Marketplace Enrollment Hits Record 14.2 Million As Deadline Looms – healthaffairs.org

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On January 13, 2022, the Department of Health and Human Services (HHS) announced that 14.2 million people had enrolled in marketplace coverage thus far during the 2022 open enrollment period. Of the 14.2 million people, about 10 million people enrolled through HealthCare.gov and about 4.2 million people enrolled through 18 state-based marketplaces.
This high-level announcement builds upon a more detailed enrollment report issued on January 10 showing that 13.8 million Americans had enrolled in coverage through December 15 for states that use HealthCare.gov and December 25 for state-based marketplaces. (December 25 was selected since this was the deadline for consumers in half of state-based marketplaces states to enroll in coverage that would begin on January 1, 2022.) In that report, HHS noted that enrollment was up significantly relative to 2021: plan selections increased by 21 percent in the 33 states that use HealthCare.gov. An additional 949,000 people enrolled in coverage through New York’s Basic Health Program between November 1 and December 25; enrollment data from Minnesota’s Basic Health Program was unavailable.
HHS continues to attribute enrollment gains to enhanced marketplace subsidies under the American Rescue Plan Act and its investments in marketing, outreach, and the navigator program. The American Rescue Plan Act extended subsidies to many middle-income people for the first time and increased the amount of subsidies for those with lower incomes. HHS previously noted that more than 90 percent of HealthCare.gov consumers are receiving premium tax credits, including more than 400,000 people who would not have been eligible but for the American Rescue Plan Act.
Per the January 10 snapshot, much of the December enrollment (11.8 million people) was among returning consumers rather than new consumers. Returning consumers include those who actively selected a plan as well as those who were automatically reenrolled into coverage.
New enrollment is critical to maintaining the health of the overall risk pool because new enrollees tend to be younger and healthier. Thus far, there have been about 2 million new consumers nationwide, which accounts for only 15 percent of total enrollment (down from 21 percent of enrollees for the entire 2021 open enrollment period).
This is a significant drop in new enrollees. But this drop reflects higher enrollment of new consumers earlier in 2021—primarily through the Biden administration’s six-month COVID-19 special enrollment period. Indeed, more than 2.8 million new consumers enrolled during this period. Many of those who continue to have marketplace coverage are now considered “returning” customers for 2022 and provide the marketplaces with a broader base of enrollees for the open enrollment period.
Recently released effectuated enrollment data from the first half of 2021 validates this assumption. The new data shows record-high effectuated marketplace enrollment, meaning a record-high number of individuals both selected a plan and paid their premium. As of September 15, 2021, an average of 11.3 million individuals had effectuated their 2021 marketplace coverage through June 2021. This is up significantly from 10.5 million individuals for 2020 (which was then a record high). (In data released previously, HHS found that effectuated enrollment was even higher at the end of the special enrollment period, with 12.2 million people with marketplace coverage as of August 2021.) Higher effectuated enrollment reflects new enrollment during the special enrollment period and suggests that more people kept their marketplace coverage throughout 2021 (relative to prior years).
The January 10 snapshot includes state-specific data to reflect marketplace enrollment in December and shows that enrollment continues to be particularly strong in states that have not expanded their Medicaid program under the Affordable Care Act. The states with the highest enrollment thus far are California (1.7 million people), Florida (2.6 million people), Georgia (654,000 people), North Carolina (638,000 people), and Texas (1.7 million people).
On January 13, the HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) released a new report showing the impact of cost-sharing reductions (CSRs) on deductibles for plans sold through HealthCare.gov. CSRs are available to people who qualify for marketplace coverage, have an income between 100 and 250 percent of the federal poverty level, and enroll in a silver plan.
While deductibles have been rising steadily, 51 percent of marketplace enrollees during the 2021 enrollment period had incomes that qualify for CSRs meaning their deductibles were reduced to $1,000 or less. This is lower than the average deductible of about $1,700 for job-based coverage in 2021.
The American Rescue Plan Act also helped consumers enroll in more generous coverage by reducing premium contributions for low-income people. By enabling people whose income is 100 to 150 percent of the federal poverty level to enroll in a free (or nearly free) silver plan, many more consumers enrolled in silver plans, making them eligible for CSRs and lower deductibles. As a result, the median deductible for new consumers that enrolled during the COVID-19 special enrollment fell from $450 to $50.
These savings are significant for those who qualify for CSRs. But for those who do not qualify—and even for those who qualify but whose income is from 200 to 250 percent of the poverty level—deductibles remain high. For 2021, average HealthCare.gov marketplace deductibles for bronze plans were $6,094 while average deductibles for non-CSR silver plans were $4,500.
Beyond the marketplace enrollment report, federal officials have released other recent data on enrollment and the uninsured rate. The first report shows continued historic enrollment through Medicaid and CHIP, and the second includes data on the uninsured rate in the first six months of 2021.
On December 21, HHS issued updated enrollment figures for Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). Overall, an estimated 83.2 million people were enrolled in coverage through Medicaid and CHIP as of June 2021. This is an increase of about 430,000 people since the May 2021 snapshot, suggesting that people continue to newly qualify for and rely on Medicaid and CHIP. Most of these people (76.3 million people) are enrolled through Medicaid compared to CHIP (6.9 million people). Compared to February 2020, enrollment has increased by nearly 18 percent—or 12.5 million more individuals.
Enrollment remains high because of Medicaid maintenance of effort requirements included under the Families First Coronavirus Response Act. In that legislation, Congress provided a 6.2 percentage point increase in the federal match rate for state Medicaid programs so long as states provide continuous enrollment throughout the declared public health emergency. The Biden administration has already given some guidance to states about how to process pending eligibility and enrollment actions at the end of the declared public health emergency. HHS also adopted a monthly SEP for low-income individuals to help ensure that those who are churning off of Medicaid coverage can successfully transition to marketplace coverage.
The same HHS announcement notes that total Medicare enrollment was nearly 64 million as of October 2021, with 36 million people enrolled in traditional Medicare and nearly 28 million people enrolled in Medicare Advantage plans. HHS posted a separate monthly enrollment report for the Medicare program.
Data from the Centers for Disease Control and Prevention (CDC) shows that the uninsured rate continued to hold steady in the first six months of 2021. This data comes from the National Health Interview Survey, considered one of the most comprehensive sources of information about health insurance coverage due to the large sample size and the fact that data is collected year-round.
The overall uninsured rate from January through June 2021 was 9.6 percent (about 31.1 million people) compared to 9.7 percent (about 31.6 million people) in 2020. For non-elderly adults (those aged 18 to 64), the uninsured rate over this time period was 14 percent. This is slightly higher than 2020, when the uninsured rate was 13.9 percent for non-elderly adults. Of insured non-elderly adults, 21.6 percent were enrolled in public coverage while 66.3 percent were enrolled in private health insurance. For children, the uninsured rate was 4.4 percent, with 44.7 percent enrolled in public coverage and 53.1 percent enrolled in private coverage. While these percentages are slightly different compared to 2020, the changes were not significantly different.
Like previous years, most non-elderly adults have private health insurance, and there is significant variation in the uninsured rate and source of coverage based on income. The uninsured rate among those whose income is 200 percent of the federal poverty level or less was much greater than the rate for those whose income is above that threshold. And Hispanic and Black people were more likely to be uninsured than white and Asian people, with differences in enrollment in public versus private coverage.
Consistent with prior reports, states that expanded their Medicaid program had a much lower uninsured rate in the first half of 2021 (10.6 percent) relative to states that have not expanded their Medicaid program (20.6 percent). The CDC also documented an increase in enrollment through the marketplaces, up to 4.3 percent in the first six months of 2021 from 3.7 percent in 2019. Marketplace enrollment was greatest among those whose income is between 100 and 200 percent of the federal poverty level and among Hispanic people.
DOI: 10.1377/forefront.20220114.493076

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