reduce the numbers of people enrolled not only in the individual market but also in employer-sponsored insurance and Medicaid. An increased percentage of unsubsidized enrollees in the individual market who do stay in will probably be underinsured, pushed into bronze plans and/or overburdened by the combination of rising premiums and out-of-pocket costs. Poor-to-nonexistent outreach from HHS may result in many current marketplace enrollees failing to shop anew and so re-enrolling in a suboptimal plan. Trump's threat to issue an executive order that reportedly would empower association health plans to evade state regulation via ERISA could bleed health enrollees out of the individual market.

Red states, meanwhile, are lining up to accept HHS's invitation to propose work requirements, time limits and more frequent enrollment redeterminations on Medicaid enrollees, which will likely reduce Medicaid takeup.

It's worth keeping in mind, though, that as long as Republicans fail to pass a repeal bill or cap federal Medicaid spending, the damage thus far can be contained, and reversed if and when Democrats regain power -- or, under divided government, Republicans tire of sabotage. Maintaining the ACA's taxes (to fund benefits), the enhanced federal match rate for the Medicaid expansion (and pre-ACA match rates for the rest of Medicaid), the marketplace infrastructure and subsidy structure -- all of that would have been a January dream come true for any ACA advocate.