Total marketplace enrollment likely approaches 13 million

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Axios reports that Vice President Harris will announce today that more than 2.5 million people have signed up for marketplace coverage during the emergency Special Enrollment Period that began on February 15 and ends on August 15. (Yesterday, Charles Gaba estimated 2.57 million total SEP enrollments as of July 31.) [Update: CMS's SEP report through July 31 is out and cites the 2.5 million total.]

Just for fun, let's take a stab on where total marketplace enrollment likely stands right now. 

We know that effectuated enrollment totaled 11,290,546 in February, and that about 2.5 million additional enrollees have been logged since then. The wild card is disenrollments during those months. To estimate them, our best hints come from monthly enrollment tallies in 2020, recorded in the effectuated enrollment snapshot for February 2021.

A huge increase in low-income ACA marketplace enrollment in nonexpansion states

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This is a postscript to my last post tracking massive SEP enrollment in nonexpansion states from February 15-June 30 of this year.  

I want to try to take the full measure of the enrollment surge in nonexpansion states at the lowest subsidy-eligible income level -- first in Open Enrollment season for 2021, and then in the emergency Special Enrolment Period (SEP) launched by the Biden administration on Feb. 15. This week, CMS reported SEP enrollment through June 30.

(This post is all numbers; please see the last post (and its backlinks to past posts ) for context, definitions, explanations.)

By my estimate, enrollment at the 100-150% FPL income level in 13 nonexpansion states (Wisconsin excluded*) in OE 2021 and the SEP for the Feb. 15-June 30 period combined exceeded 2020 enrollment in those two periods by almost 800,000.  That would be an increase of about 29%.

Three quarters of recent SEP enrollment on HealthCare.gov is in nonexpansion states

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HHS announced yesterday that new enrollments in the emergency Special Enrollment Period that began on February 15 totaled 1.24 million through May 31 in the 36 states using HealthCare.gov. That's more than triple enrollments during the same time period in 2019, the last "normal" year in which enrollment was unaffected by the pandemic. Further, HHS pointed out that since the enhanced subsidies enacted in the American Rescue Plan appeared on HealthCare.gov on April 1, 43% of new enrollees selected plans for which they will pay $10 per month or less.

Charles Gaba pointed out yesterday that the single biggest determining factor of how much a state's SEP enrollment has increased over pre-COVID time is whether the state has enacted the ACA Medicaid expansion.  Say that again.

Of the 1.2 million new enrollees, three quarters were in 13 states that had not enacted the ACA Medicaid expansion as of May 31 -- excluding Wisconsin, which offers Medicaid to state residents with incomes up to 100% of the Federal Poverty Level.*

ACA's emergency Special Enrollment Period most effective in states that have not expanded Medicaid

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CMS has released a report showing strong response in the first six weeks to the emergency Special Enrollment Period for the ACA marketplace that commenced on February 15. The emergency SEP, now extended to August 31, allows anyone who is uninsured to enroll in marketplace coverage, and allows current enrollees to change plans. From February 15 through March 31, 528,000 people enrolled via SEP this year, compared to 209,000 in 2020 and 171,000 in 2019.

The CMS report also highlights increased relative enrollment shares for black and lower income enrollees. In particular, the SEP is being accessed in large numbers by enrollees with incomes in the 100-138% FPL range -- that is, enrollees in states that have refused or not yet enacted the ACA Medicaid expansion who would be eligible for Medicaid had their states already embraced the expansion:

Among consumers requesting financial assistance, 41% have a household income between 100% and 138% of the federal poverty level, compared to 38% in 2020 and 33% in 2019.

The SEP continues a 2021 pattern: the pandemic, and government action to mitigate its financial impact, have boosted enrollment more in nonexpansion than in expansion states. In the Open Enrollment period for 2021, enrollment increased by 10% in nonexpansion states and was virtually flat in expansion states (up slightly in states that run their own exchanges, down slightly in expansion states that use HealthCare.gov).  

In the first six weeks of the emergency SEP, enrollment in expansion states using HealthCare.gov was up 95% over same-period SEP enrollment in 2020. In the nonexpansion states (all of which use HealthCare.gov), enrollment was up 176% year-over-year. Among the 36 states using HealthCare.gov in 2021, nonexpansion states accounted for 70% of SEP enrollment from Feb. 15--March 31 in 2020, and 77% this year.  

Here's the state-by-state breakout:

The ACA as it should have been: Massachusetts' ConnectorCare in a crisis

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On March 11, the Massachusetts Health Connector became the first ACA marketplace to respond to the flood of job losses triggered by the Covid-19 pandemic by opening an emergency Special Enrollment Period (SEP) in which any uninsured resident could enroll in private market coverage. Eventually, 12 of the 13 state-based exchanges opened emergency SEPs, whereas HealthCare.gov, the federal exchange serving 38 states, declined to do so, though HealthCare.gov has taken steps to ease the normal SEP-for-cause application process. 

On  May 1, Massachusetts reported that in the SEP's first 40 days, 8,300 state residents had gained coverage specifically through the emergency SEP, while 20,200 in total had enrolled in coverage in March and April -- the bulk of them via ordinary SEPs, in which an applicant reports a life change, usually loss of other insurance, that qualifies her to enroll outside of the annual fall Open Enrollment period.

It's hard to assess the success or impact of the emergency SEPs based on these kinds of data snippets, which several state marketplaces have put out. On the whole, March/April enrollment in Massachusetts represents 6.3% of enrollment as of the end of Open Enrollment in January. That does seem a somewhat elevated off-season pace.* In any case, it's likely that Medicaid will pick up the lion's share of the newly uninsured, and the enrollment report did not include Medicaid numbers.

HealthCare.gov will not require proof of loss of coverage from the newly uninsured

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CMS has refused to follow the lead of the thirteen state-based ACA marketplaces and open an emergency Special Enrollment Period (SEP) in the 38 states using HealthCare.gov, the federal ACA enrollment platform.  But the agency is taking smaller steps to smooth the enrollment path for the newly uninsured.

An emergency SEP would allow anyone who's uninsured to seek coverage in the marketplace as they can during the yearly Open Enrollment period, which on HealthCare.gov runs from Nov. 1 - December 15. Instead, only those who have have a qualifying "life change" -- e.g., loss of job-based coverage -- can enroll in marketplace plans. That requires applying for a SEP, which is a process in itself.  (Medicaid enrollment is open year-round, but many of the newly uninsured may not be aware if they're Medicaid-eligible -- all uninsured need a general message that coverage of one kind or another is available.)

Yesterday, Amy Lotven of Inside Health Policy reported (paywalled) that CMS has created a new Covid-19 page (parts of which I reviewed in my previous post) -- and, more significantly

CMS is providing flexibility around submission of certain documents, such as a document confirming loss of coverage from one’s employer, during the pandemic emergency, the agency says.

Smooth the path to Medicaid enrollment for the newly uninsured

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As tens of millions of Americans lose job-based health insurance, the heavyweight in reducing the ranks of the newly uninsured is going to be Medicaid -- at least, in the 36 states that have enacted the Medicaid expansion  (and if Democrats don't push through a 100% COBRA subsidy). Medicaid will far outweigh the ACA marketplace for several reasons:

• Medicaid eligibility is based on monthly income, whereas marketplace subsidy eligibility is based on annual income. Mid-year, marketplace subsidies are therefore weakened by income earned year-to-date.
• The average normal unemployment benefit nationally is $378 per week* -- close to the Medicaid eligibility threshold in expansion states for a single person ($1468/month) and well below the threshold for any larger family. 
• The extra $600/week UI benefit provided for up to 4 months by the CARES Act does not count as income for Medicaid eligibility purposes, but it does count toward subsidy eligibility in the ACA marketplace. 

Squinting at likely new Medicaid and marketplace enrollment as job losses accelerate

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Charles Gaba has used early enrollment data from state-based ACA marketplaces that have opened up emergency Special Enrollment Periods to hazard an estimate: If HealthCare.gov, the federal exchange that handles ACA marketplace enrollment for 38 states, were to open a no-strings attached emergency SEP for sixty days, about a million more people than usual would enroll in marketplace plans in those two months.

That's based on a rough quadrupling of normal off-season enrollment in 3 states (Maryland, Colorado, Minnesota) that have opened emergency SEPs that enable applicants to complete an application online, more or less as they would during the yearly Open Enrollment season. (In 3 states that require emergency SEP applicants to initiate the application with a phone call (Connecticut, Washington, Nevada), enrollment is up just 22-35%.) As of 2015, about 6,000 people per day were enrolling via HealthCare.gov in nine months outside of Open Enrollment season. An extra 18,000/day for 60 days (assuming an easy, wide open SEP) would come to 1,080,000 additional new enrollees.

A few further observations:

• Process matters: The difference in states that enable online applications vs. those that require a phone call to begin the process appears dramatic, though data is scarce at this point (12 SBEs, including California and New York, have opened emergency SEPs; just six have released any data).  That said, HealthCare.gov, for which CMS refused to open an emergency SEP, requires those who lose job-based coverage to verify the date they lost coverage in writing before they can enroll in a marketplace plan.  With 10 million newly unemployed in a two-week period, that could cause an administrative train wreck.


• More than two months? While an emergency Special Enrollment Period must maintain the perception that enrollment isn't open year-round, so that people don't wait until they get sick to enroll, a continuing crisis is likely to lead to continuing extensions, as has already happened in many states.


• Early days yet: Shelli Quenga, Director of Programs at the Palmetto Project in North Charleston, South Carolina, said last week that her agency was so far busiest helping people get food stamps: "people have to eat every day, so they think more about their food benefits than they do about their health benefits." That's a typical sequence of concerns, according to Quenga.


• Early days, Part B: While enrollment from the 10-odd million newly unemployed as of April 2 hasn't fully gotten going, the tidal wave of job losses probably hasn't peaked yet.


• Medicaid will matter more: Gaba reports that in Maryland, SEP enrollment from March 16 through April 6 totaled 8,454 in Medicaid (which is open year-round) and 5,735 in the marketplace. [Update, 4/23/20: MNSure, the Minnesota ACA exchange, announced SEP enrollment numbers yesterday that showed a similar percentage of users, 60%, applying for either Medicaid or MinnesotaCare, a Medicaid-like "basic health program' available to applicants in the 139-200% FPL income range.] The CARES Act, signed into law on March 27, will likely further skew enrollment toward Medicaid. As I've noted previously, the $600/week extra unemployment benefit the new law provides for up to four months counts as income for the purpose of calculating ACA marketplace subsidies, but not toward Medicaid eligibility. Up to $10,200 of extra income will disqualify many marketplace applicants for secondary Cost Sharing Reduction subsidies and render others ineligible for premium subsidies, or else will sharply reduce those subsidies. 

One widely circulated projection, from Health Management Associates, foresees up to 35 million Americans losing job-based coverage, with a mid-range estimate of 23 million, which comes to an unemployment rate of 17.5%.  Health Management foresees enrollment in ACA-compliant private plans remaining more or less flat, as some marketplace enrollees switch to Medicaid. In the mid-range estimate, Medicaid enrollment grows by some 17 million as the uninsured population rises from 29 million to 34-35 million.

I had missed the likelihood of people shifting from marketplace to Medicaid. The differing tax treatment should accelerate that too. At the same time, the unemployment income boost should newly qualify some people in states that have refused the ACA Medicaid expansion for marketplace coverage by raising their countable household income over 100 % FPL.

Related:
ACA enrollment train wreck coming
Our emerging public option: Medicaid
CARES Act may reduce coverage gap in states that refused to expand Medicaid
Enhanced unemployment benefit will skew marketplace enrollment
Emergency special enrollment periods in 12 states: How easy?
How about an emergency Special Enrollment Period for the ACA marketplace?

ACA enrollment train wreck coming

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Update, 4/21/20: On a CCIO webinar for enrollment assisters, a moderator said that HealthCare.gov as of now is accepting simple attestation from an applicant that she has lost health coverage -- the marketplace is not requiring documentation of loss of coverage. That's very good news.

On Tuesday, the Trump administration dashed widespread hopes that it would open an emergency Special Enrollment Period in the ACA marketplace for the 38 states using HealthCare.gov, the federal exchange, allowing anyone who was uninsured to apply for coverage. Twelve of the thirteen state-based exchanges have opened such emergency SEPs, and most are extending the deadline.

The White House told reporter Amy Lotven that an emergency SEP is not needed because "there's already special enrollment for job loss." That's wrong, as Charles Gaba and others pointed out: there's a SEP for loss of insurance that usually follows job loss.

Not only does that ordinary SEP exclude those who were uninsured before job loss -- it's also likely to make obtaining insurance a dauntingly difficult and dangerously slow process for the millions who do lose employer-based insurance and seek new coverage through HealthCare.gov.

The normal SEP crawl

Shelli Quenga, Director of Programs at the Palmetto Project in North Charleston, South Carolina, a nonprofit brokerage* serving primarily low income clients, explained to me that obtaining a SEP after loss of job-based (or other) insurance coverage is difficult in the best of times. "The process is deliberately cumbersome, and it's going to cause people to remain without coverage," she worries.

The newly unemployed also need an emergency Special Enrollment Period

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After a week or two of rumors that the Trump administration would open an emergency Special Enrollment Period (SEP) on HealthCare.gov, the federal ACA exchange used by 38 states, the administration announced on Tuesday that it would not do so. Twelve of the thirteen state-based exchanges have announced emergency SEPs since March 10, with only Republican-ruled Idaho demurring.

As Jeff Young put it, team Trump could not choke down "an admission that the law and its benefits help people." Their spite will likely cost some people their lives and others all their worldly wealth. As the Kaiser Family Foundation's Larry Levitt noted, some 9.2 million of the nation's uninsured were eligible for ACA marketplace subsidies at last count (i.e., as of 2018).

Normally, enrollment in ACA-compliant private plans is only possible during Open Enrollment, which runs Nov. 1 - Dec. 15 in HealthCare.gov states. A SEP is available at other times only to those who undergo a "life change," such as loss of employer coverage, marriage, divorce, death of a family member, etc.

Whether fear of COVID-19 and the huge costs of hospitalization (ranging from about $9,000-90,000 by Kaiser's estimate) would induce many of the uninsured to seek coverage is an open question.*  Poor takeup among the subsidy-eligible has persisted since the ACA marketplace launched. The 9 million subsidy-eligible uninsured estimated by Kaiser roughly match total on-exchange enrollment. Takeup is better among those rendered eligible for Medicaid by the ACA expansion, but Kaiser also estimates that about 7 million uninsured are eligible for Medicaid and CHIP. An emergency SEP, plus a concerted public information campaign, might shrink those ranks.

The main benefit of an emergency SEP opened unconditionally to all may lie elsewhere, however. ACA enrollment can be complicated at the best of times. An ordinary SEP, including one triggered by job loss and attendant insurance loss, adds friction.  An applicant has to attest to and verify the loss of insurance; the marketplace has to confirm it, grant the SEP, and then open the gate. In some states, accepting evidence of loss of coverage is up to the insurance company with which the applicant seeks to enroll.

Emergency Special Enrollment Periods in 12 state ACA marketplaces: How easy?

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Update, 4/7/20: Early emergency SEP data collected by Charles Gaba indicates that states that require a phone call to begin the SEP application are seeing slower enrollment than states where an emergency SEP application can be completed online.

Twelve of the thirteen states (including D.C.) that run their own ACA marketplaces have announced emergency Special Enrollment Periods to help the uninsured get covered while the Coronavirus rages. Washington state was first to announce a SEP,  on March 10. CMS is "evaluating" following suit for the 38 states using the federal platform, HealthCare.gov. Idaho is the only holdout (and only red state) among the SBEs.

Kudos to the states that have taken the plunge. May it go smoothly operationally. Some began with some messaging confusion, e.g., info about the emergency SEP that seemed contradicted by older messaging about conventional SEPs, granted only to individuals for life changes such as job loss instead of to anyone seeking insurance. Most of those have been straightened out, but some mixed messaging lingers.  Below, a sampling of clear and not-so-clear home page messaging.