Trump admin newly excludes many immigrants from a host of benefits

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CHC in Davenport, Iowa

Over the weekend, I learned third-hand that employees at a network of Federally Qualified Health Centers (FQHCs) in New Jersey had been told by management that the feds had forbidden them to treat undocumented immigrants.

That conclusion may be somewhat premature, but it’s grounded in abrupt and sweeping administrative action. In its latest barbaric assault on immigrants, the Trump administration has issued a series of orders banning access to most of the narrow range of federally funded benefits and programs not already off-limits to the undocumented - or to the many categories of lawfully present immigrants who are not “qualified aliens” (i.e., green card card holders, refugees, asylees and a few other categories*).

On July 10, three federal agencies — HHS, DOL and Education — issued notices (here is HHS’s) cutting off access for most non-green-card-holding immigrants to various benefits and services that had been excepted from a sweeping ban established in 1996. HHS’s list of benefits that will lose excepted status is as follows: 

HealthCare.gov should tell 600,000 low-income bronze plan enrollees: switch to silver

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The message above, provided to shoppers on HealthCare.gov who estimate low incomes, isn't enough to keep a significant number of low-income enrollees out of bronze plans.

My last post focused on the stubborn persistence of significant bronze plan selection among low-income enrollees in the ACA marketplace in 2022, despite the fact that premium subsidy increases provided by the American Rescue Plan Act made the benchmark silver plan with strong Cost Sharing Reduction free to enrollees with incomes up to 150% FPL, and much cheaper than in previous years for those with incomes in the 150-200% FPL range.

Among enrollees with income between 100% and 150% FPL, 14% -- more than 600,000 -- selected bronze plans for 2022. While bronze plan selection at incomes in the 100-150% range did tick down a bit from the prior year, it remained higher than in any year prior to 2021.

President Biden's January 28, 2021 Executive Order 14009, “Strengthening Medicaid and the Affordable Care Act," declares, "it is the policy of my Administration to protect and strengthen Medicaid and the ACA and to make high-quality healthcare accessible and affordable for every American." Bronze plans obtained by people with income below 150% FPL do not advance that policy.

Bronze plan single-person deductibles average over $7,000, compared to under $150 for silver plans as enhanced by the CSR provided to enrollees with incomes up to 150% FPL. Annual out-of-pocket maximums in bronze plans generally exceed $8,000,* compared to an average of $1,208 in silver plans. 

600,000 bronze plan enrollees below the 150% FPL threshold is almost 600,000 too many.

CMS has given itself a tool to reduce this underinsured population. Last July it finalized, and this month it implemented, a rule creating "monthly special enrollment period" for enrollees with incomes up to 150% FPL -- effectively establishing continuous year-round enrollment for the lowest-income marketplace applicants. The rule not only allows the uninsured to enroll outside the annual Open Enrollment Period; it also allows current enrollees with income up to 150% FPL to switch to a silver plan. 

HHS devotes $4.8 billion to COVID-test the uninsured. P.S. How about insuring them?

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HHS announced today that it is dedicating $4.8 billion in American Rescue Plan funds to reimburse providers for providing Covid-19 testing to the uninsured, at no cost to the uninsured patient. That's a continuation of a program initiated last spring. So far, $2.5 billion has been allocated by the Health Resources and Services Administration (HRSA) for such reimbursement.

Am I letting a current preoccupation distort my vision in seeing something of a lost opportunity (and irony) in this HHS statement?

There are approximately 29 million uninsured individuals living in the United States. While this administration has been focused on decreasing the uninsured rate, as evidenced by the more than 1 million people who have enrolled into quality health coverage through the Special Enrollment Period (SEP), much work remains. By ensuring programs like the HRSA COVID-19 Uninsured Program remains adequately funded, this administration is removing cost impediments so anyone exposed to COVID-19 may seek appropriate testing and care.

The funding announced today is dedicated to COVID-19 testing. HRSA also helps uninsured individuals’ access COVID-19 treatment and vaccinations through the COVID-19 Uninsured Program.  The program reimburses providers at national Medicare rates for providing these services.

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:

How well will healthcare.gov function for 2018?

Everyone who follows the fate of the ACA is by now familiar with the Trump administration's multi-pronged sabotage of the individual market: the constant threat to stop CSR reimbursements to insurers, which in itself has likely driven up 2018 premiums by upwards of 20%; the threats not to enforce the individual mandate, which will likely depress enrollment; the radical cutbacks in enrollment outreach and assistance; the propaganda denigrating marketplace offerings; the shortened enrollment period and gratuitous Sunday shutdown; and now, Trump's looming threat to undermine the risk pool, state authority and ACA consumer protections by giving carte blanche to association health plans.

This multi-pronged assault led me to wonder whether healthcare.gov, the federal exchange, will function adequately. I took a look at the website yesterday, and again today. And I must say, what's there is somewhat reassuring. In fact, today new prompts went up to start preparing people for open enrollment. The array of options on the home page is clear and well designed:

It is easy to get to the initial tasks that people in different situations will want to undertake:

Fly-specking a myth-busting from HHS on the ACA marketplace

As the ACA's fourth open enrollment kicks off in the face of steep rate hikes and reduced competition, HHS Secretary Burwell feels compelled to engage in some "myth busting."

Fair enough, but I in turn feel compelled to, shall we say, qualify the clarifications. My two cents are in italics, below each myth-bust.

Myth #1: Health coverage on the Marketplace is unaffordable.

On the surface, headline rate changes can look spooky – but they don’t actually reflect what the vast majority of people will pay.

If you dig deeper, most consumers shopping on the Marketplace will be able to find a plan between $50 and $100 per month, thanks to financial assistance.

Well...it depends what your definition of "vast majority" is. At present there are 10.5 million marketplace enrollees, and about 1.5 million of them are unsubsidized. There are also 6.9 million enrollees in the off-marketplace individual market, however, by HHS's tallying. Off-marketplace enrollment estimates vary; Mark Farrah Associates pegged the total individual market at 20.2 million in August, which would suggest about 9 million off-marketplace.  

HHS estimates that 2.5 million current off-marketplace enrollees are "potentially" eligible for subsidies, but "potential" does not mean "actual," and the actual number is probably considerably smaller, as I explained here. 

If 2.5 million off-marketplace enrollees were indeed subsidy-eligible, and if the 6.9 million off-marketplace count is accurate, then about 2/3 of current individual marketplace enrollees would be eligible for subsidies. The actual percentage is probably somewhat smaller. At present, by HHS's count, barely more than half of individual market enrollees are subsidized. 

It may be literally true that "the vast majority" of people shopping on the Marketplace will be subsidy eligible, but that's because most individual market customers who are subsidy ineligible are aware of that fact and don't bother with the marketplace.

The unsubsidized individual market is where the wild things are -- and will indeed be spooky for many who are not eligible for subsidies but not truly wealthy.

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.

Are 2.5 million off-exchange health plan enrollees subsidy-eligible?

A recent HHS ASPE* analysis of the ACA marketplace and the uninsured found that an estimated 2.5 million people currently enrolled in health plans bought in the off-exchange individual market are potentially eligible for premium subsidies in the ACA marketplace. That is, 2.5 million people may have foregone subsidies by buying off-exchange or may be eligible for them in 2017. That's a pretty eye-popping number -- indicating that 70% of those currently enrolled in the individual market (on- and off-exchange) are subsidy-eligible.

HHS further estimated that 9 million of the uninsured are potentially eligible for subsidies in the ACA marketplace, and that a total of 20.9 million people are subsidy-eligible -- more than double the 9.4 million enrolled in subsidized marketplace plans as of March 31 of this year. Those estimates are markedly different from those of the Kaiser Family Foundation, which estimates that 5.4 million of the uninsured are potentially subsidy-eligible, and pegs the total subsidy-eligible population at 14.9 million.

The HHS analysis is based on different survey data than the Kaiser estimate: HHS uses the National Health Interview Survey (NHIS) while Kaiser relies on the Current Population Survey (CPS). But HHS's higher estimates may stem in large part from two more fundamental differences.

Yes, the ACA marketplace needs to grow. But it also needs to shrink

As major health insurers cut back their participation in the ACA marketplace, observers have drawn the obvious conclusion that the market is too small to be viable. The CBO forecast year after year from 2010 through 2015 that 21-22 million people would be enrolled in marketplace plans in 2016; only 11 million currently are. The risk pool is older and too sicker than it should be; the marketplace needs an influx of younger and probably wealthier (and therefore healthier) enrollees.

All true. But it's probably also true that the marketplace needs to shrink even as it grows.

HHS markets to the lower income brackets

I have complained more than once about HHS's mantra that most ACA marketplace shoppers can find a plan for under $75 per month. My beef has been that the message overemphasizes premium price at the expense of balancing premium with out-of-pocket costs. That's particularly perverse since most shoppers have to buy silver plans to access Cost Sharing Reduction subsidies that render silver a better value than bronze.

Well, CMS is at it again, and in light of the marketplace's recent travails -- insurer losses, insurer exits, premium price spikes -- I was struck by another problem with the "most can get plans for under $75" assurance.

Today HHS released a brief emphasizing that since 85% of HealthCare.gov enrollees qualified for premium tax credits in 2016, that same overwhelming majority will be protected from premium price hikes in 2017. The premise is simple: if you're subsidy-eligible, you pay a fixed percentage of your income for the benchmark silver plan in your area, regardless of its sticker price. When prices rise, subsidies rise, and the spread between benchmark silver plans and cheaper bronze plans will widen slightly, slipping slightly more applicants in under the $75 and $100 thresholds.* Hence this highlight:

In a hypothetical scenario in which all Marketplace qualified health plan premiums
were to increase by 25 percent from 2016 to 2017:
          o 73 percent of consumers could find coverage for $75 or less.
          o 78 percent of consumers could find coverage for $100 or less.

Okay, but all this "most-people" messaging also brings home the fact that HHS anticipates marketplace enrollment remaining concentrated in lower income brackets -- mainly under 200% of the Federal Poverty Level (FPL). In 2016, somewhere between 61% and 66% of HealthCare.gov enrollees had incomes below that level.   HHS estimates that 70% of enrollees could have bought plans for under $75 per month, which suggests that about 70% had incomes under, say, 220% FPL.**

ACA marketplace is pricing out gold and platinum plans, while silver selection stays stable

HHS released its full report* on ACA marketplace enrollment for 2016. My primary interest as usual is in metal level selection. That is, mainly, whether the percentages of buyers selecting bronze plans (with their sky-high deductibles) and silver plans (required to access Cost Sharing Reduction subsidies, available to those with incomes under 250% of the federal poverty level) are shifting significantly.

Overall, metal level selection hasn't changed much since 2015. In all states combined, including those using their own exchanges, 23% bought bronze and 68% bought silver this year, compared to 22% bronze and 67% silver in 2015.

So wait, how did both percentages manage to uptick? That's the first of several points worth noting:

• The sharp rise in (unsubsidized) premiums in 2016 has priced a lot of people out of gold and platinum plans. In 2015, in all states combined, 7% bought gold and 3% bought platinum. In 2016, 6% bought gold and 2% bought platinum.

For legally present non-citizens, a sometimes twisted path to ACA enrollment

This week, CMS announced that it was tightening the criteria under which people who want to buy health plans in the ACA marketplace outside of the annual Open Season for enrollment can obtain so-called Special Enrollment Periods.  SEPs are granted when special circumstances create a need to buy or change insurance plans -- for example, job loss, marriage or childbirth. The tightening is in response to insurers' complaints that SEPs are too easy to obtain and people are gaming the system, 

CMS has eliminated several causes for granting SEPs. Two pertain specifically to immigrants:

• Lawfully present non-citizens that were affected by a system error in determination of their advance payments of the premium tax credit
  
• Lawfully present non-citizens with incomes below 100% FPL who experienced certain processing delays

Why were these SEPs created in the first place? And why are they now deemed obsolete or counterproductive?

A little less underinsurance on HealthCare.gov this year

[1/11 update at bottom]

It looks as though takeup of Cost Sharing Reduction (CSR) subsidies by eligible buyers on HealthCare.gov is up slightly this open season, so far. CSR reduces deductibles, copays and maximum out-of-pocket costs for buyers with incomes below 250% of the Federal Poverty Level (FPL) -- but only if they select silver plans, the second-cheapest of four metal levels.

As of the end of open season for 2015 enrollment last February, 76.8% of CSR-eligible HealthCare.gov customers had selected silver plans and so accessed the benefit. For 2016 enrollees through 12/26/15, according to HHS's latest enrollment report, CSR takeup is up to 78.4% on the federal exchange.

Here's the basic calculation for CSR takeup among 2016 enrollees:

ACA enrollment 2016: pool somewhat wealthier; silver selection holds steady

[See update at 5a and 5b: light on who's unsubsidized]

HHS released its midterm report on ACA private plan enrollment for 2016 today. A few observations:

1. While HHS was obviously lowballing when it published enrollment projections in October, enrollment has already hit the lower range of those projections. The targets were 11.0--14.1 million plan selections by Jan. 31, 2016, including 2.8--3.9 million new customers.  As of Dec. 26, all exchanges combined had just shy of 11.3 million enrollees, including 3.0 million new customers.

2. The enrollee pool in the 38 states using HealthCare.gov is slightly wealthier this year than last. For 2016 to date, 37% of hc.gov enrollees for whom income data is available have incomes in the 100-150% FPL range. As of the end of OEII last February, 40% were in that range.There have been proportionately more buyers with incomes over 250% FPL this season. The difference is probably due to new Medicaid expansions in Pennsylvania, Indiana and Alaska, which probably put a couple of hundred thousand private plan enrollees into Medicaid.

Two reasons the proportion of young adults in ACA marketplace may be rising

Sarah Kliff has marshaled good evidence that the individual mandate is working over time to pull more young adults into the ACA marketplace. As the penalty ratchets up each year, the proportion of young enrollees increases. The evidence in brief: 1) that's how it worked in Massachusetts; 2) young adults identify the mandate as a chief motivator in polling data; 3) HHS and Enroll America have brought the mandate to the fore in marketing messages; and 4) the proportion of enrollees under 35 (including children) has risen modestly this open season, from 35% in OEII to 38% so far this time around.

All of this is convincing. But the perspective of Anne Filipic, of Enroll America, also indirectly highlighted something I've put forward as a secondary cause of this year's modest spike in young enrollment: Because prices are higher this year, more young adults qualify for subsidies. Here's Filipic:

Filipic and her team already think the mandate could play a bigger role in their messaging going forward. Right now, Enroll America has a calculator that lets potential enrollees see how much financial help they'd be eligible to receive if they signed up for coverage.

About that deadline, HealthCare.gov..

HealthCare.gov really, really wants the uninsured to get covered by Jan. 1. Hence these daily emails:

Attention, Secretary Burwell: If you really want ACA shoppers to consider more than price....

This is all very well, Secretary Burwell...

Burwell acknowledged that people have had some trouble picking the right policies, with some deciding based mainly on how expensive policies were, rather than on what’s covered.

But why then did I get a voicemail on Thursday from healthcare.gov telling me that "most people" can get plans for under $75? Here's the email version of that mantra (also sent Thursday):

The message here is that monthly premium price is all that matters. Based on current enrollment, a large subset of those who can find a plan for $75 per month can find only a bronze plan below that ceiling.  Most bronze plans have deductibles north of $6,000. Meanwhile, anyone who can get a bronze plan for under $75 is eligible for Cost Sharing Reduction (CSR) subsidies, which are available only with silver plans, which have higher premiums.

HHS embraces high deductibles

It's funny how a trend impinges on your consciousness: you think something is new, then it gradually dawns that it's been going on for some time. Such is the case (for me) with an emerging mode of compensating for the unaffordability of healthcare at U.S. prices.

On Tuesday CMS, apparently stung by news accounts of ACA marketplace customers whose plan deductibles were so high they found care inaccessible, put up a blog post touting many plans' provisions of some services that are covered before the deductible is reached:

On Thursday, I took a look at the benefit structure provided by Centene's Ambetter, an insurer that has "cornered the silver market" in several large cities, including Miami, Chicago and Seattle. Ambetter plans feature high deductibles and a relatively broad array of services offered beneath the deductible:

The shrinking subsidizable ACA private plan buyer pool

This week the Kaiser Family Foundation estimated that among 32.3 million non-elderly uninsured U.S. adults, 22%, or 7.1 million, should be eligible for subsidized private plans in the ACA marketplace. HHS estimates a total of 10.5 million uninsured who are eligible for marketplace coverage, almost 80% of whom are subsidy-eligible.*

There were 8.3 million subsidized marketplace enrollees as of June, suggesting a total pool of about 15-16 million who lack access to employer-sponsored or other insurance and are eligible for subsidies. The Congressional Budge Office's most recent forecast is that by 2017, 18 million people will be buying subsidized plans in the marketplace.  Allowing for a bit of population growth, why the apparent overshoot?

The answer may lie in expectations about employer response to the ACA. CBO's 2015 projection estimates that employer-sponsored insurance will be down 6 million from the pre-ACA baseline in 2016 (and down 1 million this year).

ACA exchanges in 2016: targeting just 6.4 million subsidy-eligible uninsureds?

In a speech at Howard University College of Medicine today, HHS Secretary Sylvia Burwell laid out a few facts about the target market for the ACA exchanges -- those still uninsured and eligible for private plan coverage. A couple of key points:

• About 10.5 million uninsured Americans are eligible for Marketplace coverage in the upcoming open enrollment.


• Almost 40 percent of the uninsured who qualify for Marketplace plans are living between 139 and 250 percent of the federal poverty level (about $34,000 to $61,000 for a family of four).

HHS has confirmed for me that the 10.5 million estimate is not limited to the subsidy-eligible. At present, according to Kaiser estimates, about half of those who have bought plans in the nongroup market are ineligible for subsidies, and most of the subsidy-ineligible have bought their plans off-exchange. 

Does that, then, suggest a target market of just 5 million subsidy-eligible uninsureds? Not quite.* HHS's estimate of the target market between 139% and 250% FPL (4.2 million or a bit less) provides a basis for estimating the size of the subsidizable target market.  In 2015, about 76% of private plan buyers on the exchanges had incomes under 251% FPL.*  According to HHS's most recent enrollment snapshot, 83.7% of all exchange enrollees qualified for premium subsidies. Thus 91% of subsidy-eligible buyers were under 251% FPL. Not all of them, however, fit HHS's "40 percent" category of 139-250% FPL - because in states that refused the Medicaid expansion, eligibility for subsidized marketplace coverage begins at 100% FPL.*** In 2015, about 15% of all enrollees**** (and 20% of those under 250% FPL) were under 139% FPL and so outside HHS's category. Those between 139% and 250% FPL thus constituted about 60% of total enrollment. If that percentage holds in 2016, that would suggest that about 7 million of the 10.5 million in the target market are subsidy eligible.

But the percentage of potential buyers under 139% FPL will probably be considerably lower this year. Takeup among that group was disproportionately high: Avalere Health estimated that 76% of eligible buyers from 100-150% FPL did in fact enroll, and the percentage was probably still higher under 139% FPL (and dramatically lower for all higher income bands). Moreover, two (small states) have accepted the Medicaid expansion for 2016. If, in 2016, 10% rather than 20% of those under 250% FPL are also under 139% FPL, then that suggests about 580,000 fewer subsidizable targets. Since we're now in the realm of educated guesswork, let's say that HHS's estimate of the 139-250% market suggests that about 6.4 million of their 10.5 million overall target market is subsidizable.

At present, 83.7% of 9.9 million exchange enrollees are subsidized. If there indeed are only about 6.4 million subsidy-eligible uninsured still out there, then about 57% of the subsidy-eligible target market has been enrolled. That doesn't sound right. Kaiser has pegged the percentage of potential exchange population enrolled through June 20 at 35%.Though that estimate is not limited to the subsidy-eligible, uninsured rates are much higher in lower income brackets.

The 10.5 million estimate excludes the Medicaid-eligible and -- I assume but have not confirmed -- those in the Medicaid gap, who theoretically could buy unsubsidized plans on the exchanges. Those who earn too little to qualify for premium subsidies are unlikely to pay full price for plans on the marketplace -- although, confusingly (to me), the just-released census report on health insurance showed greater gains in private coverage than in government insurance for those whose incomes should qualify them for Medicaid under the ACA expansion.

The still uninsured: can't afford coverage or don't know what's on offer? (Or both?)

With respect to reaching the still-uninsured, Burwell cited findings from a PerryUndem study that reflect a tension between two key factors:

• About half of the uninsured have less than $100 in savings.

• Nearly three in five of the uninsured are either confused about how the tax credits work or don’t know that they are available.

The first point is a proxy for several points highlighting the financial precariousness of the uninsured. Another: 58% of respondents report having less than $100 left over each month after paying bills. In other words, many would have a very tough time with the average premium paid for marketplace plans, net of subsidies: $101 per month. At the same time, most who consider coverage unaffordable do not know what's on offer.

I have noted the same tension in data from the Urban Institute, and in other surveys of the uninsured. If the still-uninsured who qualify for premium and cost-sharing subsidies knew what was on offer, would they still consider it unaffordable? Doubtless some would and some would not. The proportion in each camp will go a long way toward determining how viable the ACA private plan marketplace will prove over the long haul.

Researchers at the Urban Institute and healthcare reporter Jed Graham have argued that the ACA subsidy structure is too skimpy to meet the needs of large percentages of the uninsured.  To whatever extent that's true overall, it's increasingly true as you move up the income scale -- as Avalere Health's analysis of takeup rates at different income levels indicates. Avalere estimated that about 76% of the subsidy-eligible uninsured with incomes under 150% FPL bought subsidized private plans, compared to 41% for those from 151-200% FPL, 30% for those from 201-250% FPL, 20% of those from 251-300% FPL, and so on down.  The threshold for really strong Cost Sharing Reduction, 200% FPL, is one dividing line between strong and weak aid.  The ACA works best for those up to that income level. At the same time, that's where most of the uninsured are concentrated.

P.S. The PerryUndem study, conducted in May 2015 and surveying some 1,270 adults, is full of interesting info about the finances and priorities of the uninsured.

UPDATE, 10/14/2015: Kaiser yesterday estimated that 7.1 million uninsured people are eligible for subsidized private plans in the ACA marketplace.

----
* I originally oversimplified this calculation, simply taking the percentage of exchange buyers under 250% FPL. Correction is in this paragraph.

** I calculated the percentage of exchange enrollees with incomes under 251% FPL in this post.

*** Thanks to Jed Graham for pointing out that HHS's estimate began at 139% FPL (rather strangely, when you consider the doubtless still-sizable number of uninsureds between under 139% FPL in states that refused the Medicaid expansion. Also among subsidized buyers under 139% FPL: legally present immigrants who are time-barred from Medicaid; they are eligible for premium subsidies even if their income is under 100% FPL (in nonexpansion states) or 139% FPL (in expansion states).

**** See this post for a calculation of 2015 exchange customer with incomes under 139% FPL. In this post, I've slightly dropped the estimate, from 16% of all buyers to 15%, in light of the recent purge of those who failed to verify their state income when asked.