START OF 2018 OPEN ENROLLMENT PERIOD

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According to a report issued last July by the Kaiser Commission on Medicaid and the Uninsured, if all states accepted Medicaid Expansion the number of uninsured would be reduced by an additional ten million people. The comprehensive report noted, however, that 4.9 million of those people were living in states that had refused the expansion and another 1.5 million were in states that had not yet decided.

Why have many governors refused the offer of the federal government to fund 100% of the expansion for three years, and 90% thereafter until 2022?  Among other reasons, the governors claim they cannot depend on the promise of federal funding, but they rarely state their main concern: the possibility that a large number of additional regular Medicaid clients will come "out of the woodwork." These are people who could have qualified previously under the regular Medicaid rules but never enrolled, perhaps because they did not know about the system, did not realize they might qualify, or did not know how to find out.  As reported by NPR in 2012: "what really has many state leaders worried is something called the 'woodwork effect.' When big parts of the health law go into force in 2014, they worry it will bring out of the woodwork the millions of people who are already eligible for Medicaid but aren't already enrolled."

It appears that many people have indeed been signing up for regular Medicaid because of the publicity about healthcare.gov and the state exchanges, as well as an easier, streamlined enrollment process required by the ACA. Evidence of the woodwork effect can be found in the latest CMS report. For states with Medicaid Expansion, there was an average increase of 14.4% in Medicaid applications Oct-Dec compared to the July-Sept average. For states not expanding Medicaid, there was an average decrease of 10.1% during the same period. This decrease may reflect a typical seasonal pattern, which makes the 14.4% increase in the Expansion states even more remarkable.

States refusing Medicaid Expansion fear the woodwork effect because the federal government pays a much smaller share of the costs of regular Medicaid: from 73 percent in a poor state like Mississippi, for example, to 50 percent for states such as Wyoming, California and Connecticut. When it comes to paying its share of Medicaid costs, the federal government will have to require that states distinguish clearly between regular Medicaid clients and the "non-elderly", non-disabled, childless, low-income adults between the ages of 19-64 who are newly enrolled because of Medicaid Expansion. 

Currently, these states (plus DC) are expanding Medicaid:

AZ, AR, CA, CO, DE, HI, IL, IA, KY, MD, MA, MI, MN, MA, NV, NJ, OH, UT, NM, NY, ND, OR, RI, VT, WA, WV

States not expanding Medicaid:

AL, AK, FL, GA, ID, LA, MS, MO, MT, NE, NC, SC, SD, TX, WI

States that may expand Medicaid or accept a modified version in 2014:

IN, KS, ME, NH, OK, PA, TN, VA, WY

Regarding the latter group, a recent article says "an unusual alliance of powerful hospital, business and religious interests has been leaning on Republican leaders to reverse course." It is probable that as the benefits of Medicaid Expansion to a state's budget become increasingly evident, such as less uncompensated care, more states will accept Medicaid Expansion despite their initial objections.

Good Morning! I have some mid-level changes to both spreadsheets this morning which visitors should be aware of:

--On the Private QHP Spreadsheet, I've replaced the very rough percent-based "Total Uninsured" numbers with the raw numbers from the same Kaiser Family Foundation table. Again, this is the same source, I'm just using the raw number view now instead of the percent view. In addition, using percentages were based on the July 2013 census estimates, while the KFF numbers are based on 2011-2012 population totals. Combine this with the percentages being previously rounded off, this resulted in some significant differences in the state numbers.

For example, at the high end, the California number changed from around 7.6 million to only 7.1 million, a half-million difference! Meanwhile, at the low end, Vermont has "dropped" from 57,000 uninsured prior to October 1st to just 47,900…which makes the original CMS projection for Vermont (also 57,000) all the more absurd.

OK, no press release or private/public breakdown yet, but the home page of New York's health exchange website is displaying a total of 351,605, up from 328,796 as of January 20.

Assuming the same 67/33 split that their previous exchange enrollments have followed, that means roughly 15,400 private enrollments and another 7,409 added to Medicaid/CHIP. I'll adjust these numbers as appropriate once a formal press release comes out.

In addition, this is the first update that takes us beyond January 23 (the date of the "3 Million" announcement), so only about half of that 15,400 will be subtracted from the "Not Broken Out Yet" amount. And with that, we've moved onto Week 17.

Washington State just released their latest official update, and as usual, they do a fantastic job of breaking down the numbers in an easy-to-follow manner, especially on the Medicaid/CHIP side.

Private QHP enrollments are up from a total of 149K (73,098 paid, 76,058 unpaid) as of 01/09 to about 168K (86,031 paid, 81,872 unpaid) as of 01/23, a 12.7% increase in 2 weeks.

Medicaid enrollments are up from a total of 198K (134,700 via Medicaid Expansion + 63,070 "Out of the Woodwork" folks who were previously qualified but weren't already enrolled) as of 01/09 to a total of almost 238K (160,587 expansion + 77,144 "woodwork") as of 01/23. This represents a 20% increase.

Between these and the other recent updates, the grand totals now stand at 3.16M Private QHPs and 7.38M Medicaid/CHIP enrollees. It's also important to stress that the Medicaid number does not include renewals of existing Medicaid/CHIP recipients.

I've written about this in passing before, but after repeated requests about the subject, I've decided to devote a full blog entry about the serious problems inherent in the CMS's state-level Private QHP projection numbers.

As far as I can tell, while the national "7 million" private enrollment projection figure issued by the CBO was based on solid analysis of the demographic situation at the time, the state-level CMS projection breakdown is, in many cases, based on little more than educated guesswork.

As the CMS put it in their own report: 

 In general, the enrollment targets provided by state- based Marketplaces are more ambitious than the initial Department enrollment targets for those specific states. As a result, using the publicly available SBM targets without adjusting other states would have raised the projected number of 2014 Marketplace enrollees by 1.4 million; therefore, the Marketplace ramp-up rates for other states were revised downward accordingly to maintain the 7 million total. 

Contributor deaconblues provides an interesting Rhode Island update. While the standard Private QHP and Medicaid/CHIP numbers haven't changed from what I already had listed (although the paid QHP number has increased slightly), there's also the addition of 4,311 RIte Care parents automatically enrolled in RI's non-profit Neighborhood Health Plan.

As deaconblue notes, "Rite Care looks like it fully covers the premium for up to 150% FPL and offers premium assistance to those between 150% and 250%...the context implies that all of the 4,311 should be somewhere under QHP - if some of these plans were fully paid by the state, would they have appeared as an asterisked note under the Medicaid Enrollments section?"

I see his point, but at the same time, seeing how it fully covers the cost up to 150% FPL while even the ACA's Medicaid expansion only goes up to 133%, it really sounds like the vast majority of these folks should be categorized on the Medicaid/CHIP side. I'll look into it and may move some or all of these over to the Private QHP side later, but for the moment I'm listing them as "Medicaid/CHIP".

Hmmm...the same article uses 2 slightly different numbers (368 and 370)...I'll split the difference for the moment :)

New Mexico is also noteworthy in that while their individual ACA market is being handled by the federal exchange (HC.gov) for the first 2 years, they're already running their own small business (SHOP) market themselves.

Meanwhile, I've been informed that Washington State only has their SHOP program running in 2 counties, while Maryland's won't be operational until April (SHOP enrollments are open year-round, while individual/family enrollments are only available through 3/31).

As of Jan. 15, 368 people had purchased insurance through New Mexico’s SHOP (Small Business Health Options Program) exchange for small businesses. 

...So far, 370 people have enrolled in insurance plans on the SHOP exchange, according to the NMHIX. A total of 1,542 employers have set up accounts on the exchange and they represent 3,962 employees.

Kentucky continues to slowly but steadily increase their tally, hitting 19% of their CMS projection target with 42,000 private QHP enrollees as of last Thursday. The 2,200 new additions have been subtracted from the "Not broken out by state" pool, bringing that total down to 486,500. Again, any new exchange enrollees which are added up through Jan. 23 will be subtracted from this since it fills out the "3 million" total announced by Kathleen Sebelius last week.

Meanwhile, on the Medicaid side, Kentucky added another 12,000 new enrollees, bringing them up to 189,000 when you add the 55K direct additions. It's important to note that according to the CMS reports, these people should all be new to Medicaid, not renewed accounts.

As of Thursday, according to the state, 176,000 Kentuckians have signed up for health insurance.

So far 42,000 have signed up for private insurance, or roughly 14 percent of the total number of uninsured Kentuckians. That compares to 134,000, or 44 percent of those eligible, who have signed up for Medicaid.

Some minor updates buried in the MNsure Board of Directors report; thanks to an anonymous tipster for calling my attention to it. Nothing major, but some small updates to both the Private QHP and Medicaid/CHIP enrollment figures (27,775 and 52,225 respectively). The most noteworthy addition is the 475 SHOP (Small Business marketplace) enrollments noted on page 27 of the report.

The story itself is pretty negative on the SHOP Small Business exchanges--apparently the Federal one (at HC.gov) won't be ready until this fall--but it at least gives the SHOP enrollment number for New York.

Exchanges in larger states aren’t doing much better with their business plans. In New York, about 5,000 employees of small businesses have enrolled in the SHOP exchange, James O’Hare, a spokesman for the state’s Department of Health, said in an e-mail.

...in which we find the third ACA-created SHOP (Small Business Health Options Program) addition of the day. 2,155 employees is a pretty miniscule number (especially for the largest state in the country), but it's something. Note that it says "2,155 employees", which most likely means about double that when you include dependents, but as always, I'm leaving it here unless I find specific sources stating otherwise.

A total of 289 small employers have signed up for coverage through Covered California’s Small Business Health Options Program, better known as SHOP. These employers will provide coverage to a total of 2,155 employees.

If you take a look at the Private QHP spreadsheet you'll see a new column: "Private SHOP Market". This is for enrollees in the ACA's Small Business Health Options Program, basically the small business (fewer than 50 employees) counterpart to the individual/family exchanges getting so much attention.

This is one of those cases where percentages mask the real picture. Yes, Hawaii has seen their Private QHP enrollments increase by an impressive 43% since December 28. However, they only had 2,192 people enrolled in the first place...the actual increase is only 934 people, to 3,126.

Furthermore, those 934 have to be subtracted from the almost half-million "Not Broken Out By State" tally at the top of the spreadsheet, since they came in before 1/24/14.

On the other hand, this also gives the first SHOP (Small Business Exchange) entry for Hawaii...another 307 people.

Hey, a person is a person...

As of Jan. 18 the Connector enrolled 3,126 people, though 13,000 applicants were deemed eligible for tax credits to reduce the cost of coverage. Of the 373 small-business groups that applied, only 75 employers were enrolled with 307 workers selecting plans.

A very nice bump in Oregon's numbers today, especially given their ongoing technical issues. Private QHP enrollments are up from 23,800 as of Jan. 15 to 30,157 as of Jan. 24. However, since yesterday's HHS Dept. announcement of appx. 3 million total enrollments was "as of this week", this doesn't impact the overall total; it simply subtracts about 6,000 from the "Unspecified" number. Expect a lot of this over the next week or two until the enrollment updates "clear" the Week 16 point.

OK, yesterday's update was apparently a bit premature; MD is actually up to over 25K, though they're still under 17% of the CBO projection figure. The Medicaid tally hasn't changed since last week.

Through January 18, 25,177 Marylanders have chosen to enroll in private health plans through Maryland Health Connection.

93,514 Marylanders signed up through the Primary Adult Care (PAC) program were automatically enrolled in Medicaid coverage on January 1, 2014, and now have full Medicaid coverage. As of January 14, an additional 29,517 individuals were newly enrolled in Medicaid effective January 1.

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