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.

Uninsurance goes upscale: The Census's Health Insurance Coverage Update for 2018

Yesterday the Census Bureau* released its health insurance estimates for 2018. The top line showed a rise in the uninsured population of 1.9 million, or 0.5% -- the first increase since the ACA's main programs launched.

Disturbingly, the number of uninsured children increased by 425,000, or 0.6%, raising children's uninsured rate to 5.5%. That spike would appear to be due mainly to a drop in Medicaid coverage, given that  Medicaid and CHIP coverage for children was down 1.2%; and the overall percentage of children with public health insurance dropped 0.8%, while the percentage of children with private health insurance ticked up 0.2%. There was also, however, a sharp spike in the uninsured rate among children in households with incomes over 400% of the Federal Poverty Level (FPL), from 1.9% in 2017 to 2.6% in 2018 -- accounting for almost half of the increase in uninsured children.

Folks at Georgetown University and the Center for Budget and Policy Priorities will probably dive  into the spike in uninsured children, as they have been doing for at least a year. Here I just want to throw some sidelights on the Census numbers generally.

1. Affluent uninsured population spikes. Notwithstanding a drop of 2 million  (0.7%) in Medicaid enrollment, the sharpest increases in the uninsured were at high incomes. At 300-399% FPL, the insured rate dropped a full percentage point, from 92.9% to 91.9%, and at over 400% FPL, the rate dropped 0.8%, from 97.3% to 96.6%. Together, these two income groups account for 55% of the population. Particularly striking, the number of uninsured at incomes over 300% FPL increased 23.8% (from 6.631 million in 2017 to 8.215 million in 2018).  The spike in uninsured children at high income levels seems congruent with this drop.

Drop in low income uninsured is partly due to drop in low income population

In 2015, I noted that Democrats had paid in political blood for devising a health reform scheme that primarily benefited people in the lower third of the national income distribution  (those with incomes below 200% of the Federal Poverty level), where more than half of the country's uninsured were concentrated pre-ACA.

Chance led me this morning to take a bird's eye view of how the income distribution of the uninsured changed from 2013 (pre-ACA) to 2017. This snapshot is based on the Census Bureau's annual September report, Health Insurance Coverage in the United States, for 2014 and 2017.

The percentage of the uninsured in the lowest income brackets has shrunk considerably. But that's in part because the percentage of the total population in those brackets has also shrunk.  In 2013, 39% of the population and 59% of the nation's uninsured were in households with incomes below $50k. In 2017, 49% of the uninsured and 34% of the total population were in households with incomes below that threshold.

Here is the breakout by income group.

Who are the "20 million" insured via the ACA?

In references to the roughly 20 million people the ACA has said to have insured, three things tend to be conflated: 1) the net increase in the insured population since ACA enactment (roughly 20 million), 2) the number insured through the ACA marketplace (10-11 million at present), and 3) the number insured through the individual market (18-20 million, about half of them subsidized).

Below, a few points aiming to clarify who's benefiting and to what degree. Teaser: don't miss my slicing of CPS data in the chart below.

1. The contributing streams to the 20 million increase in insured Americans include  a) an increase of 17 million in Medicaid enrollment since July-Sept. 2013, including nearly 12 million categorized by states as rendered newly eligible by the ACA; b) 8-9 million subsidized enrollees in the ACA marketplace, contributing to an increase in overall individual market enrollment of roughly the same size;c)  2-3 million adults under age 26 added to their parents' health plans; and 4) a possible moderate increase in enrollment in employer-sponsored plans.

A few statistical anomalies in healthcareville

Struggling with a difficult post, I just made a little list in my mind of some statistical oddities I've stumbled across in the past year or so in the wonderful world of U.S.  health insurance. Some are mysteries, some are apparent errors, and some involve frames that may give the wrong impression. In no particular order:

1)  In 2016, CBO changed the way it counts Medicaid enrollees under age 65. No, there was not a surge of 16 million unanticipated enrollments, as reported more than once. Rather, CBO started counting "dual eligibles" under age 65 in the Medicaid total, along with enrollees in various limited benefit programs.  More here.

2. Oft-quoted stat: In 2017, the ACA marketplace may have only one insurer in almost one third of U.S. counties. Less quoted: 19% of the population lives in those counties. 72% of the population lives in counties with 3-8 insurers (Kaiser). This is not to sugar-coat bad news, but the effect of recent pullbacks on people should take priority over its effect on acreage.