BEYOND THE NUMBERS
Accurately Evaluating Marketplace Enrollment
The Centers for Medicare & Medicaid Services (CMS) final count of people selecting health coverage through the Affordable Care Act’s (ACA) individual marketplace for 2021 is expected soon after open enrollment closes on December 15th. Accurately assessing this year’s HealthCare.gov sign-ups will require some adjustment — they will match last year’s on an apples-to-apples basis if they total roughly 7.65 million, about 630,000 (or 7.6 percent) below the 8.29 million in last year’s final enrollment snapshot.
This adjustment is needed for three reasons:
- New Jersey and Pennsylvania now administer their own marketplaces. The CMS snapshot no longer reflects those states’ marketplace enrollment because they moved this year from the federal government’s marketplace platform to their own. Removing New Jersey’s sign-ups lowers last year’s total by roughly 246,000 and removing Pennsylvania’s further lowers it by roughly 332,000.
- Idaho, Nebraska, and Utah expanded Medicaid in 2020. Once states expand Medicaid under the ACA, people with incomes between 100 to 138 percent of the federal poverty line are eligible for Medicaid rather than marketplace coverage. Data from states that expanded Medicaid in late 2015 and 2016 (Alaska, Louisiana, and Montana) show that it can take several years for marketplace sign-ups to fully reflect these transitions. Based on these other states’ experiences, we estimate that Medicaid expansion will lower signs-ups collectively in Idaho, Nebraska, and Utah by roughly 40,000, with some continuing decline in future years.
- Maine and Virginia expanded Medicaid in 2019. As noted, the full transition from marketplace to Medicaid coverage in Medicaid expansion states occurs over several years. Thus, we estimate that Medicaid expansion will continue to lower sign-ups collectively in Maine and Virginia by roughly 10,000 to 20,000.
These adjustments are needed to account for policies that mechanically remove people from the count of HealthCare.gov marketplace sign-ups — whether by shifting them to a state-based marketplace or to Medicaid — and, in turn, to get an accurate view of the trend in ACA marketplace coverage.
Separately, COVID-19 and the resulting deep recession could raise or lower marketplace enrollment. On the one hand, millions of people have likely lost employer-based coverage, and some now need marketplace coverage. On the other hand, millions more are enrolled in Medicaid than before the pandemic, because people’s incomes have fallen and because the Families First Coronavirus Response Act of March provided continuous coverage protections. That could reduce the need for marketplace coverage. On net, marketplace enrollment could rise or fall compared to last year. But to evaluate which occurs, it will be important to focus on adjusted, apples-to-apples enrollment counts.
Regardless, HealthCare.gov sign-ups will certainly be lower than they would have been without Trump Administration and congressional actions undermining the marketplace, including deep cuts to outreach and enrollment assistance, a greater availability of substandard plans, a climate of fear that deters eligible immigrants and their family members from getting coverage, and the repeal of the ACA’s penalty for not complying with its requirement (known as the individual mandate) to obtain coverage.