Small enrollment shifts are not so small: Zooming in from the GAO's 30,000 foot view of the ACA marketplace

It struck me, looking at the big-picture breakouts of 2017-2018 enrollment in healthcare.gov states presented in the GAO report, that shifts that I have puzzled over under a microscope look small in aggregate.

Viewed the other way round, changes that look small in aggregate mask some significant shifts among enrollees in ethnicity, income and age. A few examples below, mostly from the healthcare.gov states that the GAO focused on (while exposing HHS's willful management failures). I'm leaving aside a not-so-small shift in metal level selection that I've pretty much beaten to death, e.g., yesterday.

1. Subsidized vs. unsubsidized enrollment 
                                                                                                   2017                                       2018        

A one-point drop in the overall share of enrollees who are unsubsidized doesn't sound like much. But viewed in itself, unsubsidized enrollment was down 9.7% on healthcare.gov in 2017, compared to 5% for all enrollment. For many of the unsubsidized, moreover, the sticker shock triggered by premium increases in excess of 30% seems to have struck late. Among the unsubsidized, effectuated enrollment in all states as of March 15 was a stunning 29% below the tally as of the end of open enrollment. For the market as a whole, the drop was 9.4%; for the subsidized, it was just 5.5%. Year-over-year, effectuated enrollment  among the unsubsidized for all states as of March was down 17% .

GAO highlights the silver load offset to HHS sabotage

The GAO's report on HHS's performance in managing Open Enrollment for 2018 on HealthCare.gov hits HHS hard for dereliction of its duty to maximize enrollment in the ACA marketplace. The report lambastes HHS for using bad data to gut navigator funding; for ignoring performance data while constructing a bogus rationale for gutting advertising; and for refusing to set enrollment targets that would enable the agency to target efforts where performance was lagging.

These failures, the report asserts in measured bureaucratese,

could affect HHS's ability to meet its objective, such as its objectives of improving Americans' access to healthcare.

Unspoken is that policies instituted by HHS leadership did advance Trump's goal: to highlight and exacerbate the flaws of a program created by Democrats.

The report also includes stats that highlight the effects of "silver loading" the cost of Cost Sharing Reduction (CSR) after Trump cut off direct reimbursement of insurers for that mandatory benefit, forcing them to price it into premiums. Since CSR is available only with silver plans, most states allowed insurers to price it into silver plans only. Since premium subsidies are keyed to a silver benchmark, silver loading increased subsidies, creating discounts in bronze and gold plans. Here is a graphic representation of the discounts thus created: