By Robert B. Barnett Jr., J.D.
A CMS report found that ACA enrollment declines have begun to slow as insurance premiums have stopped increasing as much, have stopped increasing at all, or have decreased.
Average monthly enrollment in health insurance exchanges under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) has continued to drop, but the decrease slowed in 2019 as insurance premiums have begun to level off, according to a CMS report on enrollment trends. Thus, while enrollment declined 20 percent in 2017 and 24 percent in 2018, it declined by only 3 percent in 2019. Unsubsidized enrollment is dropping more quickly than subsidized enrollment, with 80 percent of the decrease in 2019 being attributed to those who do not receive subsidies (CCIIO Report, October 9, 2020).
In 2015, the average monthly enrollment rose by 7 percent to 14.5 million. Since then, however, the exchanges have experienced an enrollment decrease. A correlation exists between an increase in premium rates and a decline in enrollment rates. As premium rates "increased sharply" between 2016 and 2018, enrollment rates declined sharply. Insurance premium rates in 2019, however, remained consistent with premium rates in 2018, which has been reflected in a leveling off of enrollment declines.
Unsubsidized rates. Enrollment rates among unsubsidized enrollees declined 45 percent from 2016 to 2019, representing a loss of 2.8 million people. The result is that the subsidized portion of the market has grown much larger than the unsubsidized portion. While the subsidized portion of the market was 24 percent larger than the unsubsidized portion in 2015, by 2019 the unsubsidized portion was 140 percent larger than the subsidized portion. In 2019, the unsubsidized enrollment declined by 9 percent compared to only a 1 percent drop in subsidized enrollment. The expansion of state Medicaid coverage in some states is thought to have had some impact on the decline in unsubsidized enrollment.
State comparisons. Enrollment experiences among the states have differed, although the vast majority are experiencing declines. In 2016, overall enrollment declined in only 10 states. In 2017, however, enrollment declined in 44 states. In 2018, enrollment declined in 43 states. And in 2019, it declined in 39 states (with 10 states reporting an increase). From 2016 to 2019, unsubsidized enrollment ranged from a 4 percent decline in Rhode Island to a 90 percent decline in Iowa. The states with the biggest decreases in unsubsidized enrollment during that period after Iowa were Nebraska (81 percent), Tennessee (77 percent), Arizona (76 percent), New Hampshire (75 percent), Oklahoma (72 percent), Georgia (72 percent), West Virginia (71 percent), and Missouri (70 percent).
Once again, a correlation existed between enrollment decreases and premium increases, with the largest declines in unsubsidized enrollment occurring in those states with the largest increases in average premiums. Every state but three (District of Columbia, New Hampshire, and North Carolina) experienced either a smaller decline in 2019 or a growth in enrollment. In the five states where unsubsidized enrollment actually increased in 2019 (Alaska, Arizona, Minnesota, Iowa, and New Jersey), the average insurance premium fell by more than five percent.
MainStory: TopStory OtherAgencyIssuances EnrollmentNews HealthInsuranceExchangeNews InsurerNews PremiumNews PremiumTaxNews NewsFeed
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