Maryland ACA enrollment spotlights effects of Trump's CSR sabotage

Maryland announced late last week that its ACA marketplace enrollment for 2018 totaled 153,571, down 2.6% from 2017 -- a good result, given the shortened enrollment period, radically cut federal funding for enrollment outreach and advertising, and general confusion generated by administration sabotage.

Maryland reports, further, that African-American enrollment was up 12 percent, Hispanic enrollment up 10 percent, and enrollment in rural areas up around 10 percent. Those increases suggest that enrollment drop-off may be concentrated in the unsubsidized population, which has historically been high in wealthy Maryland -- 25% of on-exchange enrollment in 2017, compared to 16% nationwide.

That makes sense, considering that in Maryland a) premiums soared a weighted average 43.8%, according to Charles Gaba's blog, with much of the hike attributable to Trump's cutoff of CSR reimbursement, and b) Maryland insurers concentrated the added cost of CSR on on-marketplace silver plans, with cheaper silver plans available off-exchange.  Thus some unsubsidized 2017 enrollees may have been priced out by huge premium increases, and some may have moved off-exchange to find somewhat cheaper plans.

Steep as the average premium hikes were, the increase in the federal government's subsidy bill was even steeper, and that's worth looking at more closely:

Bronze and gold plan discounts in California, 2018

As I noted recently, Covered California has acted on its plan to shield marketplace enrollees from the effects of Republicans' CSR sabotage.  For 2018, a surcharge averaging 12.4% has been loaded onto silver on-exchange plans only (the only plans with which CSR is available) to cover the cost that until now has been reimbursed by the federal government.

We can now examine the effects of the surcharge, which I've done below.  The effects should theoretically be as follows (more detail here):

1. Off-exchange plan pricing should be unaffected by CSR; price differences between metal levels should remain proportionate to actuarial value at each level.
2. Enrollees with incomes under 200% of the Federal Poverty Level (FPL), for whom strong CSR is available, should be unaffected. Subsidies will rise to cover the additional premium, and silver plans will continue to offer outsized value, covering 94% (at incomes up to 150% FPL) or 87% (for incomes from 150-200% FPL) of the average user's costs.
3. Subsidized enrollees in the 200-400% FPL income range will see discounts in bronze and gold plans, since premium subsidies, which are keyed to silver plans, will rise to cover the inflated silver premium.

Let's look at how the expected bronze and gold discounts play out in some of California's 19 rating regions. Because California has standardized plan benefits at each metal level, relatively clean comparisons are possible -- though I would note that last year, relatively expensive PPOs (plans with broader provider networks) were popular in many areas.