Tuesday, March 26, 2024

ACA Enrollment assistance in 2024: A conversation with Shelli Quenga

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The enrollment doctor is in


Last week I caught up with Shelli Quenga of the South Carolina-based nonprofit Palmetto Project, who has been an ACA enrollment assistor and enrollment project director since the ACA marketplace’s first Open Enrollment Period (OEP) in fall 2013.

In the Obama years, the Palmetto Project was South Carolina’s chief grantee under in the federally funded Navigator enrollment assistance program. When the Trump administration gutted the program’s funding*, Palmetto Project converted its enrollment assistance program to a nonprofit brokerage in advance of OEP 2019. At that point, the program was operating on a shoestring, with five employees. Now, Quenga told me, they are up to 11 employees, with a couple of more hires planned.

After 11 years on the front lines of marketplace enrollment assistance, Quenga has a deep understanding of how people find their way to coverage through the ACA — or fail to. Her reflections shed light on the dynamic of the enrollment explosion of the pandemic years — particularly in the ten remaining states (including South Carolina) that have refused to enact the ACA Medicaid expansion. Enrollment overall is up 87% since OEP 2020, 147% in nonexpansion states, and 167% in South Carolina, from 214,040 in 2020 to 571,175 in 2024. In 2024, enrollment growth was concentrated at the lowest subsidy-eligible income levels, up 61% nationally in the 100-138% FPL bracket. In South Carolina, enrollment at 100-138% FPL almost doubled in OEP 2024, from 133,787 to 253,158.

Among the key points:

Saturday, March 23, 2024

ACA Marketplace in 2024: low-income enrollment up, silver plan selection down

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CMS has published its 2024 Marketplace Open Enrollment Period Public Use Files, providing detailed breakouts of enrollment by income, metal level selection, demographics, etc.

We already knew that enrollment increased by 31% nationally this year, spurred in part by the Medicaid unwinding — that is, the resumption of Medicaid redeterminations and disenrollments after a three-year pandemic-induced moratorium. While there’s always much to explore in the PUFs, two facts jump off the page for me:

  • Enrollment growth was heavily concentrated at low incomes — up 61% at 100-138% FPL and 54% in the slightly broader 100-150% FPL bracket. That’s perhaps not surprising, given that CMS announced that 2.4 million Medicaid disenrollees had enrolled in the 32 states using the federal platform, HealthCare.gov (and perhaps 2.9 million nationally, by Charles Gaba’s estimate). Year-round enrollment at incomes up to 150% FPL has likely also boosted enrollment in this bracket [added 3/23/24].

  • The decline in silver plan selection at low incomes that I flagged last March has continued. That is, growing numbers of low-income enrollees are forgoing Cost Sharing Reduction, available only with silver plans. At incomes up to 200% FPL, CSR makes silver plans roughly equivalent to platinum. Since March 2021, at least two CSR-enhanced silver plans in each rating area, with an actuarial value of 94%, are available at zero premium to enrollees with income up to 150% FPL. In the 150-200% FPL bracket, the benchmark (second cheapest) silver plan costs 0-2% of income (topping out at about $45/month for a single person) and has an actuarial value of 87%. Yet silver plan selection in the 100-150% FPL bracket was just 76.4% in HealthCare.gov states, down from 84.9% in 2022 and 89.3% in 2017. In the 150-200% FPL bracket, silver crashed from 69.5% last year to 56.7% this year. It was 83.2% in 2017.

Let’s look first at enrollment growth by income.

Friday, March 15, 2024

Biden administration to ACA enrollment assistors: Please credit yourselves

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Please add my 13-digit ID


CMS is apparently working to redress the Trump administration’s attack on the effectiveness of the nonprofit enrollment assistors chartered by the ACA and partly funded by the federal government.

Earlier this week CMS sent this memo to enrollment assistors:

The memo spells out the rationale for ensuring that navigators, CACs and EAP, who have no direct financial incentive to credit themselves on marketplace enrollments they facilitate, do so anyway:

Including your assister ID will help the Centers for Medicare & Medicaid Services (CMS) to better understand the support that the assister community provides and continue to improve the consumer experience….

Understanding your reach as an assister is important to enhancing the support CMS provides you and the consumers you assist.

There is a long history behind this exhortation.

Monday, February 26, 2024

How the Trump administration handled the ACA marketplace, Part 3: Regulation

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This post is Part 3 of an assessment of Trump administration policy with respect to the ACA, most specifically the ACA marketplace. Part 1 overviewed the administration’s early encouragement of state reinsurance programs, Trump’s cutoff of direct reimbursement of insurers for Cost Sharing Reduction subsidies, and the defunding of the Navigator enrollment assister program, paired with considerable support for health insurance brokers.

Part 2 reviewed the effective repeal of the individual mandate penalty, paired with regulations designed to boost an alternative market of ACA-noncompliant plans. Here, we’ll look at how Seema Verma’s CMS loosened rules for insurers and tightened them for marketplace applicants.

Friday, February 23, 2024

How the Trump administration handled the ACA marketplace, Part 2

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The Trump administration stretched the clock for short-term, limited duration health plans

This post is Part 2 of an assessment of Trump administration policy with respect to the ACA, most specifically the ACA marketplace. Part 1 overviewed the administration’s early encouragement of state reinsurance programs, Trump’s cutoff of direct reimbursement of insurers for Cost Sharing Reduction subsidies, and the defunding of the Navigator enrollment assister program, paired with considerable support for health insurance brokers.

Below, we’ll look at the effective repeal of the individual mandate penalty (the one legislative initiative considered), and regulations designed to boost an alternative market of ACA-noncompliant plans.

As each part keeps ballooning as I write it, we’ll leave other administrative changes, loosening requirements on insurers and tightening them on prospective enrollees, to a Part 3.

Zeroing out the individual mandate penalty. After the Republican Senate in the summer of 2017 declined to take up the ACA “repeal and replace” bill passed by the House and then failed to pass its own repeal/replace alternative, John McCain famously scotched a final attempt to pass a “skinny” repeal bill that would have simply repealed the individual mandate and brought the Senate into conference with the House, perhaps to make one more run at a more comprehensive repeal/replace alternative. Following those failures, Republicans reduced the mandate penalty to zero in their massive tax cut bill passed in December 2017.

As an expression of intent to dismantle the ACA, the zero-penalty mandate’s chief function was to enable Republicans’ final attempt to void the ACA through the courts. In February 2018, a group of 20 states, led by Texas, sued to have the mandate declared unconstitutional, and the entire ACA statute voided. The suit sought ACA nullification on the ridiculous grounds that a) the 2012 Supreme Court decision upholding the constitutionality of the mandate did so only on the basis that the mandate is a tax, and within Congress’s taxing power; b) a zeroed-out mandate is no longer a tax; and c) since the Democratic Congress passed a resolution in 2010 declaring that the mandate was an “essential part” of the ACA’s overall “regulation of economic activity,” the whole law (including myriad parts unconnected with the ACA marketplace) had to be vacated. In June 2021 a 7-2 Supreme Court majority dismissed the suit, finding that the plaintiffs did not have standing because no one was harmed by a $0 penalty. The litigation did enable the Trump administration, 20 Republican attorneys general, and 126 House Republicans who signed an amicus brief in support of the plaintiffs to display root-and-branch opposition to the ACA for another three years after the legislative repeal drive failed.

Negation of the mandate was expected to drive healthier enrollees out of the market, raising premiums and thus further reducing enrollment. In 2019, CBO forecast (p. 11) that the $0 mandate penalty would increase the uninsured population by 7 million, or a bit more than 2%, and reduce marketplace enrollment by 4 million.

Wednesday, February 21, 2024

How the Trump administration handled the ACA marketplace, Part 1

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In the wake of Trump’s vow to repeal the ACA if elected, Larry Levitt, Kaiser Family Foundation, outlines the former president’s past and purported future healthcare agenda.

One of Trump’s biggest political failures as president was his inability to persuade Congress to repeal the Affordable Care Act (ACA). However, the Trump administration did make significant changes to the ACA, including repealing the individual mandate penalty, reducing federal funding for consumer assistance (navigators) by 84% and outreach by 90%, and expanding short-term insurance plans that can exclude coverage of preexisting conditions. And, the Trump administration supported an ultimately unsuccessful lawsuit to overturn the ACA.

In one of the stranger policy twists, the Trump administration ended payments to ACA insurers to compensate them for a requirement to provide reduced cost sharing for low-income patients. At the time, Trump said this would cause Obamacare to be “dead” and “gone.” But, insurers responded by increasing premiums, which in turn increased federal premium subsidies and costs to the federal government, likely strengthening the ACA.

In the current campaign, Trump has vowed several times to try again to repeal and replace the ACA, saying he would create a plan with “much better health care.”

Trump certainly meant harm to the ACA. His comments in the wake of abruptly cutting off direct reimbursement of insurers for the value of Cost Sharing Reduction, cited by Levitt above, show his intent, as does his pressure on Republicans in Congress to pass legislation gutting its core programs. Should Trump regain the presidency, there is no question that he will pursue the agenda that Levitt outlines in his conclusion, including the ACA-related parts:

Trump’s record as president from 2017 to 2021, combined with recent comments on the campaign trail, suggest he would pursue policies to weaken the ACA, reduce federal spending on Medicaid, restrict access to abortion and family planning, and scale back benefits for immigrants if reelected as president in 2024.

Moreover, should Trump regain the presidency, he would lead a Republican party even more subservient to his will than in his first term. A Republican Congress would almost surely roll back the ACA Medicaid expansion and impose sharp spending caps on surviving Medicaid programs, as well as deregulating and largely defunding the ACA marketplace, as failed Republican legislation aimed to do in 2017. Should Democrats control one or both houses of Congress, an HHS Department filled with MAGA partisans, in line with plans currently being laid by well-funded right-wing organizations like the Heritage Foundation to root out technocratic expertise and install Trump loyalists at every level in all federal departments, would doubtless pull out all stops to undermine the marketplace and reduce Medicaid enrollments.

In Trump’s first administration, his appointments to HHS and CMS also were hostile to the structure of the ACA marketplace and the Medicaid expansion. Most notably, CMS administrator Seema Verma encouraged states to impose work requirements on “non-disabled, working age Medicaid enrollees — with some success, although the measures were largely checked by the courts. She also pushed states to conduct more frequent income and eligibility checks on Medicaid enrollees, encouraging the kind of procedural disenrollments (often of people who never received demands for information) now plaguing the post-pandemic Medicaid unwinding. '

But Verma and HHS Secretaries Tom Price and Alex Azar were also more constrained by conventional political incentives and the needs of corporate, state and individual constituents than their successors in a second Trump administration would likely be. The administration’s record with respect to ACA marketplace administration was mixed. Some measures harmed product quality and enrollment; some measures boosted enrollment and retention.

Wednesday, February 14, 2024

Unkind unwinding: Health Policy Valentines 2024

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In a year of existential threats, and an era in which the corporate practice of medicine knows few curbs, there is still a stream of health policy wins worth serenading in the time-honored (since 2012!) tradition of #HealthPolicyValentines. This year’s mash notes below.

In a year of existential threats, and an era in which the corporate practice of medicine knows few curbs, there is still a stream of health policy wins worth serenading in the time-honored (since 2012!) tradition of #HealthPolicyValentines. This year’s mash notes are below.

The Medicaid unwinding
is often blind and cruel.
But spare some V-day love
For ex parte renewal.

* * *

A valentine from Democrats,
enacted, but hardly trending:
An annual Part D cap
on out-of-pocket spending.

* * *

What’s sweeter for seniors
than sugar and spices?
Medicare negotiating
selected drug prices.

* * *

Send flowers, chocolate and smiles
for keeping insurers squirmin’
over AI-driven denials
to Casey Ross and Bob Herman.

* * *


O ACA, flawed child,
I’ll no longer carp
so long as your subsidies
remain enhanced by the ARP.

* * *

For low-income tar heels,
nothing can be finer
than Medicaid expansion
in North Carolina.

* * *

Let’s honor legislation
little known, in point of fact,
preventing harm, unnoticed:
The No Surprises Act.

* * *

As oligarch-funded theocrats
harm the women of this nation,
my love goes to the National
Abortion Federation.

* * *

And one for my wife as I join her on the far side of the age-65 threshold:

After 40 years of love
we’ll take no crap
from MA insurers —
thanks to Medigap.

* * *

While dredging up healthcare doggerel like this, I always end up with some bitter snippets, then remind myself they’re not um, valentines. Since they now exist, however, and at the risk of spoiling the mood, I’ll share a little rage rhyming:

The Supreme Court’s out of control,
but had better not go postal
by voiding the FDA rule
for Mifepristone and Misoprostol.

* * *

Nothing’s more dangerous
for those with colon polyps,
financially speaking,
than private equity rollups.

Take a trip down ACA memory lane with a visit to the Health Policy Valentines archives: Surprise! No Surprises (2023), Flowers in the graveyard (2022), Institutional edition (2021), But love grows old and waxes cold (2020), The Water is Wide: Health Policy Valentines (2019),  HPV (2018), Love Knows No Repeal (2017),  Love in the Time of Obamacare (2016), love, 2015, and Romance of the Rose, Health Policy Edition (2014).

Photo by Aykut Aktemur 

Sunday, January 21, 2024

How has the Medicaid unwinding affected various states' ACA marketplace enrollment?

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My last post stressed that ACA enrollment growth in the Open Enrollment Period for 2024 remains heavily concentrated in states that have refused to enact the ACA Medicaid expansion.

I might have pointed out, though, that the main divide in growth rates is between the 32 HealthCare.gov states and the 19 state-based marketplaces (SBMs). The difference in year-over-year enrollment growth as of Dec. 23 between expansion and nonexpansion states within the HealthCare.gov universe is not large -- 42.1% vs. 35.6%, according to Charles Gaba. Last year, the gap was bigger: enrollment in the nonexpansion states on HealthCare.gov increased by 22.7% in OEP 2023, vs. 9.9% in expansion states on the platform (Gaba). There was a similarly wide spread in growth rates in OEP 2022.

The Medicaid “unwinding” — the resumption in April 2023 of Medicaid redeterminations and disenrollments after a three-year pandemic-induced moratorium — is a major factor in this year’s enrollment gains. As of September, CMS reported that about 1.2 million Medicaid disenrollees (about 13% of the disenrolled) had enrolled in the marketplace (or in the Basic Health Programs available to low-income enrollees in New York and Minnesota) from April through September. As Medicaid disenrollments have now passed 15 million (!), close to 2 million by now may have landed in marketplace plans or the BHPs, accounting for perhaps 40% of enrollment growth.

That boost to enrollment is apparently at work in expansion and nonexpansion states alike. Of the 16 HealthCare.gov states with growth rates above the median, eight are expansion and eight are nonexpansion states. Again, expansion states are sharing more in this year’s strong enrollment growth than in prior post-pandemic years. The Medicaid unwinding may partly explain that. While growth rates remain lower in the SBM states (all of which have expanded Medicaid) than in HealthCare.gov states, strong enrollment growth (13.8%) has resumed in the SBM group in 2024 after remaining basically flat last year.

In my last post, with respect to the Medicaid unwinding, I wrote:

…state Medicaid disenrollment rates don’t clearly correlate with expansion/nonexpansion status or marketplace enrollment rates (at least not obviously; perhaps researchers will tease out significant relationships in years to come).

Here I want to take a look at another measure of the potential impact of the Medicaid unwinding on marketplace enrollment in OEP 2024: The extent to which the migration of Medicaid disenrollees into the marketplace during the off-season boosted each given state’s marketplace enrollment. CMS has tracked those enrollments, from April through September 2023, in the Medicaid Marketplace Unwinding Report. I’ve confined my focus to the 32 states using HealthCare.gov, as state-based marketplaces are quite a various lot, both in market conditions and reporting.

Thursday, January 18, 2024

ACA marketplace enrollment up 135%-plus since 2020 in nonexpansion states; may approach 100% in all states

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Marketplace enrollment in nonexpansion states is up 135% since 2020. Drink!

Updated 1/24/24

Politico’s Ben Leonard and Chelsea Cirruzzo, noting that ACA marketplace enrollment during the Open Enrollment Period (OEP) for 2024 was already up 25% over the final OEP 2023 tally as of December 23 (with OEP still running), locate the surge geographically:

So far, states in the South and the Rust Belt have had among the highest rates of enrollment growth between 2023 and 2024 plan years, according to a POLITICO analysis of HHS data.

Louisiana and West Virginia have the highest growth rates — about 63 percent each…Alabama, Arkansas, Georgia, Indiana, Mississippi, Ohio, South Carolina, Tennessee and Texas all had growth rates between 36 and 52 percent.

That is no surprise as to the southern states — for which, read primarily “states that have refused to enact the ACA Medicaid expansion.” While Louisiana is an expansion state, as are the three “rust belt states” cited above, the “nonexpansion” states have driven the marketplace’s surging enrollment growth throughout the pandemic years, as I’ve noted previously with respect to OEP 2021, OEP 2022, and OEP 2023. Every state marketplace is different, and enrollment in a given state may rise or fall in a given year or cluster of years for myriad reasons, but since OEP 2021, the shrinking pool of nonexpansion states (there were 14 in OEP 2021, 10 at present) have accounted for the vast majority of net new enrollments (75% of net new enrollments this year). That’s largely because of sustained growth in behemoths Florida and Texas, which together account for about a third of all marketplace enrollment.

The table below shows enrollment growth from 2020-2024 in the ten states that had not expanded Medicaid as of November 1, 2023, the beginning of OEP 2024. North Carolina enacted its Medicaid expansion beginning December 1, but the migration of low-income marketplace enrollees to Medicaid does not yet show up in the enrollment tallies, so I’ve included North Carolina in the nonexpansion state group. Note also that the totals for OEP 2024 run only through December 23, 2023, while OEP ended on January 16, 2024 in the 32 states using HealthCare.gov and is still running in several state-based marketplaces. Charles Gaba estimates that the final tally for OEP 2024 will rise by another 1-2 million, or 5-11%.  [Update, 1/24/24: CMS released the final enrollment snapshot for HealthCare.gov states today. National totals are near-complete, with perhaps 20,000 additional enrollees likely to be tallied in SBMs by the end of the month. I have updated the table below; for the record, the original table, with 2024 tallies through Dec. 24, is preserved at bottom.]

Sunday, January 14, 2024

New York's ACA alchemy: marketplace silver to Essential Plan platinum

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Greener pastures for New Yorkers of a certain income


New York has a pending ACA Section 1332 updated waiver proposal to CMS that would extend eligibility for the Essential Plan, the state’s zero-premium, low-out-of-pocket cost health insurance program, to applicants with incomes up to 250% of the Federal Poverty Level ($36,450 for an individual, $75,000 for a family of four) in April 2024.

The economics of the program appear to defy gravity, and perhaps suggest lessons as to the public funding of health benefits in the United States.

Shedding “Medicaid-ish” payment rates

As currently structured, New York's Essential Plan is a Basic Health Program, an option for states established by Section 1331 the Affordable Care Act. A BHP is a health coverage program for state residents with incomes up to 200% FPL offered in place of standard ACA marketplace coverage. The implicit premise of Section 1331 is that BHPs will pay lower rates to providers and plow those savings into reducing premiums and out-of-pocket costs for enrollees — rather like Medicaid.

The Essential Plan currently provides coverage with an actuarial value of 98% to enrollees with income up to 150% FPL, compared to 94% for benchmark silver coverage in conventional marketplaces, and an AV of 92% to enrollees in the 150-200% FPL income bracket, compared to 87% in the marketplace. The plan has no deductibles at any income level and includes dental and vision coverage. Plan benefits are standardized.