Record-Breaking ACA Sign-Ups with One Month of Open Enrollment Remaining

  • By December 15, ACA enrollments were up 17% from the previous year.
  • HealthCare.gov enrollees from 92% of states received medical insurance subsidies.
  • The American Rescue Plan increased enrollment through 2021, and even into 2022
  • The majority of enrollments were in states who have not expanded Medicaid
  • The marketplace has become a pandemic “security web”
  • ARP: a patch to cover the protection hole?
  • It is not clear what the future holds for increased subsidies

The Biden administration announced last week that enrollments in ACA plans for market had reached a record high of 13.6 millions* by December 15th, with a full month remaining in the open enrollment period (OEP) of 2022 in many states.

Charles Gaba estimates that this is a jump of around 2 million (17%) compared to enrollment at the same date last year. It’s also a significant increase over the previous high of 12,7 million, which was recorded by the end of open enrollment in 2016, which in most states lasted until January 31. Enrollment in market plans is expected to exceed 14 million when OEP concludes this January.

HealthCare.gov enrollees in HealthCare.gov States received medical health insurance subsidies at a rate of 92%.

In the 33 states that use the federal exchange, HealthCare.gov, the vast majority of enrollees (92%), received premium tax credits (subsidies) in order to help pay for coverage. This included 400,000 people who would not have qualified for subsidies prior to the passage of the American Rescue Plan this year. The bill not only increased premium subsidies for all income levels by 2022 but also removed the previous revenue cap of 400% of federal poverty level (FPL), which was $51,520 for an individual and $106,000 per year for a family of four. No enrollee without access to other affordable insurance pays more than 8.5% of their income for a benchmark Silver Plan (the second-most cost-effective Silver Plan in each area) by 2022. Most pay much less.

The increase in enrollment is a testament to the significant improvement in affordability that the ARP subsidies have created. The benchmark Silver plan, with a robust Price Sharing Discount, is now FREE for incomes up to 150percentFPL (19,320 dollars for an individual, $39750 for a family of four in 2022), and costs not more than 2 percent of income ($43/month per person) for incomes above 200% FPL. At higher incomes, the percentage of revenue needed for the benchmark Silver plan has also been reduced. ARP also offered free high-CSR Silver coverage to anyone who received any unemployment insurance revenue in 2021.

The American Rescue Plan increased enrollment through 2021, and even into 2022

The OEP enrollment features build on the surge in enrollment triggered by HealthCare.gov’s emergency specific enrollment period (SEP), which was opened on February 15, this year, by the Biden administration. This SEP ran until August 15, 2021, for the 33 states using HealthCare.gov and varied durations, within the fifteen states running their own exchanges. There are 18 state-based exchanges as Kentucky, Maine, and New Mexico have launched new ones in 2022.

ARP subsidies went on-line April (or May in some state markets). Between February and August, 2.8 millions individuals enrolled within the SEP. Total enrollment on-line increased by 900,000. (As people also disenrolled every month and many enrollees likely regained company-sponsored insurance during a period of rapid job growth).

As well, once the ARP subsidy increase was implemented, 8 million enrollees saw their monthly premiums drop by an average of 50%, from $134 per month to $67. The premiums for 2022 should be the same as those of SEP.

The majority of enrollments were in states who haven’t extended Medicaid

Open enrollment will see an increase in enrollment – both in the SEP for 2020 and in the OEP 2021 – in states which have not implemented the ACA Medicaid expansion. There were 14 of these states during the SEP as well as 12 during the OEP (which is still ongoing). Oklahoma and Missouri both implemented the Medicaid expansion late, in July and October of this year.

In states that have not enacted expansion, the eligibility for ACA subsidies starts at 100% FPL. Medicaid coverage is available below this threshold. In states that have not expanded, the “marketplace” is the only way to get coverage for low-income adults. Those who earn less than 100% FPL are essentially left out – the so-called protection gap. About 40% of those who enroll in the market have incomes below 138% FPL. They would be eligible for Medicaid if these states had enacted Medicaid expansion.

In OEP, the 12 non-expansion state accounts for 81% in the 33 HealthCare.gov States, and approximately two thirds of all states. Table below also shows benefits over a 2-year period, including the COVID-19 Pandemic.

In the 39 states that have enacted ACA Medicaid enlargement, (21 using HealthCare.gov as well as 18 operating their own exchanges), fewer enrollees qualify for Silver coverage without cost. In states that have enacted the ACA Medicaid expansion, individuals who earn less than 138% of FPL are eligible for Medicaid. During the current OEP, the enrollment growth in non-expansion state is significant, increasing by approximately 755,000 or 13% year-over-year.

The marketplace has become a pandemic “security web”

The’marketplace’ has acted as a barrier against uninsurance during the pandemic. This was especially true for low-income people and those in non-expansion state. According to the chart, between Dec. 15th, 2019 and Dec. 15th 2021 enrollment increased by 1.8m in these 11 states – an increase of 37%. The two-year increase for all states is in the vicinity of 25%, and could approach 3 million (from 11,4 million OEP 2020 to over 14 million by the time OEP 2022 ends in January). This is in addition to a rise in Medicaid enrollment of more than 12 millions during the pandemic.

According to government surveys, the uninsured rate did not increase throughout 2020 and may even have decreased by 2021 or 2022.

The federal government did not publish detailed statistics on who enrolled during the current OEP. However, the final enrollment report for SEP emergency was able to provide this information. Out of the 2,8 million new enrollees during the emergency SEP program, 2.1 were in the 33 HealthCare.gov state. In these states, 41 % of the enrollees received Silver plans that had the highest level of CSR. This means that they were earning less than 150% of the FPL or obtaining unemployment benefits and therefore got free coverage in plans that have an actuarial value of 94%, far above the normal for employer-sponsored insurance plans.

The median deductible in HealthCare.gov’s states is $50. This is a smart choice, since 54% of the enrollees chose Silver plans that had a robust CSR. These plans have an actuarial value between 87% and 94%, depending on whether you earn up to 150% FPL or 150% to 200% FPL. In HealthCare.gov, two-thirds paid less than $50 for protection per month. 37% of those enrolled in the program obtained coverage without paying a penny.

As mentioned above, at higher incomes, 400,000 enrollees in HealthCare.gov States who received subsidies would not have been subsidy eligible before the ARP lifted revenue caps on subsidies (previously 400% FPL). It’s likely that the same is true for several hundred thousand enrollees on state-based markets. SBEs represent a little less than a third of enrollment. However, in these states that have all expanded Medicaid, the percentage of enrollees who earn more than 400% of FPL is almost twice as high as in HealthCare.gov (12% versus 7%) during the SEP emergency.

ARP: a patch to cover the protection hole?

The strong enrollment growth in non-expansion state – an increase of 37% in just two years – means that during the pandemic some low-income people in these states found their way out of the coverage gap (due to the lack of government assistance available to most adults who earn less than 100% FPL). The CARES Act, H.R.748, provided a supplementary uninsurance income of $600 per weekly for up to four months in March 2020. This could have pushed many incomes above 100% FPL. In 2021, anyone who received any unemployment income qualified for Silver coverage without paying a dime. During the SEP emergency, 84,000 new enrollees (along with 124,000 existing enrollees) took advantage of this provision. This emergency provision will not be in effect in 2022.

Market subsidies are mostly based on estimates of future revenues. Income can be difficult to estimate for low-income people, especially those who work irregular schedules, depend on ideas, are self-employed or paid per hour. Some candidates may have been motivated to check that their estimates met the FPL 100% threshold because they wanted to be covered during the pandemic. Enrollment assistants and brokers can help candidates to use all resources available.

The Biden administration has raised funds for OEP 2022 to train and certify more than 1,500 navigators. In compliance with a court order, the exchanges stopped asking low-income applicants who estimated their income to be over 100% FPL, to provide documentation if “trusted sources” from the federal government indicated a revenue below the edge.

The relatively low enrollment growth in Wisconsin could support the idea that under the strain of pandemic some enrollees from other non-expansion state are climbing out of protection gap. Wisconsin is the only non-expansion state that does not have a protection gap. This is because it offers Medicaid to all adults who earn up to 100% FPL. Wisconsin offers free coverage to those whose income falls below the market eligibility threshold of 100% FPL. Wisconsin is the only non-expansion-state that did not experience double-digit growth in enrollments from OEP 2022 and 2020-2022.

It is not clear what the future holds for increased subsidies

The American Rescue Plan, which was designed as an emergency pandemic assistance program, has increased subsidies that only run until 2022. The Construct Back Higher bill, introduced by President Biden and passed in the House of Representatives but stalled at the Senate momentarily, would extend the ARP subsidy until 2025, or possibly even longer.

The increased enrollment in the past 12 months should put pressure on Congress to continue to improve subsidies for future years. The immediate and dramatic response of consumers to the increased subsidies is a testament to their impact. The ARP subsidies have brought the Inexpensive care Act much closer to living up to the promise that “reasonably-priced” care is expressed in the name. It’s not a moral or politically viable path to go backwards with that promise.


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