The second-biggest health insurance exchange in the U.S. is...

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Almost from the (extremely rocky) inception of the ACA marketplace in fall 2013, CMS encouraged the development of commercial Direct Enrollment (DE) platforms. These were websites hosted by commercial brokers and health insurers themselves that could collect income and other eligibility data and send it to the federal exchange, HealthCare.gov, which would determine subsidy eligibility and then send the application back to the private platform for completion of the enrollment process.  During Open Enrollment for 2019, CMS began approving brokers for Enhanced Direct Enrollment, EDE, which enabled commercial brokers to complete the whole transaction. At present there are 43 approved EDE platforms interfacing with HealthCare.gov, mostly hosted by health insurers.

The Trump administration encouraged DEs and EDEs, in keeping with its general enthusiasm for commercial brokers and hostility toward the federally established nonprofit Navigator program, for which it gutted funding -- not to say the government-run exchanges.  EDE promotion also dovetailed with the Trump CMS's development of a parallel ACA-noncompliant market of medically underwritten, lightly regulated "short-term limited development" (STLD) plans (which the administration rendered neither short-term nor of limited duration unless state governments make them so). Brokers that deploy DEs or EDEs can sell and promote STLD plans, though not on the DE/EDE platform per se. Development of the DE/EDE program had begun in the Obama administration, however.

HHS devotes $4.8 billion to COVID-test the uninsured. P.S. How about insuring them?

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HHS announced today that it is dedicating $4.8 billion in American Rescue Plan funds to reimburse providers for providing Covid-19 testing to the uninsured, at no cost to the uninsured patient. That's a continuation of a program initiated last spring. So far, $2.5 billion has been allocated by the Health Resources and Services Administration (HRSA) for such reimbursement.

Am I letting a current preoccupation distort my vision in seeing something of a lost opportunity (and irony) in this HHS statement?

There are approximately 29 million uninsured individuals living in the United States. While this administration has been focused on decreasing the uninsured rate, as evidenced by the more than 1 million people who have enrolled into quality health coverage through the Special Enrollment Period (SEP), much work remains. By ensuring programs like the HRSA COVID-19 Uninsured Program remains adequately funded, this administration is removing cost impediments so anyone exposed to COVID-19 may seek appropriate testing and care.

The funding announced today is dedicated to COVID-19 testing. HRSA also helps uninsured individuals’ access COVID-19 treatment and vaccinations through the COVID-19 Uninsured Program.  The program reimburses providers at national Medicare rates for providing these services.

Putting the "Affordable" in the Affordable Care Act: A role for the IRS

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 After the boost to ACA marketplace subsidies enacted as part of the American Rescue Plan Act (ARPA), the largest remaining bar to affordable coverage for all but undocumented Americans (who are barred from any government help for coverage) may be the affordability threshold for employer-sponsored insurance. It's ridiculously high. The IRS can provide some relief now, without portentous rulemaking.

The ACA defines employer-sponsored insurance (ESI) as affordable if a plan providing Minimum Essential Coverage (MEC) as defined by the ACA costs less than 9.5% of income. That baseline is adjusted annually to account for inflation in premiums in excess of inflation in the consumer price index and currently stands at 9.83% of income.  MEC is equivalent to bronze-level coverage in the ACA marketplace, which typically means a single-person deductible in the $7,000 range. Those for whom an employer's offer of insurance is deemed affordable are ineligible for ACA marketplace subsidies (though not ineligible for Medicaid). KFF estimates that 3.5 million uninsured people are in this category.

Obamacare enrollment at vaccination sites, part 1

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                                             Getting jabbed? Get covered too!

11 million uninsured Americans are eligible for ACA marketplace subsidies, according to KFF estimates. With the premium subsidy increases enacted in the American Rescue Plan Act (ARPA) in March, coverage can credibly be called "affordable" for most of them.  Another 7.3 million uninsured people are eligible for Medicaid, per KFF.

Ignorance of these offerings is rife. Less than a third of the public knows the ACA is still law, again according to KFF. Enrollment outreach, sabotaged by the Trump administration, has always been a challenge (as has the difficulty of navigating the application for some but not all enrollees).

While considering incremental ways to improve the ACA in my last post, it dawned on me that enrollment outreach at vaccination sites, or via email and texts connected with vaccination, was a golden opportunity to reach the uninsured.  Like most lightbulb thoughts, this one was far from unique.  It's occurred to many professional enrollment assisters -- probably hundreds. Some have acted on the thought.

The ACA as it should have been and may yet be: beyond premium subsidy boosts

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The Wall Street Journal's Stephanie Armour succinctly captures where Democrats seem to be at on the healthcare reform front:

Many progressive Democrats and President Biden are facing the political reality that far-reaching healthcare overhauls aren’t likely to succeed in the short term, which means their hopes may rest instead on building on recent Affordable Care Act changes and reducing prescription drug costs.

That is, make the premium subsidy boosts in the American Rescue Plan Act (ARPA) permanent, and maybe maybe maybe pay for it by getting some tangible form of prescription drug cost control past Democratic moderates. 

Pretty plainly left behind is the centerpiece of candidate Biden's healthcare plan, which also happens to be the continually submerged Ur-template for Democratic healthcare reform:

One more note to subscribers: feedburner stopped

 Dear xpostfactoid subscribers: as I noted a couple of weeks ago, Google is discontinuing feedburner, the subscriber service that's delivered xpostfactoid this many a year, as of July.  I accordingly transferred subscriptions to follow.it, and as the new service seems to be functioning adequately, I just cut the cord with feedburner. If you've been annoyed by getting two emails for each post, apologies: that ends now.  And if you haven't subscribed via follow it, please do, via the box at right. Thanks for reading...

In New Jersey, silver plans are free or all but free up to 200% FPL

When New Jersey launched supplemental state premium subsidies along with the launch of its state-based ACA marketplace, GetCoveredNJ, in the fall of 2020, I was somewhat taken aback to note that the state subsidies were heavily weighted toward enrollees at higher incomes. 

The supplemental NJ subsidies ranged from $20/month at an income of 138% FPL ($17,609 for an individual) to $95/month, beginning at an income somewhere between 250% and 300% FPL (around $38,000 for 40 year-old individual, according to my price checks on GetCoveredNJ).

As I noted at the time,

The smaller subsidies at low incomes leave substantial premiums in place at incomes below 200% FPL for silver plans, which carry a strong CSR [Cost Sharing Reduction] benefit up to that income threshold.

For a 40 year-old with an income of $25,000 (just under 200% FPL), the lowest cost silver plan in most of the state will cost $86/month. The deductible is $800; the out-of-pocket maximum is $2,600. The lowest cost bronze plan is $17/month, with a deductible of $6,000 and an OOP max of $7,000. Last year, cheapest silver would have cost about $125/month. 

Well, the American Rescue Plan Act (ARPA), signed into law in March, with an extra boost from New Jersey, has solved that problem, at least through 2022 (and hopefully beyond, if Democrats make the new subsidy levels permanent as they intend).  New Jersey's income-weighted subsidies mesh quite well with the subsidy boosts provided by ARPA, which reduced premiums for a benchmark (second cheapest) silver plan with strong CSR to $0 at incomes up to 150% FPL and to 2% of income at 200% FPL.

The New Jersey supplemental subsidies all but wipe out premiums for a silver plan all the way to 200% FPL.  Here's what's available to a 40 year-old with an income of $25,500:

Emergency SEP enrollment, shrinking attrition boost ACA marketplace enrollment beyond yearly top lines

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In a report issued last September, Covered California, the golden state's ACA exchange, announced that effectuated enrollment in private health plans through the exchange had reached an all-time high of 1.53 million (1,527,730) as of June 2020.   That was in the midst of an emergency Special Enrollment Period (SEP), effectively a second open enrollment season, implemented by California in response to the Covid-19 pandemic.  (In normal years, SEPs are open only to individuals who can demonstrate a qualifying "life change," such as loss of job-based insurance.)

The emergency SEP ran from March 20 through August 31, 2020. According to the September report, SEP enrollment increased by more than 100% over the same period in 2019, to 289,460.  As the CoveredCA report stresses, that's in contrast to a mere 27% increase in SEP enrollment in the 38 states then using the federal exchange, HealthCare.gov, for which the Trump administration refused to open an emergency SEP.  In September, active membership enrolled through CoveredCA reached a new all-time high, 1,551,470.  

Driven largely by the boost in SEP enrollment, plan selections as of the end of OE 2021 in California finally surpassed their 2016 high point of 1,575,340, reaching 1,625,546. (The term "plan selections" acknowledges that not all those who "enroll" in plans during OE make a first payment and thus "effectuate" enrollment and become, in CoveredCA parlance, "active members").  

While plan selections as of the end of OE have always served as the headline number for ACA marketplace enrollment, they provide a somewhat misleading picture. Every year, an average of about 10% of those who "enroll" in plans during OE never pay their first premiums, and attrition continues throughout the year, as disenrollments exceed SEP enrollments -- at least through 2019, the last year for which monthly enrollment has been published.  But attrition has been shrinking beginning in 2018, perhaps because the silver loading that began that year sharply reduced net-of-subsidy premiums for many enrollees, including a substantial number who paid zero premium.  In 2016, national enrollment as of December was 28% below the end-of-OE total for plan selections. In 2019, December enrollment was just 20% below the end-of-OE tally.

One quarter of the U.S. population is on Medicaid

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Time for an estimate of Medicaid enrollment growth since the eve of the pandemic, February 2020.  Monthly enrollment growth may finally be slowing, though it probably will not stop until the pause in disenrollments mandated by the Family First Act (passed in March 2020) is ended. Then, watch out: many states will probably commence income/eligibility checks at short intervals with a vengeance. 

As noted my previous update, the cumulative growth rate recorded in my sample, which is based on available monthly reports issued by the states, generally exceeds CMS's official tally (which lags this tally by four months) by about half a percentage point (state reports differ from CMS's official count in numerous ways).  Based on that rule of thumb, I would venture that enrollment nationally is up 16% since February 2020 and now stands at about 82.6 million for all full-service Medicaid programs. That's exactly one quarter of the U.S population. Exclude the undocumented and also legally present noncitizens who are time-barred from Medicaid eligibility, and the percentage is higher still.
[Update, 8/16/21: This estimate was high. The final tally for February is 81.4 million; CMS's total reported increase from Feb. 2020 through March 2021 is 15.6%. So my 34-state estimate is now coming in nearly a full percentage point ahead of final CMS tallies. CMS's preliminary March total is 81.7 million; the final March total will probably come in a bit over 82 million.]

ARPA should reduce underinsurance in the ACA marketplace

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• While free bronze plans have been widely available to low income marketplace enrollees since 2018, the American Rescue Plan makes free or very low-cost silver plans with much lower out-of-pocket costs widely available.
  
  
• Bronze plan enrollment at low incomes spiked during Open Enrollment for 2021
  
  
• The American Rescue Plan may already be reversing the drift toward bronze at low incomes

The Urban Institute estimates that if the American Rescue Plan Act's increases to subsidies in the ACA marketplace are made permanent, enrollment will increase by 5.1 million, and the uninsured population will be reduced by 4.2 million. The enhanced subsidies are funded only through 2022 at present.

Urban foresees most of this enrollment increase -- about three quarters of it -- occurring at incomes over 200% of the Federal Poverty Level.  But ARPA should also reduce underinsurance, primarily at incomes below 200% FPL.

While ARPA does not reduce out-of-pocket costs at any metal level, it does make silver plans, which come with strong Cost Sharing Reduction (CSR) subsidies at incomes up to 200% FPL, much more affordable to low income enrollees. 

A note to subscribers

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How much will free benchmark silver plans boost ACA marketplace enrollment in nonexpansion states?

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An Urban Institute brief estimates that if the premium subsidy increases for the ACA marketplace enacted through 2022 in the American Rescue Plan are made permanent, marketplace enrollment will increase by 5.1 million, and the uninsured population will decrease by 4.2 million.

That's somewhat higher than the increase of 3 million that KFF's Cynthia Cox floated to me as a soft estimate. A lot depends on the effectiveness of outreach and possible future improvements to the enrollment process, Cox stressed. Both estimates are pretty modest, given the magnitude of the subsidy boost, outlined below. By KFF's estimate, about 10.6 million uninsured are eligible for subsidies under the new schedule.

Here I want to focus on the category* in which Urban foresees minimal change: enrollment at 100-138% FPL in states that have refused the ACA Medicaid expansion. In those states, eligibility for marketplace subsidies begins at 100% FPL, whereas in expansion states, adults** with incomes up to 138% FPL are eligible for Medicaid. Under ARPA, benchmark silver coverage is free at this income level, and in fact up to 150% FPL. And up to that threshold, Cost Sharing Reduction boosts the actuarial value of the free silver plan to 94%, well above the average for employer-sponsored coverage. According to CMS, the average deductible for silver plans at this income level is just $69 in HealthCare.gov states (e.g., all nonexpansion states). While even modest out-of-pocket costs appear to be a barrier at near-poor incomes -- Medicaid logs higher satisfaction ratings than high-CSR marketplace coverage in surveys -- this is a very valuable free benefit.

The Urban Institute analysis estimates that ARPA will reduce the uninsured population at incomes below 138% FPL by only 312,000. The authors do not provide an estimate of the subsidy-eligible population at 100-138% FPL -- but as I noted in early April, the Kaiser Family Foundation does provide such estimates for 12 nonexpansion states.*** In those 12 states together, 1.8 million people with incomes in the 100-138% FPL range were uninsured in 2019, according to KFF's estimate.  

UI effect? ACA marketplace enrollment soared at low incomes in nonexpansion states in 2021

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Back in March 2020,  you may have read here that the emergency supplemental unemployment insurance provided by the CARES Act -- $600 per week for up to 4 months -- would likely lift some uninsured people in states that had refused to expand Medicaid out of the so-called "coverage gap." That is, the extra UI income would raise some low income people over the income threshold for marketplace subsidy eligibility in nonexpansion states: 100% of the Federal Poverty Level (FPL).

Back in December, you may have read here that as of the end of Open Enrollment for 2021, marketplace enrollment was indeed up 10% over 2020 levels in nonexpansion states, but flat in expansion states.

This month, you may have read here that takeup of marketplace coverage at incomes just over the subsidy eligibility threshold in nonexpansion states -- 100-138% FPL -- has historically been weak -- under 50% in of these states states.

More detailed data about 2021 enrollment was released by CMS on April 21. I don't think it's an exaggeration to say that enrollment at the lowest subsidy-eligible income levels in nonexpansion states exploded this year. 

"How stupid is American healthcare?"

Somehow I took this from Adrianna McIntyre as an irresistible challenge:

but there are so many ways to say "American health care system is stupid"! https://t.co/E6MuIyX0Jq

— Adrianna McIntyre (@onceuponA) April 30, 2021

And so...

Free silver plans at incomes above 150% FPL

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The American Rescue Plan enacted last month radically though temporarily boosted premiums in the ACA marketplace. The premium paid by enrollees for the benchmark (second cheapest) silver plan is now set at $0 for enrollees with household incomes up to 150% of the Federal Poverty Level, and at 0-2% of income for enrollees with incomes in the 150-200% FPL range. That tops out at $43 per month for a single person with an income of $25,520.

Bronze plans are now available at zero premium to almost any enrollee with an income below 200% FPL (and to a fair number at higher incomes).  But bronze plan deductibles average $6,921.  At incomes up to 200% FPL, silver plans come with strong Cost Sharing Reduction (CSR), which brings deductibles down to an average of $177 for enrollees with incomes up to 150% FPL and $800 in the 150-200% FPL range. The contrast is similarly dramatic in annual out-of-pocket maximums, which usually top $8,000 in bronze plans. CSR brings them down to an average of $1189 at incomes up to 150% FPL and $2529 at 150-200% FPL. 

Prior to the subsidy boost, increasing numbers of enrollees with incomes below 200% FPL were selecting bronze plans, especially in the 150-200% FPL range, where benchmark silver topped out at $135/month for an individual (see The darker side of free bronze). The newly enhanced subsidies should reverse that trend. Still, even modest premiums are often experienced as steep at low incomes, and zero-premium plans remove administrative friction that deters some enrollees (arranging and executing on monthly premium payment can be surprisingly difficult). 

The dark side of free bronze plans: Erosion of CSR silver enrollment accelerates

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While the 2021 Open Enrollment Report for the ACA marketplace released by CMS yesterday shows an overall increase in enrollment over 2020, the attendant Public Use Files show acceleration in a troubling trend: decreased selection of silver plans by enrollees with incomes below 200% of the Federal Poverty Level. Selecting bronze below that income threshold, as almost all who don't select silver plans do, means forgoing the strong Cost Sharing Reduction (CSR) that attaches to silver plans only. 

Silver Plan Selection at 100-200% FPL
HealthCare.gov states

Year	Total enrolled	Silver enrolled	Percent silver
2017	5,258,797	4,574,172	87.0%
2018	4,865,014	4,152,230	85.4%
2019	4,712,094	3,944,471	83.7%
2020	4,725,360	3,864,275	81.8%
2021	4,933,622	3,830,086	77.6%

Source (all enrollment tables): CMS State-level Public Use Files. See note below.

For enrollees below the 200% FPL income threshold, silver plans are enhanced by strong Cost Sharing Reduction subsidies that sharply reduce out-of-pocket costs. CSR raises the actuarial value of a silver plan (the percentage of the average enrollee's medical costs allegedly* paid by the plan) to 94% for enrollees with incomes up to 150% FPL and to 87% for those with incomes in the (150-200% FPL) range.  Bronze plans have an actuarial value of approximately 60%. Here's how that difference translates into deductibles in the 36 states using the federal exchange, HealthCare.gov, according to the OE Report:

ACA 2.0 -- how's it going so far?

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On a temporary basis, the health insurance-related provisions of the American Rescue Plan Act (ARPA) signed into law on March 11 moved the Affordable Care Act much closer to living up to its name. Major boosts to premium subsidies effective through 2022 at every income level -- including an absolute cap on premiums for a benchmark plan as a percentage of income for every legally present person who lacks affordable access to other insurance -- credibly put coverage within financial reach of everyone motivated to seek it, albeit with more complexity of process and exposure to out-of-pocket costs than a truly universal system would require. That's a BFD, as a former vice president might say.

The changes became effective immediately and retroactively --  three months after the end of Open Enrollment for 2021 and with an emergency Special Enrollment Period still in progress. So, almost six weeks in, how's it going? A few notes below on implementation, benefit design, and future prospects.

• Fixing a plane in mid-flight (as the emergency SEP is effectively an Open Enrollment period), federal and sometimes state governments have moved with impressive swiftness. While subsidy boosts for those already enrolled were retroactive to Jan. 1, and would be credited eventually by the IRS, HealthCare.gov got the new subsidy schedule loaded on April 1, enabling enrollees to update their applications and get the increase subsidies applied to their monthly payments as of May 1. Most of the 15 state-based marketplaces have followed suit, or set a date by which it will be done (see Charles Gaba's chart at point #2 here). On April 9, the IRS issued guidance enabling 2020 enrollees who underestimated their income and so owed back excess tax credits to take advantage of an ARPA provision forgiving that payback, announcing that the form that details tax credits paid out does not have to be filed at all, and that the IRS will credit back excess APTC already paid back without any further action from the tax filer. 

Can free silver close much of the "upper coverage gap" in nonexpansion states?

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Update, 5/4/21: New data via the CMS state-level public use files for 2021 shows that enrollment at100-138% FPL in nonexpansion states increased dramatically in 2021. See this post for an update.

The principle harm wrought by states that refused to enact the ACA Medicaid expansion after the Supreme Court rendered expansion optional is well known. More than 2 million people with incomes below 100% the Federal Poverty Level (FPL) in the fourteen states that have not yet enacted the expansion are uninsured and eligible neither for Medicaid nor for ACA marketplace subsidies, according to KFF estimates.

A secondary, less recognized harm is imposed on nonexpansion state residents whom the ACA intended to be at the upper end of eligibility for Medicaid, those with incomes in the 100-138% FPL range. In nonexpansion states, residents in this income category are eligible for marketplace subsidies. Until the American Rescue Plan Act (ARPA) was enacted last month, a benchmark silver plan with strong Cost Sharing Reduction would cost enrollees in this income range 2% of income, or a maximum of $29 per month for a single person with an annual income of 138% FPL (currently $17,609). Thanks to ARPA, benchmark silver is now free for enrollees in this income range (and up to 150% FPL).

On paper, even the pre-ARPA offering doesn't sound like a bad deal. The actuarial value of silver in this income bracket is 94%; the average deductible is around $200, and the average annual out-of-pocket maximum is about $1100. But takeup, as I noted in my last post, has been poor. Recent KFF estimates of the uninsured in this income range in nonexpansion states, set against actual enrollment at this income level in 2020, suggest that only about 53% of those eligible have actually enrolled. Take Florida out of the equation, and the takeup rate drops to 43%. 

In this post I'd like to flip the script: what if we make Florida the equation, rather than taking it out? Something in the state's marketplace is going relatively right, and has since the launch of the ACA marketplace.  In Florida, to the extent KFF's estimates of the uninsured are on target, 72% of subsidy-eligible people in the 100-138% FPL bracket are enrolled. That exceeds takeup at 100-138% FPL in the other 11 nonexpansion states tracked by KFF* by almost 30 percentage points. If those states attained Florida takeup rates, the ranks of the uninsured in this category would drop by over 700,000 -- about half of them in Texas (Figure 1).

In nonexpansion states, what percentage of near-poor adults (100-138% FPL) enroll in marketplace coverage?

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Update, 5/4/21: New data via the CMS state-level public use files for 2021 shows that enrollment at 100-138% FPL in nonexpansion states increased dramatically in 2021. See this post for an update.

In a brief estimating how many people remain in the "coverage gap" -- uninsured poor adults in states that have refused to enact the ACA Medicaid expansion -- the Kaiser Family Foundation also sheds a sidelight on a question I've been pondering.

It's this: In nonexpansion states, what percentage of those in the 100-138% FPL income bracket, who would be eligible for Medicaid had their states enacted the expansion, enroll in the marketplace coverage that's available on relatively favorable terms?

In expansion states, eligibility for marketplace subsidies begins at 138% FPL; people below that income level are eligible for Medicaid. In nonexpansion states, marketplace subsidy eligibility begins at 100% FPL. People with incomes in the 100-138% FPL income range, who "should" be in Medicaid, can purchase a benchmark silver plan with strong Cost Sharing Reduction for 2% of income, or a maximum of $29 per month at the high end. The actuarial value of silver at that income level is 94%; the average deductible is around $200, and the average annual out-of-pocket maximum is about $1100.

Where Medicaid enrollment growth may be concentrated

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I just stumbled on a little Medicaid factoid (ex-post, as always...) that made my eyes pop.  

As I've been noting for months, enrollment growth during the pandemic in the ACA Medicaid expansion population has been about double the rate of overall Medicaid enrollment growth -- about 30% for expansion population, February 2020 to February 2021, versus about 15% overall. 

The locus of rapid enrollment growth can perhaps be narrowed further. Arizona breaks out the ACA expansion population into two income categories: 0-100% FPL and 100-138% FPL. From April 2020 to April 2021, enrollment in the 0-100% FPL category increased by 21% from 133,514 to 204, 298.  In the 100-138% FPL category, enrollment increased by 94%, from 76,121 to 147,775.

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:

Is the U.S. uninsured rate at an all-time low?

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Enough states have reported Medicaid tallies through February to posit that the pandemic has increased enrollment by more than ten million nationally since February 2020. Adjusting for the usual difference* between CMS's official totals (now posted through November**) and my sample below (based on state monthly reports), year-over-year enrollment growth since February 2020 is likely about 14.8%, and total enrollment likely stands at about 81.7 million. A quarter of the U.S. population is enrolled in Medicaid.

I don't think we've fully fathomed the effect on access to health insurance of the pandemic, the battered and flawed but still functioning and funded ACA programs in place as the pandemic hit, and pandemic relief measures.  Consider...

The Families First Act effectively required states to pause Medicaid disenrollments for the duration of the Covid-19 emergency, and enrollment will continue to grow until that moratorium ends.***  Enrollment growth among those rendered eligible by the ACA Medicaid expansion is close to 30%. In the ACA marketplace, average monthly enrollment in 2021 will probably exceed 2019 enrollment by at least a million, perhaps more, spurred by extended Special Enrollment Periods and subsidies enhanced by the American Rescue Plan Act. As the population ages, Medicare enrollment grows by about 1.5 million yearly. Meanwhile, the huge job losses triggered by the pandemic appear to have had only a modest effect on employer-sponsored insurance: enrollment through September was down by just 2-3 million, according to a KFF estimate.

Will 60-64 year-olds have a choice between Medicare and Obamacare? What will that look like?

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I turned 62 recently. Yesterday, for the first time, I took seriously the possibility that my wife and I might be enrolled in Medicare before we turn 65.

According to the Wall Street Journal's Stephanie Amour and Kristina Peterson, the Democrats' next healthcare initiative, envisioned for spring 2022, is likely to contain

measures to reduce drug prices and expand health coverage, lawmakers said. Proposals to expand Medicare eligibility from age 65 to 60 and to enable the federal government to negotiate drug prices in the health program for seniors—both of which President Biden supported on the campaign trail—are also likely to be included.

I can think of a lot of reasons these measures -- paired so that the prescription drug savings will finance the expanded eligibility -- may not happen.  But the odds that they will be enacted are not negligible. Democrats' success holding together to pass the $1.9 trillion Covid relief package have made a lot of bold initiatives seem possible.

If Democrats do manage to drop the Medicare eligibility age, they are also likely to make permanent the major increases to premium subsidies in the ACA marketplace enacted through 2022 in the Covid relief bill, the American Rescue Plan Act. And the two initiatives could overlap -- or clash -- to some degree.

The possibility of passing all of the above raises questions: will Medicare be offered to 60-65 year-olds on the same terms as Medicare for people over age 65?  Will enrollment delayed past age 60 be penalized on the same terms as enrollment delayed past age 65 at present? If enrollment at 60-65 is optional, will those who lack access to employer-sponsored insurance also be eligible for subsidized ACA marketplace coverage? -- will they have a choice between the two programs?

If Medicare is indeed subsidized as heavily at ages 60-64 as at age 65 and over, and if enrollment is optional, and if the ARPA subsidy schedule for the ACA marketplace (or something close to it) becomes permanent, some 60-65 year-olds will have a tough choice to make between Medicare and marketplace coverage. 

Broadly speaking, those with incomes up to 200% of the Federal Poverty Level (FPL) will likely find lower costs in the marketplace -- if they're not dually eligible for Medicare and Medicaid. Those with incomes over 400% FPL will likely favor Medicare.  In between is a gray area, with tradeoffs that are charted and discussed below.

An American Rescue Plan benefit you'll have to wait for

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UPDATE: On April 9, the IRS solved the problem described, announcing that 2020 marketplace enrollees who received APTC do not have to file Form 8962. 

The Internal Revenue Service announced today that taxpayers with excess APTC for 2020 are not required to file Form 8962, Premium Tax Credit, or report an excess advance Premium Tax Credit repayment on their 2020 Form 1040 or Form 1040-SR, Schedule 2, Line 2, when they file.

Those who filed prior to the passage of the American Rescue Plan Act and paid back excess APTC do not have to file an amended return; the IRS will reimburse them.

----

In addition to increasing premium subsidies for 2021 and 2022 in the ACA marketplace, the American Rescue Plan Act signed into law by President Biden on March 11 provides an important benefit to 2020 marketplace enrollees. Section 9662 of ARPA stipulates that those enrollees who underestimated their income and so would normally have to pay back some the Advanced Premium Tax Credits (APTC) received will not have to pay back the excess APTC. 

That includes people who estimated their incomes at below 400% of the Federal Poverty Level, the cap for APTC eligibility, but ended up with a declared income above that threshold. Normally, they would have to pay back all APTC received. This year, they owe nothing.

That is not a trivial benefit. According to IRS estimates,* in 2019 3.2 million tax filing households paid back a portion of the APTC they received in 2018, with paybacks totaling $4.4 billion, or about $1,375 per household.  Estimating 1.7 enrollees per filing household** suggests payback of about $800 per enrollee. Similarly, the CBO report*** on the costs of ARPA estimated that APTC forgiveness for 2020 (when total enrollment was nearly identical to that of 2018) would cost $4.7 billion in 2021. (See Charles Gaba's detailed analysis here.)

Should younger enrollees in the ACA marketplace be more heavily subsidized?

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Enrollment in the ACA marketplace skews old.  In 2020, only 26% of enrollees were in the 18-34 age range, while 28% were over age 55. That creates two problems: 1) a lot of uninsured young adults, and 2) a high-cost risk pool, which means higher costs for the federal government in premium subsidies.

The healthcare provisions in the American Rescue Plan (ARP) signed into law by President Biden on March 11 radically reduce the percentage of income paid by ACA marketplace enrollees for a benchmark silver plan (the second cheapest silver plan in each rating area). But the reductions are most stark at the bottom and top of the income scale, as the table below (from the CBO's February analysis of the legislation in progress) illustrates.

Enrollees with incomes ranging from 250% FPL up to, say, 600% FPL may still find premiums a heavy lift -- and younger adults are disproportionately likely to forego them. A bill introduced in the House by Florida Democrats Stephanie Murphy and Donna Shalala, HR 6545, the Health Insurance Marketplace Affordability Act, aims to entice younger adults into the marketplace by increasing subsidies for younger adults in inverse ratio to the increase in premiums as age rises. The bill will soon be reintroduced to mesh with the ARP.

Medicaid expansion enrollment grew nearly 30% year-over-year in 19-state sample

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Time for an update on Medicaid expansion enrollment growth since the pandemic struck. Below is a sampling of 19 expansion states through January of this year, and 14 states through February.

Maintaining the assumption, explained here, that relatively slow growth in California would push the national total down by about 2.5 percentage points, these tallies still point toward year-over-year enrollment growth pushing 30% from February 2020 to February 2021. If that's right, then Medicaid enrollment among those rendered eligible by ACA expansion criteria (adults with income up to 138% FPL) may exceed 19 million nationally and may be pushing 20 million.  That is, if this sampling of a bit more than a third of total expansion enrollment represents all expansion states more or less accurately, again accounting for slower growth in California.

The American Rescue Plan Act makes free coverage available to many below 100% FPL in nonexpansion states

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An odd provision  the American Rescue Plan Act that President Biden signed yesterday provides that anyone who receives any unemployment insurance income this year will be deemed to have income of no more than 133% of the Federal Poverty Level (FPL), qualifying them for a free silver plan in the ACA marketplace. 

Silver plans at that income come with the highest Cost Sharing Reduction (CSR), raising the plan's actuarial value to 94%, which translates to an average deductible of about $200 and an average cap on annual out-of-pocket costs of about $1100. The plan is free because ARPA zeroes out premiums for a benchmark silver plan at incomes up to 150% FPL.

When I first read about this provision, I thought that maybe it was intended in part as one more way to chip away at the "coverage gap" in the twelve remaining states that have refused to enact the ACA Medicaid expansion (rendered optional to states by the Supreme Court in 2012). In those states, eligibility for ACA marketplace subsidies begins at 100% FPL, and families with incomes below that threshold get no help obtaining coverage. The Kaiser Family Foundation estimates that about 2.2 million people in nonexpansion states (chief among them Texas, Florida, Georgia and North Carolina) are in the coverage gap.

In Memoriam: Jules B. Sprung

My father, Jules Sprung, died this past Saturday after a short hospital stay -- of kidney failure specifically, and old age generally. He was very frail, but alert and engaged until his very last days in the hospital. My mother has taken meticulous loving care of him as he very gradually lost the ability to take care of himself. 

We miss him dearly but are at peace with the conclusion of a life well lived. An obituary is below. Thanks to Dan Woog, author of the blog 06880, a chronicle of daily life in Westport, CT, for publishing a skillfully edited version.

---

Jules B. Sprung, a resident of Westport with his wife Barbara since 1976, died on March 6 in Norwalk Hospital. The cause was kidney failure. He was 92.

Jules founded and ran two mail-order office supply companies, Hudson Pen, Inc. and Sarand, Inc., selling the latter in 1988 and working afterward as a marketing consultant. Sarand, based in New York City, employed dozens of people from the mid-seventies through the 1980s.

In his retirement, Jules taught swimming classes for children for many years at the Westport YMCA, where he was an honored presence at the pool until the pandemic curtailed operations in 2020.  He was also president of the Indian River Green condo complex on Saugatuck Road in Westport, where he and Barbara moved in 2002.

The ACA as it should have been -- sort of, for a while at least

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Strictly speaking, by my my lights, "the ACA as it should have been" would be "Medicare for all who want it": a public plan paying Medicare rates to providers, accepted by all providers who accept Medicare, with competing private plans paying similar rates to providers and probably offering somewhat more generous coverage as a tradeoff for limitations in provider choice. These plans would be available to all, including those with access to employer-sponsored insurance. Oh, and add an OOP cap -- a cap on annual out-of-pocket costs -- to the public plan -- as we should do for traditional Medicare.

In the political universe we're bound by, however, "the ACA as it should have been" denotes the ACA more or less as is, but with subsidies generous enough to make coverage in the ACA marketplace truly affordable to most Americans who lack access to other insurance -- excluding (always, alas) undocumented immigrants.  

And that is about to happen! -- temporarily at least -- when Biden signs the American Rescue Plan Act of 2021 later this week (see Section 9661).   It's an eye-rubbing moment for progressives who've dreamed fruitlessly for a decade of an Affordable Care Act offering affordable coverage to almost all comers.

The Kaiser Family Foundation is trying to tell us something

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The Kaiser Family Foundation is one of the most reliable and comprehensive source of healthcare data and analysis in the U.S. Its authority rests in part on maintaining an implicit policy neutrality, letting facts speak for themselves. But sometimes facts speak loudly, and that's the case with a remarkable brief detailing the extent to which the United States' failure to set payment rates for providers, or compel all payers to negotiate common rates, drives our out-of-control spending on healthcare, and our failure to provide affordable access to all.

The brief is an emperor-has-no-clothes declaration, aggregating facts well known to healthcare scholars and simply spotlighting the consequences of our collective failure -- unique among wealthy countries -- to curb the market (and political!) power of hospitals and doctors by forcing them to deal with all payers as a unit. It's a slingshot aimed at an industry Goliath preparing a nuclear arsenal of lobbying and propaganda against any initiative that aims to expand the footprint of government payment rates.

Does mandatory maximum silver loading require a risk adjustment fix?

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I want to address a somewhat technical issue concerning regulatory action to require that gold plans in the ACA marketplace be priced below silver plans -- that is, regulatory action on the state or federal level mandating maximal silver loading.

Gold plans should be priced below silver plans because silver plans --on average -- carry a higher actuarial value than gold plans. "Actuarial value" refers to the percentage of the average enrollee's costs covered by the plan, according to a formula created by CMS (that formula could use adjustment, but that's another story). Gold plans have an AV of 80%, plus or minus a few percentage points. Silver plans have a baseline AV of 70%, but that's only for enrollees with incomes above 250% of the Federal Poverty Level (FPL). Below that threshold a secondary subsidy, Cost Sharing Reduction (CSR), available only with silver plans, boosts AV to 73%, 87%, or 94%, rising as income falls.  Most silver plan enrollees obtain AV of 94% or 87%.

In Health Affairs: The Biden administration should complete the silver loading revolution

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The Covid relief legislation making its way through Congress would vastly increase premium subsidies in the ACA marketplace for two years but would not touch out-of-pocket costs. Premium subsidies would still be set against a silver benchmark -- that is, designed to make the second-cheapest silver plan "affordable." At incomes over 250% FPL, silver plans have deductibles averaging $4816.

In Health Affairs, David Anderson and I have a post positing that the Biden administration can complement the subsidy boosts by requiring insurers to price gold plans below silver plans. That is, by requiring full "silver loading."

In The American Prospect: My Take on Jonathan Cohn's The Ten Year War

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I have a review in The American Prospect of Jonathan's Cohn's inside-the-creators' heads chronicle of the ACA's embattled formation and enactment:

Jonathan Cohn, a leading contemporaneous chronicler of the ACA’s formation and enactment, and now author of The Ten Year War: Obamacare and the Unfinished Crusade for Universal Coverage, is well aware of these shortcomings and faulty assumptions, as well as of the law’s resilience and partial success, such as reducing the uninsured population by about 35 to 40 percent. The book’s chief value, for me at least, lies in illuminating the creators’ perspectives at various crunch points in the law’s conception and enactment.

Cohn takes us back to a long time ago, in a galaxy far, far away, in which Democrats still hoped to win Republican support for major legislation...

The nuance with which Cohn captures the various players' assumptions and motives, and the pressures brought to bear on them, provides some real retroactive clarity, from what already feels like a substantial historical distance. I hope you'll read the review, which relies on substantial excerpts.

Medicaid enrollment likely reaches 81 million in January

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Chart updated 3/3/21

This is an update to my recent post estimating total national Medicaid enrollment at upwards of 80 million through December, up from 71.2 million in February 2020, the last month before the pandemic struck the economy.

I've added December updates from four states -- including the big one, California -- to the sample, as well as adding Nebraska, which enacted the ACA Medicaid expansion beginning in October. As I forecast, continued relatively slow growth in California drops the full-sample rate of increase by about two and a half percentage points.  

As always, the official CMS tally for all states, currently stuck in September, is likely to show a somewhat smaller increase than my sample. For September, my sample showed an increase of 9.7% over February, while CMS currently shows a 9.4% increase in the same period.  Conservatively, then, I'll posit that CMS will show a 12.5% increase from February through December 2020, which would put national enrollment at 80.1 million.  (The sample consists of states for which I can find monthly enrollment reports.)[Update, 4/5/21: CMS's preliminary November total shows an increase of 11.6% since February, as I forecast on New  Year's Eve, compared to the 12.0% increase for the same period charted in my sample below.*]

Obama's assumptions about healthcare reform, in 2009 and today

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Jonathan Cohn today published an adapted excerpt from his book about the Affordable Care Act, The Ten Year War, coming out on Tuesday. The article's centerpiece is Obama's own assessment of what went right and wrong in the design, passage, and enactment of the ACA.  Of the ACA's basic design, which had become a consensus Democratic by the time Obama was elected, Cohn notes, "It was a far cry from the government-run insurance plan that Harry Truman once championed, but Democratic leaders embraced it as the best they could get..."

 ― and so did Obama, who repeated in our interview his belief that something like a government-run, “single-payer” system would probably work best, but creating one right away would be too difficult. 

“We have a legacy system that is one-sixth of the economy,” Obama said. “The idea that you could, in some way, dismantle that entire system ― or even transition it entirely ― to a single payer system looked politically impractical and probably really disruptive. ... The best chance to actually get people healthier was going to be to design a system that acknowledged 85% of the American people have health insurance and that plugged the gap for those 15% who don’t.”

Obama's neat foreclosure of other possibilities here reminds me of the technique deployed throughout his memoir, A Promised Land, of showcasing his undeniable rationality within a framework bound by self-imposed limits, or limits imposed by his choice of advisers, or -- sometimes -- by what was politically possible.  I see two fallacies here.

A public option by inches: Bennet and Kaine's Medicare-X

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This week Democratic Senators Michael Bennet (CO) and Tim Kaine (VA) introduced an updated version of their Medicare-X Choice Act, first introduced in 2017 and again in  2019 (summary here, bill here). The bill would introduce a strong public option into the ACA marketplace and small group markets, paying Medicare rates to providers in most markets, though up to 150% Medicare in rural markets. It would also improve subsidies at every income level on a schedule that's become the Democratic legislative default -- e.g., in the Coronavirus relief legislation. Enrollees would pay the following percentages of income for a benchmark silver plan:

Note that benchmark coverage is free at incomes up to 150% FPL (currently about $19k/year for an individual), and there is no income cap on subsidies: no one who lacks access to other insurance (e.g., an employer-sponsored plan) would pay more than 8.5% of income for benchmark silver. The 2019 version capped subsidies at 13% of income -- a measure of how far Democrats have come in adjusting their concept of affordability.

Compared to the healthcare reform plan Joe Biden introduced as a candidate in 2020, the bill has two major limitations. First, it does not offer subsidy eligibility to people who have access to other "affordable" insurance, including an offer of insurance from an employer with a premium below 9.5% of income. (The bill does fix the family glitch, offering subsidy eligibility to employees with families if the employer's family plan costs more than 9.5% of income.) It is not "Medicare for all who want it," notwithstanding presidential candidate Bennet's past claims to the contrary.  

Health Policy Valentines 2021: Institutional edition

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Americans don't have much faith in government, and it's hard to think of our society as one that's pulling together in the face of the pandemic and its revelation of our systemic inequities. But it's not all dysfunction, oligarchy, rising fascism and disregard for the common good.  And we do have a serious new bid from the Biden administration for good government.

This year's #healthpolicyvalentines are from various organs of government and other institutions to the American people.

From the Biden Coronavirus task force

Producing and dispensing fact
is our core Defense Production Act

From SCOTUS

Inseverable?
Did I hear Roberts scoff?
The vestigial mandate
will be cut off.

Obama's inside-out view of the public option

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I have been slowly working my way through Obama's memoir with a kind of wariness of being emotionally sucked in. Like all political memoirists, Obama presents himself as having made the best decisions he could given what he knew at the time. True, in the sense that his motives were good, his process was good, and his intellect is good. But still self-serving, and sometimes disingenuous.  

For all Obama's solicitation of a wide range of views, his narrative presents the predominance of certain views and voices as a given.  For example, regarding the size of the stimulus, Obama recounts this mid-December exchange:

Immediately after the election, examining the worsening data, we had raised the number to $500 billion. The team now recommended something even bigger. Christy mentioned a trillion dollars, causing Rahm to sputter like a cartoon character spitting out a bad meal. “There’s no fucking way,” Rahm said. Given the public’s anger over the hundreds of billions of dollars already spent on the bank bailout, he said, any number that began “with a t” would be a nonstarter with lots of Democrats, not to mention Republicans. I turned to Joe, who nodded in assent.

And that's it: political reality foreclosed, while Larry Summers foreclosed on the economic argument for more stimulus-- and Christine Romer's input is reduced to a "mention."  In Obama's telling, the stimulus his administration proposed was audaciously gargantuan by any current standard. 

Under Covid relief bill, no Obamacare enrollee should have coverage less than valuable than gold

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It's here! After five years in which progressives have dreamed of boosting the generosity of subsidies in the ACA marketplace, the framework for half the Covid relief bill released by the House Ways and Means yesterday would do so temporarily, for 2021 and 2022. The subsidy schedule is even more generous than that of the Affordable Care Enhancement Act passed by the House last June (and left to die in the Senate, natch). Here are the percentages of income required to purchase a benchmark (second cheapest) silver plan (Part 7, beginning on p. 83):

Keep in mind that Cost Sharing Reduction (CSR) raises the actuarial value of a silver plan from a baseline of 70% (which leaves very high out-of-pocket costs) to 94% at incomes up to 150% FPL (where it's free) and to 87% -- better than most employer-sponsored plans at incomes ranging from 150-200% FPL.  This radical change may happen fast, and be effective immediately. The implications are kind of dizzying. Three notes:

Raised minimum wage creates an imperative to improve ACA marketplace subsidies at low incomes

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David Dayen flags a paper by UC-Berkeley economist Michael Reich that finds a budget impact from raising the minimum wage (which should render eligible for the reconciliation bill). The paper

found $65.4 billion per year in savings, through a combination of increased tax revenues on higher wages and reduced federal expenditures on safety net programs due to eligibility thresholds. 

As Dayen points out, the federal savings are not in themselves something to cheer about:

Increased taxes on higher wages still put a worker out ahead, to be sure. But reductions in federal benefits could create a treadmill effect, with the government taking away what the private sector is forced to pay out. As $15 an hour isn’t really a living wage in much of the country, clawing back benefits isn’t a perfect scenario. 

One of the benefits that some people will earn themselves out of as the minimum wage rises is Medicaid. Eligibility for Medicaid as expanded by the ACA is offered to adults with incomes up to 138% of the Federal Poverty Level ($1,468 per month for an individual, $1,303/month for a family of four). To date, 38 states plus D.C. have enacted or will soon enact the expansion, with the last two of those, Oklahoma and Missouri, scheduled to expand eligibility in July of this year.)

Estimate: ACA Medicaid expansion enrollment may have grown 25% from February to December 2020

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As Covid-19 burned its swath through the U.S. in December, Medicaid enrollment in the ACA expansion category (adults with monthly incomes up to 138% of the Federal Poverty Level) continued the rapid growth that started with the pandemic.

Enrolment increased 2.7% from November in the 17 states for which I've been able to locate monthly expansion-category enrollment reported through December. In those 17 states, enrollment increased 27.6% from February 2020 -- the last month in which the economy was unaffected by the pandemic -- through December.

Medicaid enrollment likely near 80 million in December

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I am pretty confident that total Medicaid enrollment, which stood at 71.2 million in February 2020 according to CMS's adjusted total, is now in the neighborhood of 80 million.*

CMS's official tally through September shows a 9.4% increase from February. My tally below, based on monthly enrollment reports in 33 states, shows a 9.7% increase from February through September, 11.8% through November, and a likely further 1% increase in December (California will as usual drag the all-state percentage increase down a bit). A 12.4% increase from February through December would suggest 80 million total enrollees -- pretty close to a quarter of the U.S. population.