Gateway to a dark age: 2024 in review

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.

Carnival for Muskovites; Lent for the rest of us

All bloggers (excuse the archaism…) get a free end-of-year post reviewing their year’s work, right? Here goes.

First I have to confess that it feels a bit odd to review themes in the relatively mundane world of ACA administration and performance in a year that in the 11th month shaped up as an annus horribilis, with Trump’s reelection. On the healthcare front, the parade of cranks and perverse contrarians nominated by Trump threaten disaster at the CDC, NIH and FDA, while a Republican Congress readies a fresh run at the kind of catastrophic spending cuts that Republicans have fantasized about for decades. My hope is that with the smallest possible majority in the House, Republicans will fail or (to be fair to some chunk of their members) balk at major cuts to Medicaid or major legislative changes to the ACA. I even retain a sliver of hope that the boosts to ACA subsidies enacted in the American Rescue Plan Act, currently funded only through 2025, will be extended, at least in part. But I expect deep wounds to our institutions, in healthcare as everywhere. If damage stops short of outright catastrophe, we can count ourselves lucky.

One major thread in this year’s posting is the concentration of enrollment growth in the ACA marketplace in the post-ARPA years in states that refused to enact the ACA Medicaid expansion. This is not primarily a result of enrollment fraud, as alleged by the Project 2025-adjacent Paragon Institute under the leadership of Trumpist health economist Brian Blase, who is laying the groundwork for major cuts to public health insurance programs. In July I countered Blase’s charges at some length, while acknowledging valid points — e.g. the obvious need for a crackdown on broker fraud (a crackdown begun this summer, per below) and for some regulatory tightening (eliminating the ability of low-income enrollees to make monthly enrollment changes, an option exploited by unscrupulous brokers). Marketplace enrollment growth in OEP 2024 and, it’s now emerging, in 2025, was driven in large part by the Medicaid unwinding (a fact that Blase acknowledges but casts in a nefarious light).

---

Subscribe for free:

As we brace for Trump 2.0, I hope my 3-part review of Trump 1.0’s administration of the ACA marketplace (along with a more recent parsing of Trump and Vance’s claims that Trump “strengthened” the ACA) may prove useful. Surprise: it wasn’t all bad — although it seems that Trump’s “heroism was quite inadvertent” (to paraphrase Woody Allen’s antagonist in Love and Death) on the main count (see: silver loading).

A rising tide of broker fraud in the ACA marketplace burst into view this year, via excellent reporting from KFFs Julie Appleby, underpinned by a lawsuit alleging fraud perpetrated by a major EDE web-broker and a pair of agencies deploying dozens of downline agencies. In several posts, I delved into the evidence and CMS’s response. Posts included a look at gray-area fraud and sloppy agency practice; a close look at the expanded allegations in an amended complaint from the plaintiffs alleging large-scale fraud; and red flags in a past CMS celebration of rapidly expanding broker participation in the marketplace.

The Biden years were a heady time for ACA watchers — though always shadowed by the threat of a Trump resurgence. Medicaid enrollment, including among those made eligible by the ACA expansion, swelled, a a three-year pandemic-induced moratorium on disenrollment played out — then shrank back in an “unwinding” of that moratorium kicked off in May 2023, leaving a net increase since the eve of the pandemic of about 11%, or 8 million, as of August 2024. The enhanced marketplace premium subsidies implemented with ARPA in March 2021 triggered a near-doubling of enrollment, from 12 million in OEP 2021 to a likely 24-odd million by the end of OEP 2025. The unemployment rate has hovered near 4% for the entirety of Biden’s term, a full employment level not sustained since the 1960s. Not surprisingly, the uninsured rate dropped to an all-time low of 7.9% nationally in 2023 (the last year tracked).

All that enrollment growth is under threat from a new Trump administration and majority-Republican Congress. Medicaid enrollment will be cut by, at the very least, work requirements being readied now in red states. The Republican Congress will try for truly catastrophic further cuts — e.g., reducing the federal match rate for the ACA expansion population; further reducing match rates for “rich” states; and imposing block grant funding or per capita caps on federal Medicaid funding. In the ACA marketplace, the odds are against renewal of the ARPA subsidy boosts. While there is allegedly little appetite among House Republicans to allow the subsidies to revert to pre-ARPA levels, it’s hard to imagine them taking positive action to extend subsidies scheduled to sunset in 2026. Perhaps Democrats will manage to slip extensions into must-past omnibus spending bills.

As Republicans at least gesture toward major cuts, progressives will dust off and update their analyses of the major cuts threatened in 2017 — as the Center for Budget and Policy Priorities, Georgetown’s Center on Health Insurance Reforms and Center for Children and Families, the Center for American Progress, and Charles Gaba are already doing. It will be a weary rematch. As in 2017, fending off catastrophic defunding and major repeal will be the best outcome to be hoped for. Perhaps the more intense danger is on the public health/disease management front, as Trump appointees gear up to disarm our already-inadequate defenses before the next pandemic and roll back decades of progress in vaccination and infectious disease control. Happy New Year!

Thanks for reading xpostfactoid! Subscribe for free:

How has the Medicaid unwinding affected various states' ACA marketplace enrollment?

 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!

My last post stressed that ACA enrollment growth in the Open Enrollment Period for 2024 remains heavily concentrated in states that have refused to enact the ACA Medicaid expansion.

I might have pointed out, though, that the main divide in growth rates is between the 32 HealthCare.gov states and the 19 state-based marketplaces (SBMs). The difference in year-over-year enrollment growth as of Dec. 23 between expansion and nonexpansion states within the HealthCare.gov universe is not large -- 42.1% vs. 35.6%, according to Charles Gaba. Last year, the gap was bigger: enrollment in the nonexpansion states on HealthCare.gov increased by 22.7% in OEP 2023, vs. 9.9% in expansion states on the platform (Gaba). There was a similarly wide spread in growth rates in OEP 2022.

The Medicaid “unwinding” — the resumption in April 2023 of Medicaid redeterminations and disenrollments after a three-year pandemic-induced moratorium — is a major factor in this year’s enrollment gains. As of September, CMS reported that about 1.2 million Medicaid disenrollees (about 13% of the disenrolled) had enrolled in the marketplace (or in the Basic Health Programs available to low-income enrollees in New York and Minnesota) from April through September. As Medicaid disenrollments have now passed 15 million (!), close to 2 million by now may have landed in marketplace plans or the BHPs, accounting for perhaps 40% of enrollment growth.

That boost to enrollment is apparently at work in expansion and nonexpansion states alike. Of the 16 HealthCare.gov states with growth rates above the median, eight are expansion and eight are nonexpansion states. Again, expansion states are sharing more in this year’s strong enrollment growth than in prior post-pandemic years. The Medicaid unwinding may partly explain that. While growth rates remain lower in the SBM states (all of which have expanded Medicaid) than in HealthCare.gov states, strong enrollment growth (13.8%) has resumed in the SBM group in 2024 after remaining basically flat last year.

In my last post, with respect to the Medicaid unwinding, I wrote:

…state Medicaid disenrollment rates don’t clearly correlate with expansion/nonexpansion status or marketplace enrollment rates (at least not obviously; perhaps researchers will tease out significant relationships in years to come).

Here I want to take a look at another measure of the potential impact of the Medicaid unwinding on marketplace enrollment in OEP 2024: The extent to which the migration of Medicaid disenrollees into the marketplace during the off-season boosted each given state’s marketplace enrollment. CMS has tracked those enrollments, from April through September 2023, in the Medicaid Marketplace Unwinding Report. I’ve confined my focus to the 32 states using HealthCare.gov, as state-based marketplaces are quite a various lot, both in market conditions and reporting.

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.