"Anyone without health insurance can apply now" -- way to keep it simple, NYSOH

I have criticized messaging on ACA exchanges that's likely to confuse the majority of people newly uninsured after being laid off in the current crisis.  The main problem is that the exchanges submerge information about Medicaid, which is likely to insure more than twice as many newly uninsured people as is the ACA marketplace for private plans. Many who are eligible for Medicaid are likely never to find that out on the exchange websites.

Having obsessed about this a bit (1, 2, 3), I was pleased to encounter a Twitter ad from the New York ACA exchange, New York State of Health, that IMO gets the messaging right:

Anyone without health insurance can apply now thru #NYSOH. Enrollment is open for all NY State of Health Programs: Medicaid, Essential Plan, Child Health Plus and Qualified Health Plans. Find out what you qualify for by calling 1-855-355-5777 or visiting: https://t.co/v3Ojbz5NCV pic.twitter.com/97t8pPIDSU

— NY State of Health (@NYStateofHealth) June 26, 2020

How's New York's ACA marketplace doing? (updated)

In Kaiser's newly updated estimates of  the percentage of potentially eligible residents each state has enrolled in health plans through its ACA marketplace, New York gets short shrift.

According to Kaiser's measure, New York's health exchange is at just 26% capacity. But that's because the state launched a Basic Health Plan (BHP) that provides ultra low-cost insurance* to residents with incomes up to 200% of the Federal Poverty Level (FPL) who are not eligible for Medicaid. About 155,000 enrollees in the BHP (dubbed the Essential Plan) would have been eligible for subsidized private plans had the state not launched the BHP.

As I mentioned yesterday, Kaiser's more meaningful measure is the percentage of the subsidy-eligible population that each state has enrolled in subsidized private plans (because those who don't qualify for subsidies mainly buy off-exchange).Kaiser updates that metric bi-annually, but hasn't done so yet in the wake of the 2016 enrollment period. But based on its last estimate of the subsidy-eligible population in each state, we can take a stab at New York's current success rate.

Last September, before New York launched the Essential Plan, Kaiser estimated that the state had 532,000 residents potentially eligible for private plan subsidies. The Essential Plan currently has 379,559 enrollees. But 225,000 of them are in a special category: they are legally present noncitizens that the state was previously enrolling in Medicaid purely on its own dime (see note below**). Roughly 155,000 Essential Plan enrollees would have fit Kaiser's "potentially eligible population" for subsidized private plans last fall. In fact, most of them probably were in private plans.***

In addition, in 2016, New York enrolled 271,964 residents in private plans through its ACA exchange. According to HHS' spreadsheet of state level data, 54% of those private plan enrollees were subsidized, or a little shy of 147,000.  Add that to the 155,000  Essential Plan enrollees who would have been eligible for subsidized private plans last year, and approximately 302,000 enrollees in the two programs meet Kaiser's "potentially eligible" criteria.  That's 56.7% of 532,000, Kaiser's previous "subsidy-eligible" estimate. In other words, about 57% of New York's population that would have been eligible for subsidized private plans as of last fall are now enrolled either in such plans or in the Essential Plan [updated and corrected, 3/19 -- previously I missed the spreadsheet data].

New data: health exchange design matters

Why was there such huge variation among states in the proportion of ACA private plan buyers in the first open season who bought bronze plans -- the plans with the lowest premiums and highest deductibles and copays? In Hawaii, 41% of ACA shoppers bought bronze; in Mississippi, 8% did.

Part of the answer, as I've noted before, lies in a state's relative levels of wealth and health. Lower income buyers are eligible for generous Cost Sharing Reduction (CSR) subsidies that reduce deductibles, co-pays and yearly out-of-pocket (OOP) maximums -- but only if they buy silver plans.

Fortunately, most did. If you're sick and poor, a $6,000 deductible is likely to give you pause -- even if the plan is all but free and you don't come in knowing what a deductible is. On Healthcare.gov, only 15% of buyers eligible for any kind of subsidy bought bronze. The percentage is probably considerably lower among those eligible for strong CSR subsidies -- that is, buyers with incomes under 200% of the Federal Poverty Level (data from states that broke out metal level selection by income band, cited below, suggests as much).

Another factor plainly has a strong impact, though, and may account for some wealth/health anomalies in state performance. That's website design. In Connecticut, which had a 2013 median household income of $67,781, second highest in the nation, just 16% of all buyers in the first open season selected bronze. In Colorado, with a median income of $63.371, 40% bought bronze.

That's doubtless because the Connecticut site shows CSR-eligible applicants silver plans first; that is, the menu of plans available to a given user defaults to silver, both in the pre-application "shop-around" feature and in the actual application. The Colorado site, in contrast, does next to nothing to steer CSR-eligible buyers toward silver. The shop-around is cumbersome; the filter by metal level is hard to find (at the bottom of the screen, and you have to scroll back up to activate it). Perhaps more importantly, unlike on Healthcare.gov, applicants who qualify for CSR and make a move to buy a bronze plan receive no warning that they're leaving benefits on the table.

New data from Connecticut

The strongest evidence of the impact of site design comes from data about the choices of buyers with household incomes below 200% FPL (CSR is available but much weaker for those between 200-250% FPL). HHS did not provide this information for the 36 states that used Healthcare.gov in the first open season, and neither did most states. Colorado did, however, and so did New York (median 2013 household income $53,843).  And now, Access Health Connecticut has provided me with CT numbers for the current open season, which began on November 15.