Action Needed to Keep Marketplace Enrollment Strong

Despite uncertainty created by repeated congressional attempts to repeal the Affordable Care Act (ACA) and Trump Administration efforts to undermine the health insurance marketplaces, nearly as many people signed up for marketplace coverage for 2018 as for 2017. While enrollment remained strong, significant headwinds that confronted this open enrollment period almost certainly reduced sign-ups. And looming challenges — including repeal of the ACA’s individual mandate and additional harmful Administration actions — will require states and independent groups that help support marketplace outreach and enrollment to work even harder to sustain coverage gains, as we explain in a new paper.

The 2019 open enrollment period will present major additional challenges. The end to the ACA’s requirement that most people enroll in coverage or pay a penalty and the potential expansion of short-term health plans that don’t have to meet ACA standards may prompt fewer healthier consumers to enroll in marketplace coverage. A less healthy pool of consumers will drive up premium sticker prices and make health care less affordable for those who wish to keep comprehensive coverage. Other challenges include a new Administration rule that will further limit access to consumer assistance to help people enroll, and immigration rules under consideration that could deter marketplace-eligible people from signing up for health insurance.

The outcome of open enrollment for 2019 will depend in large part on whether states take steps to protect their markets and their consumers. States should:

• Protect their markets from the proposed expansion of short-term and other substandard plans. States have broad authority to protect their markets and consumers by blocking expansion of these plans, as Maryland recently did on a bipartisan basis.
• Make coverage more affordable for consumers. States can make coverage more affordable by instituting state reinsurance programs or providing supplemental tax credits that fill gaps or offer more generous assistance than the federal premium tax credits that help low- and moderate-income people afford insurance.
• Restore an individual mandate. With the federal mandate penalty repealed, states can enact their own individual mandates to help keep their individual market affordable, as New Jersey and other states are considering.
• Maintain or restore a longer open enrollment period. States that run their own marketplaces should extend the open enrollment period beyond the shortened period for states that use the HealthCare.gov eligibility and enrollment platform. Ten states did so for 2018; states with longer enrollment periods on average saw stronger sign-ups.
• Respond to the Administration’s decision to stop cost-sharing reduction (CSR) payments in ways that protect and benefit consumers. In response to the Administration’s decision to end CSR payments to insurers, most states required insurers to limit cost increases to silver-level plans, since consumers are only eligible for cost-sharing reductions if they enroll in a silver-level plan. That approach can reduce costs for subsidized consumers and protect unsubsidized consumers from CSR-related premium increases. States that did not take this approach for 2018 should do so for 2019.
• Conduct outreach and consumer application assistance to promote enrollment across Medicaid, the Children’s Health Insurance Program, and the subsidized marketplace. Together these programs provide a continuum of coverage to people without affordable employer-based coverage. Combined outreach for all of these programs is often the best way to reach low- and moderate-income people, who may not know which program they’re eligible for until they apply.

Independent groups that contribute to marketplace outreach and enrollment will also have an even more important role to play for 2019. During 2018 open enrollment, many groups stepped up their efforts to help compensate for the Administration’s outreach cuts. Next year will require new and strengthened partnerships, an aggressive media strategy to promote open enrollment, and more investment to conduct outreach and support consumer groups that provide enrollment assistance.