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ACA Repeal Impact

UPDATE 1/17/16: This morning the Congressional Budget Office released their projections of how many people would likely lose healthcare coverage if the GOP proceeds with a partial repeal of the Affordable Care Act. My state- and county-level estimates assume a full repeal (including wiping out regulations like guaranteed issue, community rating and so forth), which I estimate would add up to around 24 million people without including "Young Adults on Parents' Plans", or around 25.3 million with them included.

The CBO's projection, however, like the Urban Institute's, assumes a partial repeal, which would remove Medicaid expansion, federal subsidies and the individual/employer mandate penalties...but would leave the rest in place. This would actually have a more devastating impact, as it would decimate the off-exchange (full-price) individual market as well. They project around 32 million people losing coverage by 2026 under this scenario...or roughly 8 million more individual market enrollees than the 8.9 million I'm estimating under the full repeal scenario.

Of course, the number of off-exchange indy plan enrollees varies widely from state to state and even county to county, but if you want to get an idea of how the state/county-level numbers would look under the CBO "partial repeal" projection, simply double the number of individual market enrollees to each state/county.

For instance, in Oakland County, Michigan, my estimate is ~35,000 highly-subsidized exchange enrollees and ~53,000 Medicaid expansion enrollees, or around 88,000 total. Under the CBO's projection, I'd add roughly 35,000 more off-exchange and unsubsidized on-exchange enrollees, for a total of ~123,000 people losing coverage.

Alternately, you could just increase the TOTAL number for each state by around 1/3 to get a rough idea of the maximum possible devastation.

I've pulled together all of my state/county-level breakout entries into a single location (scroll down for links to individual states). This way people can look up specific states to see what the potential impact of the ACA being repealed would be in terms of people losing their healthcare coverage. I even added this link to the main menu above.

Remember: I'm only including those who I expect could lose their coverage, not the impact to Medicare, pre-ACA Medicaid, Group Coverage and so on.

Some important caveats which apply to all county-by-county breakouts, and a few which only apply to specific states:

YOUNG ADULTS ON PARENTS' PLANS:

  • In the full 50-state summary, I include an extra column for "Young Adults on their Parents' Plan"; there's around 3.1 million of these folks nationally. I only estimate around 1.4 million of them are actually at risk of losing their current policy coverage because about 2/3 of the states already had a similiar law on the books at the state level prior to the ACA, though the specific provisons and cut-off ages varied. I've taken my best guess at how many wouldn't be protected by pre-existing (hah!) laws.
  • In addition, I have no county-level data whatsoever for the "Young Adult" numbers. Since this is probably the most likely part of the ACA to survive any repeal/replacement anyway, I've chosen to leave this category off of the individual state tables altogether.

MEDICAID EXPANSION:

  • In nearly all ACA Medicaid expansion states, these are hard numbers taken directly from the state public health department websites, quarterly/monthly reports and so on. The "as of" date varies from state to state, but all are within the past year.
  • For Arizona, the county-level Medicaid data wasn't split between "traditional" and "ACA expanded", but statewide, expansion enrollees make up about 21% of the total, so I'm assuming 21% of each county's Medicaid enrollees are expansion-specific.
  • Louisiana just launched ACA expansion in July, and has already signed up 374,000 people...who might be kicked right back off again.
  • New York and New Jersey's ACA expansion numbers are a bit complicated: Both states had already partly expanded Medicaid before the ACA using a waiver arrangement with the federal government. Then the ACA expanded Medicaid a bit further in each state. Then the original waiver expired...but no one bothered renewing them since the ACA made it moot anyway. This means that if the ACA actually is repealed, not only would those made eligible for Medicaid in each state be kicked off, but so would everyone enrolled via the now-expired waiver.

PRIVATE PLANS VIA THE ACA EXCHANGES:

  • The Centers for Medicare & Medicaid provided a handy county-level ACA exchange enrollment breakout for the 38 states which were handled by HealthCare.Gov last year. This includes the total number of people who selected Qualified Health Plans (QHPs) via HC.gov as of 2/01/16. For each county, I start with that number, then modify it via several steps:
  1. First, I multiply it by the projected increase (or in some cases, decrease) in total QHP selections by the end of January.
  2. I then take the percentage in each county expected to receive Advance Premium Tax Credits (APTC) (ie, federal subsidies), since those paying full price now are unlikely to lose their coverage (Note: I'm assuming the entire individual market won't collapse, which is also a distinct possibility)
  3. I then lop 10% off of that number to account for those who simply never end up paying their first month's premium to begin with, and are thus never enrolled in the first place
  4. Finally, I reduce that number by another 10% to remove those who are only receiving nominal subsidies, and who therefore would likely be able to suck it up and hold onto their policies.

For example: Let's suppose that in a given county, 10,000 people selected QHPs during open enrollment last year, of which 85% received subsidies, in a state where I expect about 5% growth this year.

My estimate would be: 10,000 x 1.05 x 0.85 x 0.90 x 0.90 = 7,229 people enrolled, effectuated & receiving subsidies high enough that they'd be seriously screwed if taken way.

  • I've found county breakouts for some of the remaining 12 states, but not others; like the Medicaid numbers, some are elusive.

Finally, there's no need to "break out" the District of Columbia numbers; I assume the whole District is basically considered a single county.

Assuming 37,000 people enroll in private exchange policies by the end of January, I estimate around 25,500 of them would be forced off of their private policy upon an immediate-effect full ACA repeal, plus another 169,000 enrolled in the ACA Medicaid expansion program, for a total of over 195,000 West Virginians kicked to the curb.

As for the individual market, my standard methodology applies:

Assuming 265,000 people enroll in exchange policies by the end of January, I estimate around 175,000 of them would be forced off of their private policy upon an immediate-effect full ACA repeal, plus another 692,000 enrolled in the ACA Medicaid expansion program, for a total of over 865,000 Ohioans kicked to the curb.

As for the individual market, my standard methodology applies:

As I noted when I crunched the numbers for Texas, it's actually easier to figure out how many people would lose coverage if the ACA is repealed in non-expansion states because you can't rip away healthcare coverage from someone who you never provided it to in the first place.

My standard methodology applies:

Illinois is pretty straightforward. Assuming 400,000 people enroll in exchange policies by the end of January (a modest 3% increase over last year), I estimate around 275,000 of them would be forced off of their private policy upon an immediate-effect full ACA repeal, plus the 643,000 enrolled in Medicaid expansion as of June 2016, for a total of just over 918,000 Illinoisians kicked to the curb.

As for the individual market, my standard methodology applies:

As I noted when I crunched the numbers for Texas, it's actually easier to figure out how many people would lose coverage if the ACA is repealed in non-expansion states because you can't rip away healthcare coverage from someone who you never provided it to in the first place.

My standard methodology applies:

As I noted when I crunched the numbers for Texas, it's actually easier to figure out how many people would lose coverage if the ACA is repealed in non-expansion states because you can't rip away healthcare coverage from someone who you never provided it to in the first place.

My standard methodology applies:

  • Plug in the 2/01/16 QHP selections by county (hard numbers via CMS)
  • Project QHP selections as of 1/31/17 based on statewide signup estimates
  • Knock 10% off those numbers to account for those who never end up paying their premiums
  • Multiply the projected effectuated enrollees as of March by the percent expected to receive APTC subsidies
  • Then knock another 10% off of that number to account for those only receiving nominal subsidies
  • Whatever's left after that are the number of people in each county who wouldn't be able to afford their policy without tax credits.

In the case of Georgia, assuming 567,000 people enroll in exchange policies by the end of January, I estimate around 396,000 of them would be forced off of their policy upon an immediate-effect full ACA repeal.

Hat tip to Dan Goldberg for the heads up. (also thanks to Amy Shefrin)

Yesterday I crunched some numbers and estimated that, assuming a full ACA repeal w/immediate effect and no replacement, roughly 800,000 New Yorkers would almost certainly lose their healthcare coverage, including:

  • ~129,000 highly-subsidized QHP enrollees,
  • ~380,000 Basic Health Plan enrollees, and
  • ~286,000 Medicaid expansion enrollees

However, according to a major press release from NY Governor Andrew Cuomo's office this morning, I massively underestimated the Medicaid total:

Over 2.7 Million New Yorkers Would Lose Coverage
Estimated State Budget Impact of $3.7 Billion
Counties Across New York Would Lose Over $595 Million in Direct Spending
New York Residents Would Lose $250 Million in Health Care Savings Tax Credits

As I noted when I crunched the numbers for Texas, it's actually easier to figure out how many people would lose coverage if the ACA is repealed in non-expansion states because you can't rip away healthcare coverage from someone who you never provided it to in the first place.

My standard methodology applies:

  • Plug in the 2/01/16 QHP selections by county (hard numbers via CMS)
  • Project QHP selections as of 1/31/17 based on statewide signup estimates
  • Knock 10% off those numbers to account for those who never end up paying their premiums
  • Multiply the projected effectuated enrollees as of March by the percent expected to receive APTC subsidies
  • Then knock another 10% off of that number to account for those only receiving nominal subsidies
  • Whatever's left after that are the number of people in each county who wouldn't be able to afford their policy without tax credits.

In the case of Florida, assuming they hit 1.825 million exchange enrollees this year, it comes to a whopping 1.35* million people.

*(updated 1/30/17 w/revised estimates)​

OK, this appears to be quickly turning into my next project thing. The methodology here is pretty much the same as the other states; the only major difference is that while I do know the total Medicaid enrollment for each county (as of December 2016), I don't have that broken out between traditional and expanded Medicaid. Fortunately, I have a hard state-wide number for that: Around 398,000, or roughly 20.8% of the state-wide total. I've therefore multiplied each county number by 20.8% to get a rough estimate of the ACA expansion tally for each.

Like Texas, I'm also no longer expecting Arizona to beat last year's Open Enrollment total by much. Assuming 209K QHP selections, there should be around 125K indy market enrollees and 399K Medicaid expansion enrollees who'll be in a world of hurt post-repeal, or roughly 524,000 altogether.

(sigh) OK, after doing this for Michigan earlier today, I said that I wasn't gonna do this for every state, and I'm not...but the irony is that the 19 non-expansion states are actually easier to compile this data for than the expansion states...because you can't rip away healthcare from someone you never provided it to in the first place. Anyway, someone requested that I do a county-level estimate of how many people would likely lose their healthcare coverage in Texas under a full repeal of the Affordable Care Act, so here it is.

Regular readers (and Twitter followers) know that for the past month I've been heavily pushing my state-by-state analysis projecting how many people I expect to lose their healthcare coverage if/when the Republican-held Congress follows through on their promise to repeal the Affordable Care Act. As noted in that post and the various links within it, part of the projection is very specific and confirmed (ie, the exact number of Medicaid expansion enrollees), while the rest is more speculative. For one thing, I don't know exactly how many people will have enrolled in ACA exchange plans, because we're still in the middle of the open enrollment period; even then, the percentage of those enrollees who will be receiving APTC assistance is still unknown as well...and even then, not all of those folks will be receiving substantial subsidy assistance which would make or break their ability to keep their policy.

01/12/17: PLEASE NOTE: I know there's a whole bunch of updates/revisions below; this is because I'm constantly updating both the Medicaid expansion and exchange policy numbers daily, in real time as I'm able to compile the most recent enrollment numbers. In most cases the numbers are quietly increasing, although in a few cases I've revised them downward.

I operate this site by myself and I do have a day job, family, etc, so if I haven't updated your state, be assured I'll get to it as soon as possible.

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