(updated w/latest election results)

In January 2021, the U.S. Senate will have at least 48 Democrats (including 2 Senators who caucus with the Dems) and at least 50 Republicans.

The last two seats are both in Georgia. Elected GOP Senator David Perdue was up for re-election against Democrat Jon Ossoff and a Libertarian candidate, while appointed GOP Senator Kelly Loeffler was running for the first time in a "jungle primary" against another Republican and several Democrats in a special election.

Under Georgia state law, if no candidate receives at least 50% of the vote (plus 1) in the November election, the top two finishers go on to a runoff election on January 5th.

Since no candidates in the special election came close to 50%, it will go to a runoff between Loeffler and top Democratic finisher Rev. Raphael Warnock...and the regular Senate race will also going to go to a runoff between Perdue and Ossoff, as Perdue has fallen below the 50% threshold.

There's a lot on everyone's plate at the moment. A global pandemic which has already killed over 230,000 Americans and infected 9 million more. The entire West Coast is on fire while the Gulf Coast is being hit with hurricanes. And there's some sort of election coming up on Tuesday, I hear.

Meanwhile, in just eleven days the Republican-controlled Supreme Court will hear oral arguments in a case brought by Republican plaintiffs (and sided with by a Republican Justice Department) over whether the Affordable Care Act should be struck down en masse because a Republican-controlled House and Republican-controlled Senate decided to change the individual mandate penalty amount from $695 to $0.

However, there's one other important thing happening with the ACA in just two days: The 2021 ACA Open Enrollment Period begins on Sunday, November 1st.

As I do every year, here's a list of important things to remember when selecting a health insurance policy. Some of these are the same every year and apply nationwide; others are specific to the 2021 enrollment period and/or to particular states.

1. DON'T MISS THE DEADLINE!

Health Insurance Town Halls Offered to Michigan Consumers with Questions about Open Enrollment 

Thousands of Michiganders have lost health coverage during the COVID-19 pandemic, and the Michigan Department of Insurance and Financial Services (DIFS) is offering virtual town hall events to help answer questions about open enrollment on the Health Insurance Marketplace, which runs until Dec. 15.  

These live online town hall meetings are part of a series of events that will help consumers learn and ask questions about signing up for a health plan on the Health Insurance Marketplace. To attend a virtual town hall event, click the event link at its start time. Instructions for attendees are available and explain how to join an event and ask questions. 

Event Information: 

The Massachusetts Health Connector (MA's ACA exchange) doesn't generally post official enrollment data reports via press releases, but I have a contact there who sends me their latest numbers from time to time during Open Enrollment:

Here's where we are at, currently:

  • January effectuations: 275,003
  • Feb. and March effectuations: 5
  • Plan Selections: 9,143
  • Total enrollments: 284,151

As a reminder, "effectuations" have paid the first month premium and are good to go. Plan selections still need payment to start.

Massachusetts is a bit unique among the ACA exchanges--they, along with Rhode Island, are the only ones which handle premium payments as well as policy enrollments. This means that they don't just track how many people select policies, they also know how many of those who enroll have actually paid their monthly premiums.

Access Health CT, Connecticut's ACA exchange, is posting updates to their Open Enrollment Period (OEP) numbers every Friday. Last week they reported 100,094 Qualified Health Plan (QHP) selections during the first 20 days of the 2021 OEP, which sounds more impressive than it is, since 95,857 of those were current enrollees having their auto-renewals front-loaded; only 4,237 of them were actually new enrollees. Nothing wrong with that, of course.

This week, they report that they have 100,345 total QHP selections, of which 5,632 are new. On the surface this sounds off...shouldn't it be 101,489 total? I'm pretty sure the reason for the discrepancy is that not every current enrollee actually renews/re-enrolls for the following year. The exchange plugs them in as renewing, but they can still go in and actively cancel their renewal, which reduces the total a bit. In this case, it sounds like 1,144 current enrollees have done so over the past week. This gives a net increase of 251 over the past week, or 36 per day.

"Picture worth 1,000 words" and all that.

I was doing this earlier in the summer but stopped updating it in August; I've started over with a fresh spreadsheet and have expanded it to include every U.S. territory, including not just DC & Puerto Rico but also American Samoa, Guam, the U.S. Virgin Islands and even the Northern Mariana Islands.

I've done my best to label every state/territory, which obviously isn't easy to do for most of them given how tangled it gets in the middle. The most obvious point is that New York and New Jersey, which towered over every other state last spring, are now utterly dwarfed by North & South Dakota, which are skyrocketing.

North Dakota recently became the first state to cross the 10% infection threshold, with South Dakota not far behind. Iowa, Wisconsin, Nebraska and Utah could all potentially hit the 10% milestone by New Year's Eve as well.

The data below comes from the GitHub data repositories of Johns Hopkins University, except for Utah, which come from the GitHub data of the New York Times due to JHU not breaking the state out by county but by "region" for some reason.

I've made some important changes starting this week:

  • First: Until now, I've been using the 2016 Trump/Clinton election results for partisan lean for each county. Now that the dust has (mostly) settled on the 2020 election, I've updated this to the Biden/Trump results for 2020. There's a few states where I don't have county-level data for 2020 yet (AK, CT, MA, NH, NY, RI & VT). In most of these states it's only broken out by city- or legislative district-level so far; in New York, they still haven't reported a large chunk of the vote itself yet. For those 7 states I still have them categorized by the 2016 results, but will update these with 2020 status in the future.
  • Second: I've also added columns listing the actual Biden/Trump vote percentage for each county to give a feel for how partisan it is. Again, I'm defining "Swing District" as any county where the difference is less than 6.0%. There's 188 swing districts (out of over 3,100 total), with around 35 million Americans out of 331 million total, or roughly 10.6% of the U.S. population.

With these updates in mind, here's the top 100 counties ranked by per capita COVID-19 cases as of Saturday, November 28th (click image for high-res version). Blue = Joe Biden won by more than 6 points; Orange = Donald Trump won by more than 6 points; Yellow = Swing District

The Affordable Care Act includes a long list of codified instructions about what's required under the law. However, like any major piece of legislation, many of the specific details are left up to the agency responsible for implementing the law.

While the PPACA is itself a lengthy document, it would have to be several times longer yet in order to cover every conceivable detail involved in operating the ACA exchanges, Medicaid expansion and so forth. The major provisions of the ACA fall under the Department of Health & Human Services (HHS), and within that, the Centers for Medicare & Medicaid (CMS)

Every year, CMS issues a long, wonky document called the Notice of Benefit & Payment Parameters (NBPP) for the Affordable Care Act. This is basically a list of proposed tweaks to some of the specifics of how the ACA is actually implemented.

For example, here's what the actual PPACA legislative text itself said about the annual Open Enrollment Period (OEP):

(6) Enrollment periods.--The Secretary shall require an Exchange to provide for--

Way back in October 2013, I launched the ACA Signups project as a light, nerdy hobby thing which was only supposed to last around six months, through the end of the first ACA Open Enrollment Period (March 31, 2014). Instead...well, let's just say that it's more than seven years later and I'm still doing this.

The reality is that The Graph itself doesn't serve a whole lot of useful function anymore. The enrollment patterns were erratic the first couple of years but have since settled into a pretty predictable...if not downright boring pattern for both the federal and state exchanges. The main reason I keep doing it each year is mostly out of tradition these days; after all, without The Graph, there wouldn't be an ACA Signups and I wouldn't have become a healthcare policy wonk in the first place.

Hot off the presses, via the Centers for Medicare & Medicaid:

Week Three, November 15 - November 21, 2020

In Week Three of the 2021 Open Enrollment period, 758,421 people selected plans using the HealthCare.gov platform. As in past years, enrollment weeks are measured Sunday through Saturday. 

Every week during Open Enrollment, the Centers for Medicare & Medicaid Services (CMS) will release enrollment snapshots for the HealthCare.gov platform, which is used by the Federally-facilitated Exchange and some State-based Exchanges. These snapshots provide point-in-time estimates of weekly plan selections, call center activity, and visits to HealthCare.gov or CuidadoDeSalud.gov.

The final number of plan selections associated with enrollment activity during a reporting period may change due to plan modifications or cancellations. In addition, the weekly snapshot only reports new plan selections and active plan renewals and does not report the number of consumers who have paid premiums to effectuate their enrollment.

"Picture worth 1,000 words" and all that.

I was doing this earlier in the summer but stopped updating it in August; I've started over with a fresh spreadsheet and have expanded it to include every U.S. territory, including not just DC & Puerto Rico but also American Samoa, Guam, the U.S. Virgin Islands and even the Northern Mariana Islands.

I've done my best to label every state/territory, which obviously isn't easy to do for most of them given how tangled it gets in the middle. The most obvious point is that while New York and New Jersey are still far above every other state, other states are quickly catching up...and the trajectories of both North & South Dakota are incredibly disturbing in particular.

This isn't technically ACA-related, but it's certainly healthcare related and it was posted via the Minnesota ACA exchange, MNsure:

ST. PAUL, Minn.—The Minnesota Insulin Safety Net Program, launched earlier this year, provides a pathway for Minnesotans in urgent need of insulin (less than a 7-day supply on hand) to access the life-saving drug through their pharmacy. The program—implemented by MNsure, the state's health insurance marketplace, and the Minnesota Board of Pharmacy—was created to help Minnesotans facing difficulty affording their insulin.

The Insulin Safety Net Program is made up of two parts: 1) The urgent need program for eligible Minnesotans to receive a once-per-year 30-day supply of insulin immediately at their pharmacy for no more than a $35 copay; and 2) The continuing need program for eligible Minnesotans to receive up to a year supply of insulin for no more than $50 per 90-day refill.

Interested individuals should visit MNinsulin.org to see if they qualify and learn how to apply.

Who qualifies?

via Connect for Health Colorado:

Coloradans Are Getting Covered During the Pandemic

DENVER – Nearly 30,500 Coloradans signed up for a health insurance plan through Connect for Health Colorado’s Marketplace between Nov. 1 and Nov. 20. Through the first three weeks of the Open Enrollment period, approximately 73 percent of applicants qualify for financial help to help pay their monthly premiums.

Unlike many of the state-based exchanges, the Colorado ACA exchange is not "front-loading" their autorenewals of existing enrollees. They address this further down the press release:

“Unfortunately, the pandemic is continuing to grow and affect our communities. That’s why it’s more important than ever that Coloradans have access to affordable and quality health coverage.” said Chief Executive Officer Kevin Patterson. “I urge Coloradans to connect with us online, over the phone, or by making a virtual appointment with a certified Broker or Assister. We are here to make your enrollment as easy as possible.”

"Picture worth 1,000 words" and all that.

I was doing this earlier in the summer but stopped updating it in August; I've started over with a fresh spreadsheet and have expanded it to include every U.S. territory, including not just DC & Puerto Rico but also American Samoa, Guam, the U.S. Virgin Islands and even the Northern Mariana Islands.

I've done my best to label every state/territory, which obviously isn't easy to do for most of them given how tangled it gets in the middle. The most obvious point is that New York and New Jersey, which towered over every other state last spring, are now utterly dwarfed by North & South Dakota, which are skyrocketing.

The data below comes from the GitHub data repositories of Johns Hopkins University, except for Utah, which come from the GitHub data of the New York Times due to JHU not breaking the state out by county but by "region" for some reason.

Note that a few weeks ago I finally went through and separated out swing districts. I'm defining these as any county which where the difference between Donald Trump and Hillary Clinton was less than 6 percentage points either way in 2016. There's a total of 198 Swing Counties using this criteria (out of over 3,200 total), containing around 38.5 million Americans out of over 330 million nationally, or roughly 11.6% of the U.S. population.

With these updates in mind, here's the top 100 counties ranked by per capita COVID-19 cases as of Saturday, November 21st (click image for high-res version). Blue = Hillary Clinton won by more than 6 points; Orange = Donald Trump won by more than 6 points; Yellow = Swing District

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