ACA marketplace enrollment 2021-2023: Where the growth is and isn't

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The Open Enrollment Period for the ACA marketplace in 2023 was the second OEP in which the enhanced premium subsidies created by the American Rescue Plan Act (ARPA) in March 2021 were in effect. The table below shows enrollment patterns at different income levels and state groupings in what we can now call the post-ARPA era (extended through 2025 by the Inflation Reduction Act of 2022).

ARPA rendered benchmark silver coverage free at incomes up to 150% of the Federal Poverty Level; removed the previous 400% FPL income cap on subsidy eligibility, capping benchmark silver premiums at 8.5% of income above that threshold; and reduced the percentage of income required to buy a benchmark silver plan at income levels in between.

A data note before diving in: In the 18 state-based exchanges (SBEs), the data for enrollment at incomes above 400% FPL appears anomalous and probably erroneous, at least in 2022, as discussed at bottom. The far right column, which combines “income unknown” and reported incomes over 400% FPL (as well as income under 100% FPL, which was grouped with income above 400% FPL as “other” in CMS’s 2021 reporting) may give some idea of enrollment patterns at high incomes in the SBEs. Enrollment at income under 100% FPL, included by necessity, shouldn’t change much: it barely changed from 2022 to 2023, accounts for 1.4% of total enrollment and just shy of 10% of enrollment in the “<100%/>400% FPL/unknown category.”

Some takeaways from the data below:

ACA marketplace enrollment surged at high incomes in 2022

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Enrollment in the ACA marketplace has historically -- and appropriately -- been weighted toward people in low-income households. Lower income workers are less likely to have access to affordable employer insurance. While just 17% of the U.S. population is in households with income between 100 and 200% of the Federal Poverty Level (FPL), 52% of marketplace enrollees nationally had income in that range as of the end of the Open Enrollment Period (OEP) for 2021. In the twelve states that have still refused to enact the ACA Medicaid expansion, where most adults with income below 100% FPL have no access to subsidized insurance, more than half of enrollees have incomes below 150% FPL.

The American Rescue Plan Act, passed in March 2021, boosted premium subsidies in the ACA marketplace at every income level, removed the former income cap on subsidy eligibility (400% FPL), and made silver plans with strong Cost Sharing Reduction free at incomes up to 150% FPL, as well as much cheaper than previously in the 150-200% FPL income bracket (0-2% of income instead of roughly 4-6% for a benchmark silver plan).  During the emergency Special Enrollment Period that ran through half of 2021, fully 45% of enrollment in the 36 states then using the federal exchange, HealthCare.gov (where enrollment is dominated by the nonexpansion states) had income below 150% FPL. About 62% were below 200% FPL. Enrollment growth in OEP for 2021 (before the ARPA subsidy boosts were enacted) was also concentrated in nonexpansion states and heavily weighted toward low incomes in those states.

Given this history, as enrollment surged during the Open Enrollment Period for 2022, I was blithely confident that growth was concentrated at low incomes. I was wrong.  Texas health insurance broker Jenny Hogue was onto something:

Jenny Chumbley Hogue

@kgmom219 Replying to  @xpostfactoid

In my little corner of Texas, its not the 100%'ers that moved back, its the people who were getting killed with the subsidy cap pre-ARPA. A lot of conversations started with "is it true I can get a subsidy if my wife and I make more than $70K?".

Another Hanukkah miracle due in Week 7 of ACA Open Enrollment for 2020?

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Last year, enrollment in the ACA marketplace in the 39 states using HealthCare.gov trailed the prior-year enrollment pretty dramatically in each of CMS's "weekly enrollment snapshots."  By the end of Week 6, enrollment was at 88.3% of the total at the same point in December 2017.  Then lo, at the end of Week 7 the gap had shrunk from 12% to 4%.  What caused the late surge?

The surge was illusory. Week 1 was a day short last year. That was no mystery, and trackers accounted for it, noting that first-week enrollments stood at about 125,000 per day. What was not fully accounted for in advance was that the extra day made up in Week 7, which had seven enrollment days last year vs. just six in 2017, carried a lot more weight than the shorted November day, as enrollment is much heavier at the end of the season. As I noted at the time:

Virtually no enrollment loss in state-based ACA exchanges in 2018

I imagine it's been noted before, but states that run their own ACA exchanges collectively had virtually no enrollment losses in 2018, while enrollment in the 39 HealthCare.gov states shrank 5%.

The loss even among unsubsidized exchange enrollees in the state-based exchanges (SBEs) was very slight, just 1% -- compared to 10% in the HealthCare.gov states. After Trump cut off federal funding for Cost Sharing Reduction (CSR) subsidies, most of the SBEs silver-loaded CSR costs on-exchange, and allowed insurers to offer silver plans off-exchange with no CSR priced in (for an explanation, see note below). That includes California, which accounts for almost half of SBE enrollment. It might therefore have been expected that more unsubsidized enrollees in the SBEs would have moved off exchange. And where unsubsidized on-exchange enrollment did drop, it will be hard to determine if many may have enrolled in ACA-compliant plans off-exchange.