Where are Pennsylvania's low-income 2014 private plan enrollees?

As I've noted before,  I've been been trying to determine what happened to Pennsylvania's apparently large number of  low-income 2014 private plan enrollees who became eligible for Medicaid when the state belatedly enacted the ACA Medicaid expansion, effective Jan. 1 2015. My working hypothesis has been that large numbers of them stayed auto-enrolled in QHPs -- or re-enrolled prior to the expansion kickoff in December. Detailed enrollment data released by HHS early this month calls that notion into question however.

Here was the original premise. Most of Pennsylvania's 2014 enrollees in private plans (so-called Qualified Health Plans, or QHPs) re-enrolled for 2015.  As of May 2014, Pennsylvania had 318,000 enrollees. As of the end of open enrollment in mid-Feburary 2015, 276,732 were re-enrolled, according to the breakout HHS published this month. A large percentage of those re-enrollees might now be Medicaid-eligible -- and so theoretically ineligible for private plan subsidies. I had originally estimated that about one third of QHP enrollees as of late 2014 -- perhaps 90,000 -- had incomes under 138% of the Federal Poverty Level (FPL), which would qualify them for Medicaid. Then I learned that by February, CMS had compiled a a list of 141,000 Pennsylvania households with at least one QHP enrollee determined to be Medicaid-eligible (CMS has confirmed this for me.)  If accurate, that's close to or more than half of PA's QHP enrollees as of late 2014 (Those households had some 175,000 members).

Moreover, for 2015 the state had 160,961 auto-enrollments - enrollees who took no action and so were automatically re-enrolled in their 2014 plan or a substitute provided by their insurer.  That suggests a large potential pool of people who may not have noted or chose to ignore their eligibility for what was originally Pennsylvania's "private option" Medicaid expansion, which was quite rocky at the outset.

Why am I now questioning this premise? The current income distribution of Pennsylvania's QHP enrollees, revealed in the data HHS published in early July, looks more like that of an expansion state than a nonexpansion state. As of of the end of open enrollment in mid-February 2015, 131,470 out of a total of 472,697 Pennsylvania QHP enrollees, or 28%, had incomes in the 100-150% FPL range.

In Washington State, too many low-income bronze plan buyers

Washington HealthPlanFinder, the state's ACA exchange, has set the standard for enrollment data reporting, providing a more detailed and complete account of private plan buyers' demographics and behavior than any other state to date. Washington is a wealthy state, with a median household income (2013) of $60,106, compared to a national median of $51,939.   Its buyers of private plans on the exchange (known as Quality Health Plans, or QHPs) are accordingly a much wealthier group than the average among the 37 states that used the federal exchange, healthcare.gov.

Only 12.5% of Washington's QHP buyers have incomes under 150% of the Federal Poverty Level (FPL), compared to 24% in those healthcare.gov states that accepted the Medicaid expansion -- and 50% in healthcare.gov states that refused the expansion. (In non-expansion states, eligibility for QHP subsidies began at 100% FPL, versus 138% FPL in expansion states, and those between 100 and 138% FPL swelled the QHP enrollments, accounting for about a third of all enrollments in non-expansion states.) Low takeup in this low-income band perhaps explains in part why Washington has reached just 32% of its target QHP market as calculated by the Kaiser Family Foundation, versus 42% for the nation as a whole. Conversely, Washington has been very successful in expanding its Medicaid rolls. The enrollment report tallies 533,628 "Medicaid expansion adults," far exceeding a 2012 Urban Institute forecast of 330,000.

Too many poor buyers of bronze plans

While Washington's relatively small number of enrollees in the 100-150% FPL income band may be in large part a matter of demographics, there is one way in which the state exchange has seemingly failed lower-income buyers. Takeup of Cost Sharing Reduction subsidies, available only with silver plans and only to buyers with incomes below 250% FPL, is lower in Washington than on healthcare.gov, and much lower than in states like New York and Connecticut that take special measures to highlight CSR for those who are eligible for it.