The ACA as it should have been -- sort of, for a while at least

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Strictly speaking, by my my lights, "the ACA as it should have been" would be "Medicare for all who want it": a public plan paying Medicare rates to providers, accepted by all providers who accept Medicare, with competing private plans paying similar rates to providers and probably offering somewhat more generous coverage as a tradeoff for limitations in provider choice. These plans would be available to all, including those with access to employer-sponsored insurance. Oh, and add an OOP cap -- a cap on annual out-of-pocket costs -- to the public plan -- as we should do for traditional Medicare.

In the political universe we're bound by, however, "the ACA as it should have been" denotes the ACA more or less as is, but with subsidies generous enough to make coverage in the ACA marketplace truly affordable to most Americans who lack access to other insurance -- excluding (always, alas) undocumented immigrants.  

And that is about to happen! -- temporarily at least -- when Biden signs the American Rescue Plan Act of 2021 later this week (see Section 9661).   It's an eye-rubbing moment for progressives who've dreamed fruitlessly for a decade of an Affordable Care Act offering affordable coverage to almost all comers.

In ACA marketplace, more discount counties -- but which counties count?

Taking the country as a whole, are ACA marketplace offerings more or less attractive to prospective enrollees, subsidized and unsubsidized, in 2019 than in 2018?

The question takes on urgency as a lag in on-exchange enrollment persists into week 4 of Open Enrollment for 2019. In the 39 states using HealthCare.gov, enrollment is down 11% compared to this time last year. If plan offerings are roughly equal in value to last year's, depressed enrollment could easily be accounted for by repeal of the individual mandate penalty, establishment of a parallel lightly regulated, medically underwritten "short-term plan" market, and further drastic cuts to federal spending on enrollment assistance and advertising. Still, in 2018 the windfall bargains generated by silver loading (see note at bottom) partly offset the prior round of Trump administration sabotage, and the question lingers whether something similar may happen this year.

Some top-line facts may suggest that marketplaces are offering better value to more people in 2019 than in 2018. Unsubsidized premiums are down slightly on average. More states are silver loading, creating discounts in bronze and gold plans and/or encouraging insurers to offer off-exchange silver plans with no CSR load. The number of counties where a gold plan is available for less than the benchmark silver plan has increased from 595 in 2018 to 1136 in 2019. And the Kaiser Family Foundation reports that free bronze plans are available to subsidized enrollees at every subsidy-eligible income level in more counties in 2019 than in 2018.

There are counties and counties, however. One county may have 10 million people; another, 95. The Kaiser report includes a map that color-codes counties where free bronze is available to a 40 year-old with an income of $30,000 for the first time in 2019  A mouseover reveals that most of those counties are rural.

HHS projects no growth in individual market for health insurance in 2017

The salient point about HHS's enrollment projection for the ACA marketplace in 2017 is that it does not project any growth in the individual market as a whole.

The ASPE brief laying out the forecast projects 13.8 million enrollments in the ACA marketplace by the end of open enrollment 2017, an increase of 1.1 million over the end of the 2016 enrollment period. That estimate includes 1.1 million people expected to move from off-marketplace coverage into the marketplace -- a projection based on HHS's recent estimate that 2.5 million off-marketplace enrollees are potentially eligible for marketplace subsidies.

Since insurers' ACA-compliant off-marketplace plans share a risk pool with their on-marketplace plans, a total market that stays flat will not improve insurers' risk pools, except to the extent that those who come on-marketplace switch from pre-ACA grandfathered and grandmothered plans (as far as I can tell, the ASPE brief does not clarify whether some of the anticipated transfers will come from such plans, which are phasing out). Thus the individual market as a whole may not be any more attractive to insurers next year than this year, except to the extent that this year's price hikes cover last year's losses, or the pent-up demand for medical care on the part of previously uninsured marketplace enrollees starts to level off, or regulatory and risk adjustment changes have a positive effect.

On the other hand, as Kaiser's Cynthia Cox pointed out on Twitter, a transfer from off-marketplace to on-marketplace may reduce insurers' temptation to end their marketplace participation and sell off-marketplace only in some regions.