off the charts
POLICY INSIGHT
BEYOND THE NUMBERS

Record Marketplace Enrollment Result of Policymakers’ Renewed Commitment to Health Coverage

Nearly 14.5 million people nationwide signed up for health coverage during the Affordable Care Act (ACA) marketplace open enrollment period ending January 15 — a 17 percent increase over the 2021 open enrollment period and the highest enrollment ever. (The enrollment figure will rise when results are reported from the longer open enrollment periods in six states.) Increased federal commitment to expanding health coverage fueled this record enrollment, with more improvements to come. Congress and the Biden Administration helped expand and enhance marketplace coverage in several ways:

Lower premiums. The main factor fueling historic enrollment growth is the significant premium reductions, especially for people with low incomes, included in the American Rescue Plan for 2021 and 2022. The Rescue Plan reduced premiums to zero, after accounting for the premium tax credit, for enrollees with income below 150 percent of the poverty line ($12,880 for a single person or $21,960 for a family of three) and reduced premiums significantly for most enrollees with incomes above this level. On average, HealthCare.gov (the federal marketplace) enrollees saw a 23 percent premium reduction.

The Rescue Plan also extended eligibility to people with income over 400 percent of the poverty line whose premiums consume a disproportionate share of their income, limiting their premium cost in the marketplace to no more than 8.5 percent of their income. Overall, nearly one-third of enrollees chose a 2022 plan with monthly premiums of $10 or less.

Expanded access to unbiased enrollment assistance. The Administration’s record $90 million investment quadrupled the number of navigators, who raise awareness of health coverage options under the ACA and help people apply and enroll in the marketplace. This is a stark contrast to the anemic funding under the Trump Administration, which cut navigator funding by 84 percent. Starting this year, rules expanded the navigators’ role to now provide post-enrollment assistance, including services such as filing appeals of eligibility decisions, educating people on how to use their health insurance coverage, providing support in reconciling advance premium tax credit amounts on their tax returns, and reporting changes in circumstances (such as changes in income or household composition) that might affect the amount of premium tax credit they should collect in advance.

Navigator services are particularly important for groups that have historically faced enrollment difficulties, such as people who need translation services or lack internet at home. Expanded assistance is particularly needed by Black and Latino people, who are more likely than white consumers to seek in-person help. And additional evidence suggests that outreach and enrollment assistance could be essential for Latino adults, who are more likely to encounter application and language barriers to enrollment.

Longer enrollment period. The Centers for Medicare & Medicaid Services (CMS) extended HealthCare.gov’s open enrollment period, shortened by the Trump Administration, by one month to January 15. CMS had ample reasons to extend it, including to reduce barriers to coverage, especially among eligible but unenrolled people. The usual enrollment period occurs at the end of the year, when research shows people experience higher levels of financial and mental stress, making it a particularly difficult time to enroll in health coverage. Lower-income people are likely to experience especially acute financial pressure between Thanksgiving and New Year’s Day, as expenses such as gifts and heating bills strain household budgets, making the extension much-needed for people who likely qualify for the most generous financial help. The Administration launched a robust outreach and media strategy during the longer enrollment period to make people aware of the coverage and cost assistance available.

For people with lower incomes, there will also be a new monthly special enrollment period, to be implemented this spring, to allow people with income at or below 150 percent of the poverty line to enroll now that the general enrollment period has closed.

Proposed future improvements. The Administration has proposed more changes to marketplace coverage for 2023, with a focus on improving equity and enhancing the quality of marketplace plans. Every year CMS puts forward rules that change certain marketplace policies in the coming year. This year’s proposed rules, taken together, would make coverage and the open enrollment season work better for consumers. For example, the proposed rule changes would:

  • Explicitly protect LGBTQ people from discrimination in marketplaces, by agents and brokers, and in health plans, restoring protections removed by the Trump Administration;
  • Prevent insurers from shirking payment of rebates they owe consumers when they spend too little of the premiums they collect on health care services and quality improvements;
  • Create standards for network adequacy — which help ensure plans have sufficient hospitals, specialists, and other providers in their networks — to strengthen consumers’ access to care; and
  • Require marketplace insurers to add standardized plans to their offerings. These plans would have the same benefits, deductibles, and cost-sharing amounts, allowing people to compare plans from insurers based on a more limited set of factors, such as premiums and provider networks. This helps to simplify the process of comparing and choosing a plan.

Reaching a compromise on a Build Back Better bill could solidify and further expand marketplace enrollment. The bill’s extension of the Rescue Plan improvements to the premium tax credit would continue to help people afford health insurance, and 2.2 million people — 60 percent of whom are people of color — could gain coverage due to the bill’s closure of the Medicaid coverage gap, which would open a path to coverage for people with incomes below the poverty line who live in the 12 states that didn’t expand Medicaid.

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Director of Health Insurance and Marketplace Policy