ACA marketplace enrollment in Covid-19 season: Flat? Up a million? Both?

Subscribe to xpostfactoid 

 As millions of Americans lose job-based health insurance during the pandemic months, Medicaid, bolstered by the ACA Medicaid expansion, has served as a far more potent protection against becoming uninsured than the ACA marketplace, for several reasons:

1. As family incomes crash, about twice as many newly unemployed and uninsured become eligible for Medicaid as for subsidized marketplace coverage, according to Urban Institute calculations (2.4 times as many in expansion states; 1.6 times as many in nonexpansion states).  Medicaid eligibility is determined on a current monthly basis, while marketplace subsidies are calculated on the basis of estimated annual income.


2. The emergency extra $600/week unemployment insurance provided for up to four months (now expired) by the CARES Act does not (did not) count with respect to Medicaid eligibility, but did count in calculation of marketplace subsidies, severely weakening them (it continues to count, since the relevant measure is annual income).

Surprise/no surprise: ACA marketplace enrollment is UP in 2020 (on-exchange only)

Subscribe to xpostfactoid

Mystery of the ACA marketplace: every year since 2016, while total signups during Open Enrollment have ticked down, the percentage of those who effectuate their enrollment by making their first payment has risen.

On Friday CMS released 2020's first Effectuated Enrollment Snapshot, showing enrollment as of February. Enrollment is about 1% higher than in February 2019, though it was about 0.3% lower as of the end of Open Enrollment. It's also slightly higher than in February 2018.  The gap between total plan selections as of the end of Open Enrollment and effectuated enrollment after all first payments are due is the lowest ever.

The feds are taking cost sharing and premium subsidies away from many ACA private plan enrollees

CMS's latest snapshot of private plan enrollment in ACA marketplaces shows significant attrition, from 10,197,187 total enrollments as of March 31 to 9,949,079 as of June 30, a drop of 2.4%. That's mainly -- in fact entirely -- because of stepped-up enforcement of citizenship or immigration status.

That increased vigilance also explains an apparent anomaly that jumped out at me from the numbers: the drop in plan holders whose plans are enhanced with Cost Sharing Reduction (CSR) subsidies is larger than the drop in enrollment among silver plan holders. Since CSR is available only with silver plans, one might have assumed that a drop in CSR enrollment would simply reflect a drop in silver plan enrollment among those with incomes under 250% FPL, the cutoff for CSR eligibility. Yet CSR enrollment dropped by 278,103 -- 4.8% -- compared to a silver enrollment drop of 142,336 (2.0%).

It turns out that the marketplaces are cracking down on enrollees whose stated income doesn't match other data, presumably mainly from tax returns, and reducing or withdrawing CSR benefits as well as premium subsidies when enrollees don't verify their income claims. That's in tandem with increased enforcement with respect to immigration or citizenship status. Here's the explanation: