Cutting off CSR subsidies will hit red state enrollees especially hard

As Republicans gear up to repeal the ACA,  the Kaiser Family Foundation has helpfully broken out how many of the 9.4 million subsidized enrollees in the ACA marketplace (as of March 31) live in each state, and what share of an estimated $32.8 billion to be paid out in premium tax credits this year will be paid out for enrollees in each state.

Greg Sargent, assessing the potential political fallout of cutting off those subsidies, notes:

Some of the states with the highest populations of people getting subsidies are represented by GOP Senators. This includes Florida (more than 1.4 million); Texas (more than 913,000); North Carolina (more than 499,000); Georgia (more than 427,000); and Pennsylvania (more than 321,000). Many other states with GOP senators also have sizable populations getting subsidies.

Today also happens to be the day when a federal appeals court delayed further proceedings in House Republicans' suit to stop the executive branch from funding the Cost Sharing Reduction (CSR) subsidies that reduce out-of-pocket costs for 57% of marketplace enrollees. Since a lower court upheld the suit in May, but stayed any action to cut off the payments, the delay effectively leaves it up to the Trump administration whether to drop the Obama administration's appeal and thus cut off those subsidies, effectively crippling the marketplace instantly* (and disrupting Congressional Republicans' alleged "repeal-and-delay" plans, which would keep the marketplace functioning until a replacement plan is enacted).

It therefore seems appropriate to note that CSR subsidies are particularly prevalent in the 19 states that have refused to enact the ACA's Medicaid expansion -- most of which are Trump country. That's because in those states, a subset of those whom the ACA intended to make eligible for Medicaid, people with incomes between 100% and 138% of the Federal Poverty Level (FPL), are instead eligible for subsidized marketplace coverage.   And since they are in the lowest income bracket eligible for subsidized marketplace coverage, they get the highest level of CSR support for the lowest price.

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:

Saved from the Medicaid Gap

Prompted in part by my observation last week that at least a third of Florida's 1.4 million private plan enrollees on healthcare.gov would have been Medicaid-eligible if the state had accepted the ACA Medicaid expansion, Richard Mayhew poses a question (or rather, elaborates on one posed in a comment on my post):

Liberal technocrats have been assuming that the states which refuse to expand are giving up massive amounts of money and thus economic growth by refusing to expand Medicaid will eventually expand.  However, are we accounting for the additional cash flow coming in as premium and cost sharing subsidies for people making between 100% and 138% Federal Poverty Line.

Leaving aside the financial question, we can make some reasonable estimates as to what percentage of those who would have been eligible for Medicaid had their states not refused the expansion are now in subsidized private health plans purchased on healthcare.gov. (All but one of the states that refused the expansion use the federal exchange).

On one side of the equation, we have Kaiser's state-by-state estimates of how many people fall in the Medicaid gap -- that is, have household incomes under 100% of the Federal Poverty Level (FPL) but are shut out of Medicaid in their state. On the other side is the number of subsidized private plan buyers in non-expansion states who have incomes in the 100-138% FPL range -- those who would have been eligible for Medicaid if their states had accepted the expansion.

Refusal to expand Medicaid swelled Florida's private plan ACA signups

Today CMS released detailed county-by-county enrollment data for private plans signups in the 37 states using healthcare.gov in 2015, as of February 22, just past the end of open enrollment,*. State-by-state income and metal level selection figures can be toted up from the county data Let's take a quick look at Florida and specifically Miami-Dade county, site of 2015's strongest signup surge.

We already knew that Florida -- which to date has refused to enact the ACA Medicaid expansion -- became the state with the most private plan enrollments, logging just shy of 1.6 million by the end of open season in February. According to the Kaiser Family Foundation, the state had enrolled 57% of its potential marketplace population as of March 31, 2015 (at which point Kaiser shows private plan enrollment at 1.4 million), second best in the country.  Of the 1.6 million state enrollees reported by HHS, 392,000 were in Miami-Dade County. Kaiser's research has previously spotlight Hialeah, a mainly Hispanic region just outside Miami (and in Miami-Dade County), as home to the zip code with the largest number of signups in the U.S.  Enrollment fever took hold there -- "Consumers can sign up for coverage in a mall, at a discount store, at a shoe store, and even at a barber shop," reported the Miami Herald in January.

"You oughtta be in Medicaid..."

Today's data release confirms that as in states that refused the Medicaid expansion generally, Florida's and Miami-Dade's private plan enrollments were swelled by enrollees who would have been eligible for Medicaid if the state had accepted the expansion. In Florida, 856,092 private plan enrollees -- more than half (53.6%) of the total -- had incomes between 100% and 150% of the Federal Poverty Level (FPL).  That compares with 47% in all states using healthcare.gov that refused to expand Medicaid, and just 22% in expansion states.

Those with incomes in 100-138% FPL range would be Medicaid-eligible if the state had expanded. We don't know exactly how many there are, but my prior analysis of national enrollment numbers suggests that at least two thirds of the 856k in the 100-150% FPL range are Medicaid-eligible -- a bit more than a third of all private plan enrollees in the state (and maybe a good deal more).

In Miami-Dade, the proportion of low-income enrollees is even more eye-popping. Fully two thirds of enrollees -- 259,000 out of 392,000 -- had incomes in the 100-150% FPL range.  Some 85% had incomes under 200% FPL, the threshold below which really strong Cost Sharing Reduction (CSR) subsidies are available with silver-level plans.

I hope this is representative

In a portrait of the Florida electorate, reeling after years of unemployment and foreclosure, the Times' Susan Saulny relays one lifelong Republican's take on the two leading contenders for the GOP nomination:

“One had those ethics violations,” he said of Mr. Gingrich, referring to his time as House speaker. “As for the other one,” he said of Mr. Romney, “he is just a liar.” 

Truth in advertising! Those impressions are wholly accurate. Just keep tearing each other up, boys.