Kaiser: ACA marketplace at 70% capacity among subsidy-eligible

The Kaiser Family Foundation has published an updated assessment of ACA marketplace enrollment to date and what full capacity would look like.  At present, total signups for private plans in the marketplace nationwide stands at 12.7 million, a total that's likely to drift down to somewhere between 10 and 11 million by year's end.  Kaiser estimates that if the national marketplace matched the performance of the 10 best-performing states to date, 16.3 million would be signed up by the end of open enrollment, drifting down to about 14.7 million by year's end.

There's a lot to unpack here. At the outset, I want to highlight a couple of noteworthy findings, discussed in more detail below. The first one is not actually spelled out in this report.

• According to Kaiser's estimates, nationwide, at present about 70% of the subsidy-eligible potential marketplace customer base have signed up for marketplace plans. That will probably drift down to somewhere around 60% by year's end. Of 12.7 million total enrollees, 82%, or 10.4 million, were subsidized. According to Kaiser's Sept. 30, 2015 estimate, 14.8 million Americans were potentially eligible for premium subsidies at that time.


• Kaiser's findings as to which income groups are cutting their uninsurance rates most dramatically* raise questions about the prevailing understanding of who finds the marketplace most attractive, at least by implication. Both Avalere Health and the Urban Institute have found that eligible marketplace shoppers with the lowest incomes have high takeup rates, which drop sharply and steadily with income. Kaiser finds that people in the lowest income bracket, below 150% FPL, have the second-lowest reduction in their uninsured rate among the income groups -- just an 18% reduction, compared to 33% reduction at 150-200% FPL, 23% at 200-300%, and 22% for those above 400% FPL (and so subsidy ineligible).

How the ACA reversed two decades of insurance bleeding for the near-poor (and cut uninsurance for the poor too)

I've noted before that while the ACA works best for uninsured people with incomes under 200% of the Federal Poverty Level (FPL),* that's also where the uninsured are concentrated. While just about exactly one third of the U.S. population is below 200% FPL,  55% of the uninsured were below that level in 2013,  according to the Census Bureau's  Census' Current Population Survey 2015 Annual Social and Economic Supplement.**

A Health Affairs article by Nicole Huberfeld and Jessica Roberts spotlights one reason for the concentration of the uninsured at low income levels. While the availability (or affordability) of employer-sponsored insurance has dropped for all income levels since early this century,

The decreases in coverage were measurably greater for middle- to low-income workers; for example, those earning more than 400 percent of the federal poverty level (FPL) experienced a 2.8 percent drop in employer-sponsored coverage from 2000 to 2011, but people earning less than 200 percent of the FPL experienced a 10.1 percent drop in employer-sponsored coverage.

That snippet sent me to the most recent National Health Interview Survey  (NHIS) update, which indicates that the ACA has plugged this gap by making both private and public insurance available to lower income workers. (Stats for 1997-2010 are here.)

Hey, Jeb! Who's getting those "huge new subsidies" under the ACA?

Touting his new ACA replacement plan, which would wipe out ACA coverage rules for insurers and replace means-tested ACA private plan subsidies with tax credits for catastrophic coverage available at any income level, Bush asserted:

Obamacare created huge new subsidies for low-income Americans, but it left middle-income Americans facing higher premiums and higher out-of-pocket costs.

There are some grains of truth to that.  People who 1) get their insurance in the individual market,  2) earn too much to qualify for subsidies (that is, over 300-400% of the Federal Poverty Level (FPL)), and 3) don't have pre-existing conditions pay more  than they would have pre-ACA.* You could argue, too, that the ACA has driven up out-of-pocket medical costs, if not premiums, for people with employer-sponsored insurance (ESI) -- or at least that it will do so once the Cadillac Tax kicks in, if it ever does. The claim is highly contestable, though, as neither premiums nor out-of-pocket costs have risen faster in ESI than in pre-ACA years and myriad factors are at work. Really, it's simply too early to tell.

But Bush's statement, like most Republican claims to speak in defense of "the middle class," reveals a top-heavy view of what "middle class" means. His sneer at "huge subsidies" is also a sneer at huge swaths of the U.S. population -- where the uninsured are concentrated.

A recent Census report** indicates that in 2014 the ACA caused large drops in the uninsured rate among Americans with incomes under 100% FPL ( a 4.2 point drop, from 23.5% to 19.3%), 100-199% FPL (a 5.3 point drop) and 200-299% FPL (4.2 points.).