ACA enrollment under ARPA: The view from near 100% FPL (and San Antonio)

Subscribe to xpostfactoid

The ACA's tragic coverage gap confronts poor people in the 12 states that have refused to date to enact the ACA Medicaid expansion with a cruel logical absurdity: they may earn too little to qualify for government-supported health coverage.  Adults in households with incomes below the Federal Poverty Level (100% FPL) do not qualify for subsidized coverage in the ACA marketplace.

A few weeks ago, I noted that on May 5 CMS put a modest patch on the coverage gap by rescinding a Trump era policy of demanding income verification from marketplace applicants in nonexpansion states if "trusted data sources" indicated that the applicant's income was likely below 100% FPL -- i.e., ineligible for subsidies -- and the applicant had estimated an income above that threshold. (Since HHS's computer systems can't be retooled instantly, CMS explained, the exchanges will continue to request documentation in these circumstances for some time -- but in followup communication, they will "notify those consumers that they need not provide the requested information.")

In effect, a low-income applicant can make a good faith estimate of a household income in the coming year above 100% FPL and qualify for subsidized coverage (now free through 2022, if income is below 150% FPL, thanks to the subsidy boosts in the American Rescue Plan enacted on March 11). Documentation will not be required (though awkwardly, it will be requested for some time).  If income for the year in question ultimately proves to fall below the 100% FPL threshold, there is no clawback of subsidies granted, unless the applicant's income estimate is made with "intentional or reckless disregard for the facts."* 

The opportunity for low-income applicants to estimate their way into free coverage is the sort of regulatory forbearance that inspires high moral dudgeon from conservative adversaries of the ACA. In fact, though, poor or near-poor people in nonexpansion states who get as far as applying for health coverage - many don't, as ignorance of ACA programs is pervasive -- are likelier to underestimate their income than overestimate it. 

Obamacare enrollment in nonexpansion states is up 26% year-over-year and 41% since June 2019 (estimate)

Subscribe to xpostfactoid

Not to indulge in monomania, I want to offer a clearer snapshot than previously of really major marketplace enrollment gains in the pandemic period in states that had not enacted the ACA Medicaid expansion as of June 30 of this year.  As the uninsured rate in the nonexpansion states was nearly double the rate in expansion states as of 2019 (15.5% vs. 8.3%),  particularly rapid enrollment growth in those states -- most of it at low incomes -- is having a significant impact where help is most needed.

Every June, CMS publishes "effectuated" (i.e., paid-up) enrollment in each state as of February of that year. Those reports also break out monthly enrollment by state in the year prior. This year, that information is supplemented by monthly reports on off-season enrollment, stimulated this year by an emergency Special Enrollment Period (SEP), running from February 15 through August 15 in the 36 states using HealthCare.gov, which is the functional equivalent of a second Open Enrollment Period (the 15 states that run their own exchanges have also opened emergency SEPs.) The SEP reports provide enough data, or so I assume below, to estimate effectuated enrollment through June 30 of this year.

By my estimate, enrollment in 13 nonexpansion states as of June 30 -- excluding Wisconsin, for reasons discussed below -- is up 26% year-over-year, and 41% since in June 2019. That's a two-year increase of 1.74 million.  Enrollment is up by more than 50% since June 2019 in Texas, Georgia and Mississippi. It's up by almost 500,000 in Texas and by more than 650,000 in Florida.

Obamacare mid-year enrollment is likely up 19% over past peak

Subscribe to xpostfactoid

see 6/18/21 update at bottom

Charles Gaba estimates current enrollment in the ACA marketplace at 12.4 million. That's based on effectuated enrollment as of February of 11.3 million, plus about 1.6 million new enrollments during the emergency Special Enrollment Period (SEP) commenced on Feb. 15, minus an estimate of monthly attrition based on last year's monthly totals. Attrition may be a bit higher, but this is a good estimate.

A lot of people who pay attention to marketplace enrollment patterns have imprinted a number: 12.7 million. That was the (rounded) national total of signups for coverage as of the end of Open Enrollment  season (OE) in 2016 -- long understood to be the peak year for marketplace enrollment. Plan selections declined in subsequent years, probably due in part both to soaring premiums in 2017 and 2018 and Trump administration sabotage (which contributed to 2018 premium hikes though not to the correction of 2017).

Plan selections as of the end of OE is a very different metric, however, from effectuated enrollment, which measures people who are paid up on their premiums. Attrition was high in 2016: effectuated enrollment peaked at 10.8 million in March, and average monthly enrollment for the year was 10.0 million. Attrition fell in the Trump years, for reasons we'll touch on below, and fell further last year, as the pandemic triggered high SEP enrollment. 

This year, the emergency SEP, coupled with massive boosts to premium subsidies enacted in the American Rescue Plan, has triggered SEP enrollment that's 3.5 times higher than in 2019, the last pre-pandemic year. The SEP enrollments logged to date have almost certainly outpaced normal attrition as experienced in the pre-pandemic years.  The ARP subsidy boosts have likely reduced disenrollments as well as stimulating new enrollment.

Bottom line: marketplace enrollment growth is larger than meets the eye, at least for those who measure "12.4 million" against the 2016 end-of-OE peak. June enrollment as estimated by Gaba is 20% higher than June enrollment in 2016, and 19% higher than in June 2020, when SEPs triggered by the pandemic pushed mid-year enrollment to a new high. 

ARPA should reduce underinsurance in the ACA marketplace

Subscribe to xpostfactoid

• While free bronze plans have been widely available to low income marketplace enrollees since 2018, the American Rescue Plan makes free or very low-cost silver plans with much lower out-of-pocket costs widely available.
  
  
• Bronze plan enrollment at low incomes spiked during Open Enrollment for 2021
  
  
• The American Rescue Plan may already be reversing the drift toward bronze at low incomes

The Urban Institute estimates that if the American Rescue Plan Act's increases to subsidies in the ACA marketplace are made permanent, enrollment will increase by 5.1 million, and the uninsured population will be reduced by 4.2 million. The enhanced subsidies are funded only through 2022 at present.

Urban foresees most of this enrollment increase -- about three quarters of it -- occurring at incomes over 200% of the Federal Poverty Level.  But ARPA should also reduce underinsurance, primarily at incomes below 200% FPL.

While ARPA does not reduce out-of-pocket costs at any metal level, it does make silver plans, which come with strong Cost Sharing Reduction (CSR) subsidies at incomes up to 200% FPL, much more affordable to low income enrollees. 

Obama's assumptions about healthcare reform, in 2009 and today

Subscribe to xpostfactoid

Jonathan Cohn today published an adapted excerpt from his book about the Affordable Care Act, The Ten Year War, coming out on Tuesday. The article's centerpiece is Obama's own assessment of what went right and wrong in the design, passage, and enactment of the ACA.  Of the ACA's basic design, which had become a consensus Democratic by the time Obama was elected, Cohn notes, "It was a far cry from the government-run insurance plan that Harry Truman once championed, but Democratic leaders embraced it as the best they could get..."

 ― and so did Obama, who repeated in our interview his belief that something like a government-run, “single-payer” system would probably work best, but creating one right away would be too difficult. 

“We have a legacy system that is one-sixth of the economy,” Obama said. “The idea that you could, in some way, dismantle that entire system ― or even transition it entirely ― to a single payer system looked politically impractical and probably really disruptive. ... The best chance to actually get people healthier was going to be to design a system that acknowledged 85% of the American people have health insurance and that plugged the gap for those 15% who don’t.”

Obama's neat foreclosure of other possibilities here reminds me of the technique deployed throughout his memoir, A Promised Land, of showcasing his undeniable rationality within a framework bound by self-imposed limits, or limits imposed by his choice of advisers, or -- sometimes -- by what was politically possible.  I see two fallacies here.

Trump healthcare reruns: Graham-Cassidy and the Sundowning Kid

Subscribe to xpostfactoid via box on right (requires only an email address; you'll get 2-3 emails per week on average)

April Fool! Trump is once again promising an ACA replacement with low premiums and low out-of-pocket costs.

The cost of ObamaCare is far too high for our great citizens. The deductibles, in many cases way over $7000, make it almost worthless or unusable. Good things are going to happen! @SenRickScott @senatemajldr @SenJohnBarrasso @SenBillCassidy

— Donald J. Trump (@realDonaldTrump) April 1, 2019

It's coming along great:

The president brought up healthcare again on Friday, claiming he would have a “much better” plan than Obamacare. “The health care’s going very well,” he told reporters in Florida.

Takes a person back...to, say, Jan. 15, 2017

President-elect Donald Trump said in a weekend interview that he is nearing completion of a plan to replace President Obama’s signature health-care law with the goal of “insurance for everybody"...

Trump said his plan for replacing most aspects of Obama’s health-care law is all but finished. Although he was coy about its details — “lower numbers, much lower deductibles” — he said he is ready to unveil it alongside Ryan and Senate Majority Leader Mitch McConnell (R-Ky.).

“It’s very much formulated down to the final strokes. We haven’t put it in quite yet but we’re going to be doing it soon,” Trump said.

Congressional races are all about "pre-existing conditions." Gubernatorial races spotlight Medicaid

Last week I wrote about how Democrats running in red states use "protection for people with pre-existing conditions" as a proxy for defending the ACA as a whole. In many states, Democrats still can't call the ACA by its name or discuss its actual programs. For example, in an ad that's gone viral, Joe Manchin never mentions the ACA -- or the ACA Medicaid expansion that has cut West Virginia's uninsured rate in half.  He's not alone.

Today brings two articles on how the healthcare debate is shaping up in races across the country. One qualifies my claim a bit; the other corroborates it.

In Huffington Post, Jonathan Cohn spotlights three gubernatorial races -- in Michigan, Ohio and Nevada --  in which the Democratic candidate is openly attacking the Republican for opposing Medicaid expansion, while the Republican is repudiating that past rejection. These are purple states, at least historically, that have increased their Medicaid enrollment by 1.3 million collectively since mid-2013. They've cut their combined uninsured populations from 2.9 million in 2013 to 1.5 million in 2017. according to Census survey results released this month.  Now, Republican candidates Schuette (Michigan), DeWine (Ohio) and Laxalt (Nevada) have all pledged to preserve the expansion, notwithstanding their prior opposition to it. In the governor's races, the expansion is an open topic of discussion.

Bring back the PPACA!

A reader writes: 

It is two years out [from Trump's election] and every major press outlet uses "Obamacare." That just polarizes things.

They should have come up with a better name than Affordable Care Act. That does not even capture modified community ratings – guaranteed issue –essential benefits – private enterprise (the  Republican plan). This is why Medicare for All getting better polling. 

My first thought was, imagine trying to get across "guaranteed issue,"  "modified community ratings" and "essential health benefits" in a bill title. Then a near-forgotten set of syllables popped into my head: the Patient Protection and Affordable Care Act (PPACA). "Patient protection," of course, is all about guaranteeing access to comprehensive coverage to all who want it -- including people with pre-existing conditions, who constitute somewhere between a fifth and half the population.

Nancy Pelosi famously/infamously said "we have to pass the bill so that you can find out what's in it," and people do understand and like the protections for people with pre-existing conditions. A Kaiser Family Foundation poll released today makes that clear:

Christopher Ruddy's alt-Trump

Christopher Ruddy, Trump buddy and CEO of the gaslight site Newsmax, wantonly misrepresents the ACA while proposing what he regards as a Tumpian alternative to "Ryan Care II" (for which Trump has now gone all-in, flaunting his powers of intimidation even as he yields to right-wing demands that the bill un-insure millions more swiftly).

Let's leave the lie-specking for later (see bottom).  Buddy Ruddy does Trump the doubtless undeserved honor of crediting his stated intentions for health reform as expressed in, for example, Trump's January 15 Washington Post interview:

“We’re going to have insurance for everybody,” Trump said. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.” People covered under the law “can expect to have great health care. It will be in a much simplified form. Much less expensive and much better.”

Also promised: "lower numbers, much lower deductibles."

There is only one mode of healthcare delivery in the U.S. that can deliver on those promises. And lo, Ruddy makes it his centerpiece -- Point 4 in a 7-point program:

Attention, Paul Krugman: Not everyone votes

Am I crazy or is Paul Krugman making a really elemental mistake here?

As Greg Sargent points out, the choice of Tom Price for HHS probably means the death of Obamacare. Never mind the supposed replacement; it will be a bust. So here’s the question: how many people just shot themselves in the face?

My first pass answer is, between 3.5 and 4 million. But someone who’s better at trawling through Census data can no doubt do better.

Here’s my calculation: we start with the Census-measured decline in uninsurance among non-Hispanic whites, which was 6 million between 2013 and 2015. Essentially all of those gains will be lost if Price gets his way.

How many of those white insurance-losers voted for Trump? Whites in general gave him 57 percent of their votes. Whites without a college degree — much more likely to have been uninsured pre-Obama — gave him 66 percent. Apportioning the insurance-losers using these numbers gives us 3.42 million if we use the overall vote share, or 3.96 million if we use the non-college vote share.

The assumption appears to be that everyone votes. Turnout this year is currently reported at 58.6%. It's probably lower for most of those who gained insurance via the ACA, as their incomes are below median: according to the Current Population Survey, almost three quarters of those who gained insurance in both 2014 and 2015 have incomes below twice the Federal Poverty Level, and nearly all have incomes under 300% FPL. Lower income people have lower turnout rates.  It would appear that Krugman's total needs to be sliced almost in half.

What's a healthcare article without a touch of Levitty?

It is a fact universally acknowledged among healthcare reporters that there are two ways to structure an article.

The first is to give Kaiser's Larry Levitt the lead quote to articulate or validate an asserted trend.

The second is to use other authorities to assert said trend -- and deploy Levitt about two-thirds down to inject a note of skepticism or a reality check. Today offers a perfect specimen of plan b: Gaming Obamacare, by Politico's Paul Demko.  The thesis is brought to you by the nation's insurers:

Obamacare customers are gaming the system, buying coverage only after they find out they’re ill and need expensive care — a trend insurers warn is destabilizing the fledgling health law marketplaces and spiking premiums for everyone.

700 words in, we're well prepped for the Levitt Reality Check:

More on Charles Gaba's "Two glaring errors in the WSJ anti-Obamacare editorial"

Charles Gaba has caught a couple of glaring errors in a Wall Street Journal editorial claiming that the ACA private plan marketplace is on the road to failure. The most important error misrepresents the state of the current and potential nongroup market -- that is, the pool of people who buy or could buy their health insurance on their own, with or without ACA subsidies.

Gaba captures the main point: that contra WSJ assertions, most of those who buy their insurance off-exchange are not subsidy eligible, and are mingled in the same risk pools as those who buy on-exchange. I'd like to further clarify, though, how much progress those markets have made toward full capacity, and to what extent those who are eligible for subsidies have so far enrolled.

Here's the WSJ editorial board's "state of the market" overview:

Alabama's Obamacare buyers ride a Silverado

Spotlight here is on Alabama in my continuing close look at how many low income ACA private plan buyers accessed Cost Sharing Reduction (CSR) subsidies by buying silver plans. (Yesterday, HHS released detailed county-level data about buyers of private plans on healthcare.gov, the federal exchange, enabling a close look at state stats.)

CSR is available to buyers with household incomes below 251% of the Federal Poverty Level (FPL), and strongest for buyers under 201% FPL. It is available only with silver plans, the second-cheapest of four metal levels available on ACA exchanges -- a fact that's less than obvious to the average shopper, Buyers under 201% FPL are leaving a really strong benefit on the table if they don't buy silver plans (see the note at bottom for more detail). I consider the percentage of buyers under 201% FPL who select silver an important measure of how well the exchange is functioning in a given state. (Those in the 201-250% FPL range are likelier to have good cause to forego the relatively negligible CSR provided at that level.)

Love in the time of Obamacare

Ah, mid-February, when love and ACA open enrollment both come to climax. Tis the (second annual) season for #Healthpolicyvalentines:

Affordable insurance?
I don't have any.
You are my only
Essential Health Bennie.

        *     *     *

I've turned 26
But what does my Mama care?
She knows I'll stay covered
Thanks to Obamacare.

      *     *     *

Bronze plans are skimpy,
Golds rake your bucks in.
Silver is sweet
with Cost-Sharing Reduction.

     *     *     *

The ACA and the white working class

When Bill Gardner this morning pointed out, as many have, that Americans approve of the core components of the ACA but disapprove of the law, I expected the corollary to be "slander works," or"it's really hard to communicate how these moving parts fit together," or some combination of the two.

Instead, I was confronted with this chart from a paper by Henry Aaron and Gary Burtless:

This subsidized health insurance was brought to you by...?

Urging caution in response to current ACA signup stats and polling results, Jonathan Bernstein reiterates his  favorite question with regard to the political fallout:

How many of those in the exchanges, in expanded Medicaid, and newly eligible for their parents’ insurance plans are aware that they are covered by Obamacare? I’ve consistently guessed that a large number of people wouldn't make the connection, but we still have no data.

I have always found the possibility that some people would sign up for coverage made available through the ACA without knowing that the ACA (or "Obamacare") was responsible fascinating and challenging. Sometimes Bernstein emphasizes that over time -- say, five years from now -- a lot of people who buy Qualified Health Plans or sign up for Medicaid on Healthcare.gov or the state exchanges won't know that their options originated with the new law. That seems easier to credit than that a significant percentage, if not a majority, of this year's signups would not know that "Obamacare" was the source of their coverage.

Regarding awareness among this year's signups, a few thoughts:

1. It takes a village:  Drew Altman, President of the Kaiser Family Foundation, points out that in California, which spent more on ACA outreach than all the federal exchange states combined, relatively few of the uninsured signed up on their own:

Twas the Night Before Shutdown (complete)

Twas the night before shutdown: the House changed its rules
To hold us all hostage to vain spiteful fools.

Poison pills had been stuffed in the CR with care
To deprive shiftless "others" of Obamacare.

A Senate CR, disinfected and clean,
Was blocked from a vote by the rightwing machine.

And Boehner with his baritone, and Cruz with his glower,
Took to podiums to prove gu'mmint could not sink lower.

So workers were furloughed and services shuttered.
The president was grounded, th'economy sputtered...

And all of a sudden the government mattered!
And Cruz and his crew with their own spite were spattered.

Twas the Night Before Shutdown...Twas the Night Before Default

The epic continues...

Then Collins cooked up something Murray could swallow,
Five queens signed on, and the old bulls clicked "follow":

Senate-House conference on terms uncoercive,
Tweaks to Obamacare none too subversive,

Debt ceiling bump-up and short CR, clean,
Sequester not locked in for 2014.

Markets exhaled and the indexes soared,
Till Boehner rolled one more grenade of discord:

"Don't touch that hostage! A price must be paid --
Even if only by us and our aides...

National default is a bridge none too far
To uphold our values -- whatever they are."

Thus Boehner spooled his caucus one last yard of rope
To twine round their necks, as the nation's last hope.

Lo, Heritage Action gave one mighty yank,
The diehards jumped ship, and the House CR sank.

    To be continued (if the world does...)

Twas the Night Before Shutdown, Canto I
UPDATE: Here's the whole thing

The party that loses by winning

On July 4, 2011, when the Republicans were in the process of nailing Obama to the debt ceiling, David Brooks wrote:

If the Republican Party were a normal party, it would take advantage of this amazing moment. It is being offered the deal of the century: trillions of dollars in spending cuts in exchange for a few hundred billion dollars of revenue increases.

With about $4 trillion in deficit reduction over ten years the agreed target, Obama was ready to settle for just $800 billion in new revenue, a roughly 4-to-1 ratio of spending cuts to revenue . But the GOP passed up Brooks' 'deal of the century.' A four-fifths win for the no-new-taxes-ever crowd wasn't good enough for them.

They did "win," though, by forcing Obama to swallow, under threat of national default, the Budget Control Act, which purported to match every dollar of debt ceiling increase with a dollar of deficit reduction, with no concession on the Republicans' part that any of that reduction would come through tax increases. Nor has it, now that Republicans have learned to love the sequester, or professed to. The BCA imposed over $900+ billion in cuts to discretionary spending over ten years, and then another $1.2 trillion through sequestration if a Congressional supercommittee could not agree on a plan to replace that second tranche with a deficit reduction package of equal value. Since Republicans would not agree to any sequester replacement including new revenue, it is still with us, and the DBA's deficit reduction mix remains (approximately, counting interest savings), spending cuts $2.5 trillion, revenue 0.

Democrats should shut down the government

Not really. But they should let Republicans shut down the government rather than agreeing to a two-month continuing resolution that will bring on debt ceiling apocalypse.

When word was that Boehner would postpone a budget showdown until the debt ceiling is reached in November and try to force a defunding of Obamacare then, I suspected that he and his party would shift gears and seek to extract more attainable budget concessions. That has now happened, as Chait summarizes:

The Republican leadership is perfectly aware that a debt default could have explosive implications and that the Obama administration is not willing to negotiate over it. It’s already formulating a line of retreat to back out of this threat. As Politico reports, they want to tie together negotiations over the debt ceiling with negotiations over budget sequestration. Then they can extract concessions from Obama on the budget and sell them to their base as a ransom for lifting the debt ceiling, rather than admit they just gave in on the debt ceiling.

"Gave in" is a relative term. Extracting further budget cuts beyond sequestration would be a major GOP victory by my lights, if not by the GOP base's. And they may get it. As Chait warns here and has warned before, a debt default (stemming from failure to raise the debt ceiling) is a " vastly more dangerous threat" than a government shutdown. Yet Chait, like Greg Sargent and Brian Beutler, seems to have more faith than I do about what Obama will not yield to if faced with a debt default: