Unwinding to the marketplace in Maryland

Note: All xpostfactoid subscriptions are now through Substack alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit xpostfactoid on Substack and sign up!

In October, CMS reported that of the roughly 5.5 million people disenrolled from Medicaid from the start of the “unwinding” (the end of the pandemic-induced 3-year moratorium on Medicaid disenrollments) through July 31, about 600,000 (592,291) had enrolled in ACA marketplace coverage. Another 95,000 enrolled in the Basic Health Programs that in New York and Minnesota serve lower income enrollees who would otherwise be eligible for subsidized marketplace coverage.

As Charles Gaba notes, these tallies suggest that about 12% of those disenrolled from Medicaid from April to July have enrolled in marketplace or BHP coverage. If that ratio held into November, about 1.1 million of the 10.1 million disenrolled from Medicaid according to KFF’s estimate may have ended up in the ACA marketplace. According to tracking by Georgetown’s Center for Children and Families, as of October, based on the most recent state reports ranging from July to September, net Medicaid enrollment was down by 5.8 million. Assuming that net disenrollment might top 7 million by now, the marketplace may have insured about 15% of the net coverage loss, perhaps a bit higher for adults (as most children who are not insured through employment-sponsored plans end up in Medicaid or CHIP). Here’s hoping a larger percentage of the newly disenrolled find coverage from employers — or already have done so, and have been double-insured since some point after Medicaid redeterminations were paused in March 2020.

While the marketplace is taking up only a modest sliver of those disenrolled from Medicaid, the influx represents a substantial boost to marketplace enrollment. David Stewart, Health Insurance Program Director at the Maryland Area Health Education Center West, which serves primarily rural counties, tells me that since May, appointment traffic for enrollment assistance in his program was more than double normal volume prior to the Open Enrollment Period that began on November 1. To get a sense of how that increase in interest might translate in enrollment I went to the Maryland Health Connection in search of data, and to my surprise, found detailed monthly reports. And indeed, new enrollments from May through September in Maryland in 2023 were more than triple the 2022 total. While enrollment in Maryland as of April 2023 was down 2.7% from April 2022, enrollment as of September 2023 was 13.2% higher than in September 2022.

The elephant not in the room on ACA exchanges

Subscribe to xpostfactoid via box at top right. You'll get 2-3 posts per week, mostly re ACA.

Here's the home page on the Maryland Health Connection, the state's ACA exchange. What's missing from this picture?

Open thread: How Trump's cutoff of CSR funding affected Maryland enrollment

My last post looked at the drop-off in silver plan selection among Marylanders eligible for strong Cost Sharing Reduction subsidies in 2018. CSR is available only with silver plans. When Trump cut off federal funding for CSR, insurers in Maryland priced it into on-exchange silver plans only,which generated large discounts in bronze and gold plans for subsidized buyers . For an explanation of how that worked, see the first note at bottom. For a summary of the discounts to the subsidized on offer in Maryland in 2018, see the second note.

Today, let's kick back and squint at the changes in metal level choices in Maryland at each income level (including the upper brackets this time) from 2017 to 2018. I'll offer a couple of observations below the charts now, and maybe more through the weekend. I invite you to offer your own.

Here are the percentages who chose each of the three main metal levels in each income band in both years. In both years, a bit under half of all enrollees had incomes under 200% of the Federal Poverty Level, and so were eligible for strong CSR (about 98% of them, anyway).  At bottom, the raw numbers at each metal level are charted, courtesy of the Maryland Health Connection. (Platinum and catastrophic plans accounted for 3% of enrollment between them in both years.)

2017

Income (% FPL)	% bronze	% silver (CSR)	% gold
< 100	3	96	0.7
100-138	4	95	0.5
138-150	7	92	0.5
150-200	10	88	1.0
0-200 (strong CSR)	7	92	0.8
200-250 (weak CSR)	21	74	3.2
250-300	30	60	6.0
300-400	31	57	7.4
>; 400	33	48	11.6
Unknown	26	54	11.0
Total	18	74	0.5

2018

Income (% FPL)	% bronze	% silver (CSR)	% gold
< 100 <100 p="">	10	80	7
100-138	8	84	7
138-150	9	83	8
150-200	13	76	10
0-200 (strong CSR)	11	79	9
200-250 (weak CSR)	24	46	28
250-300	32	32	33
300-400	37	25	34
> 400	42	24	27
Unknown	35	34	22
Total	23	55	19

A downside to silver loading: CSR takeup drops in Maryland

note 3/30 updated at bottom.

Maryland is one state that experienced beneficial effects from Trump's cutoff of federal funding for Cost Sharing Reduction (CSR) subsidies. In Maryland, insurers concentrated the cost of CSR into silver plans offered on-exchange only, creating dramatic discounts in gold and bronze plans for many subsidized buyers, as well as cheaper off-exchange silver plans for the unsubsidized (who nonetheless were stung by super-high premium increases). In January, I reviewed the bounty available to subsidized buyers:

Throughout the state, all subsidy-eligible* enrollees with incomes below 200% of the Federal Poverty Level (FPL) could obtain an bronze plan for under $20 per month. Most at this income level -- e.g., everyone over 30 -- could get a bronze plan for under $4 per month. In the state's most populous counties, subsidy-eligible buyers could get a gold plan for just a few dollars more than a silver one.  And in several rural counties, an enormously expensive benchmark (second cheapest) silver plan, which determines subsidy size, rendered silver and gold plans as well as bronze plans free for many enrollees.

Probably as a result of those discounts, subsidized enrollment in the state increased slightly over 2017, despite the shortened enrollment period and sharply reduced advertising and enrollment assistance funding from the Trump administration (overall enrollment was down slightly). Gold plan selection almost quadrupled.

Those were the benefits. But there was a downside as well. CSR,  available only with silver plans, makes silver plans roughly equivalent to platinum for enrollees with incomes up to 200% of the Federal Poverty Level (FPL). Among enrollees with incomes below that threshold, as with higher income enrollees, silver selection dropped significantly.

Today the Maryland Health Connection sent me a breakout of metal level selection by income for 2017, to go with the 2018 numbers they supplied in January.  Below, I've extracted the percentage changes in selection of each metal level among those eligible for CSR. Note aggregate numbers for all groups up to 200% FPL. At 200-250% FPL, CSR is available but negligible.  Switching to discounted gold and bronze makes sense for many in that income range.

Choosing a metal level in the CSR-addled Maryland marketplace: Not bad, enrollees!

In Maryland's ACA marketplace, as in much of the country, Trump's cutoff of reimbursement to insurers for Cost Sharing Reduction (CSR) drove huge premium increases for unsubsidized buyers -- but also bizarre bargains for the subsidy-eligible.

Throughout the state, all subsidy-eligible* enrollees with incomes below 200% of the Federal Poverty Level (FPL) could obtain an bronze plan for under $20 per month. Most at this income level -- e.g., everyone over 30 -- could get a bronze plan for under $4 per month. In the state's most populous counties, subsidy-eligible buyers could get a gold plan for just a few dollars more than a silver one.  And in several rural counties, an enormously expensive benchmark (second cheapest) silver plan, which determines subsidy size, rendered silver and gold plans as well as bronze plans free for many enrollees.

The effects of these pricing anomalies on the subsidized were mostly beneficial, as you might expect. Discounted (not to mention free) gold plans are a real boon to enrollees with incomes over 200% FPL, for whom silver plans have high out-of-pocket costs (sharply reduced for those up to 200% FPL by strong CSR). And free bronze plans are better than nothing, even with the $6200 deductible they carry in the most populous counties.

But anomalous pricing also can create problems. Some enrollees eligible for strong CSR might be tempted to choose  bronze plans (deductible $6200) over silver (deductible $0). Some enrollees under 200% FPL might also have been tempted by gold plans that cost slightly more than the cheapest silver -- not recognizing that CSR-enhanced silver plans cover more of their out-of-pocket costs than gold (i.e., are just straight-out more valuable).

So how did enrollees' choices shake out? Courtesy of the Maryland Health Connection, I have a breakout of enrollees metal level choices at different income levels, posted below.  And they look pretty good:

A few observations:

Subsidized ACA marketplace enrollment ROSE 2% in Maryland in 2018

ACA marketplace enrollment in Maryland for 2018 was down only slightly (2.6%) in 2018 That's a strong performance, as I noted earlier this week, "given the shortened enrollment period, radically cut federal funding for enrollment outreach and advertising, and general confusion generated by administration sabotage."

I also speculated that the drop-off may have been concentrated in unsubsidized prospective enrollees -- the only ones materially hurt by the state's enormous premium spikes (which actually benefited subsidized enrollees by inflating subsidies).  That is in fact the case.

In 2018, 32,171 enrollees in on-exchange private plans in Maryland were unsubsidized, according to numbers sent to me by the Maryland Health Connection (the state's ACA marketplace). That's out of 153,584 total enrollees (21%). In 2017, as of the end of Open Enrollment, 38,903 were unsubsidized out of a total of 157,832 enrolled (25%), according to Public Use Files published by CMS.*

That is, subsidized enrollment for 2018 was up about 2% -- to 121,413, compared to 118,928 in 2017. That jibes with the Maryland exchange's reporting that African American enrollment was up 12%, Hispanic enrollment up 10%, and rural enrollment up about 10%.

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:

Mysteries of the Maryland ACA Marketplace, cont.

As I noted on Oct. 3, Maryland Health Connection, the state's ACA exchange, sent me enrollment data indicating that Maryland may have the highest "CSR takeup rate" in the country. That is, in 2015, Maryland private plan buyers whose incomes qualify them for Cost Sharing Reduction (CSR) subsidies, which are available only with silver plans, chose silver and access the benefit at market leading rates. In Maryland, 86% of CSR-eligible buyers chose silver, compared to a national average of about 76%. That's doubtless in large part because Maryland cloned the web interface of the Connecticut exchange, which does an excellent job steering CSR-eligibles toward silver.

There are some peculiarities in the Maryland data, though, and they're thrown into sharper relief by the raw numbers of silver plan enrollees at each income level, which I did not have when I posted last week. Chief among them is a relatively huge number of buyers, 22%, with incomes low enough to qualify them for Medicaid, unless they're lawfully present non-citizens not yet eligible for Medicaid because they've been in the country less than five years.

Mysteries of the Maryland Marketplace

(Update post here)

As I've noted before, Connecticut's ACA exchange has been a market leader in steering private plan buyers whose incomes qualifying them for Cost Sharing Reduction (CSR) subsidies into silver-level plans (CSR is available only with silver). Also noted, back in January: When Maryland cloned Connecticut's technology and web interface in 2015, silver plan takeup improved.

Now, Maryland Health Connection, the state's ACA exchange, is reporting a market-leading level of silver plan selection among CSR-eligible buyers -- that is, buyers with incomes up to 250% of the Federal Poverty Level (FPL).  Nationally, about 76% of private plan enrollees who qualify for CSR buy silver plans and obtain the benefit (coincidentally, CSR-eligibles also make up about three quarters of all marketplace customers). Yesterday, Maryland announced that 86% of CSR-eligible enrollees in the state bought silver and accessed the benefit.

That's all the more the more striking in that just 62% of all buyers on the Maryland exchange selected silver, versus 68% nationally. The numbers indicate: