FYI, Maine's ACA exchange enrollment will likely drop 20% next year...for a good reason.

...assuming racist Governor Paul LePage actually stops being a jackass long enough to actually implement it.

According to the CMS/ASPE 2016 Final Enrollment Report, during the 2016 Open Enrollment Period, Louisiana enrolled 214,148 people in exchange-based Qualified Health Plans.

However, during the 2017 OEP, Louisiana only enrolled 143,577 people...exactly 33% fewer.

Most states dropped a bit year over year in 2017 in large part due to the Trump administration cutting off outreach/marketing during the critical final week, but Louisiana saw the worst year over year drop. Why? Well, the most obvious reason was pretty simple: The state expanded Medicaid halfway through the year.

Under the Affordable Care Act, Medicaid expansion covers people earning up to 138% of the Federal Poverty Line...but due to an odd quirk in how it was written, Advance Premium Tax Credits (APTC) start as low as 100% of the FPL. In expansion states, anyone earning less than 138% FPL is automatically kicked over to Medicaid (or CHIP, in the case of children)...but in non-expansion states, a lot of exchange-based enrollees earn somewhere between 100-138% FPL. Of course, they only have to pay 2% of their household income towards premiums, so the policies are heavily subsidized by the federal government, but it's still worse coverage and more expensive for them than Medicaid would be.

That means that when a previously non-expansion state goes ahead and expands the program, the exchange enrollees in that 100-138% range get moved from private, heavily subsidized ACA exchange plans over to Medicaid.

How many people? Quite a few. In Louisiana, fully 48% (around 103,000) of those 214K enrollees from 2016 earned between 100-150% FPL. Assuming an even spread up the income line, that means roughly 78,000 of them earned 100-138% FPL.

The drop in exchange enrollment last year happened to be exactly 70,571 people.

However, it's not quite that simple--there are other factors which control whether more or fewer people enroll each year. Aside from expanding Medicaid mid-year, Louisiana's situation should have been fairly similar to most other states. As it happens, the other three dozen states run via HealthCare.Gov saw an average drop of 4.7% from 2016 to 2017, so I'm pretty sure Louisiana would still have lost around 10,000 enrollees even if they hadn't expanded. That leaves around 60,500 people who were migrated over from exchange plans to Medicaid for 2017.

But what about the other 17,500 or so? What happened to them?

Well, remember that LA didn't actually expand the program until July 2016, and it took months for the transition to go through. My guess is that some of those folks still enrolled in exchange plans for 2017 and weren't actually transferred off those plans until after OE5 numbers were plugged in. That means they wouldn't be removed until 2018.

And sure enough, look what happened this year.

From 2017 - 2018, Louisiana was again the worst-performing state year over year enrollment, dropping another 23% from 143,577 to just 109,855 enrollees...a net loss of 33,722 people.

Meanwhile, their Medicaid expansion program enrollment has jumped from around 400,000 as of the January 2017 to nearly 465,000 today. I'm pretty sure that the "missing" 17,500 former exchange enrollees are part of that growth.

OK, so what does all of this have to do with Maine? Simple:

  • In 2017, 79,407 people selected exchange policies, of which 21,084 earned between 100-150% FPL.
  • Assuming an even spread, that means around 16,000 of them earned 100-138% FPL, or ~20% of all exchange enrollees.
  • This year, 75,809 people selected QHPs on the exchange in Maine
  • Assuming Medicaid expansion is actually enacted and there's no other significant factors whcih come into play (lord knows there will be, including the first "official" response ot the lack of a mandate penalty), I'd therefore expect roughly 20% or 15,000 people to be moved from the ACA exchange over to Medicaid instead. This would theoretically leave roughly 61,000 enrolling in 2019 ACA exchange policies this fall.

On the one hand, from a PR perspective this makes the exchange performance look bad. On the other hand, it should actually improve the risk pool for the remaining individual market enrollees...because lower income people tend to be in worse shape, so siphoning off the 100-138% FPL crowd over to Medicaid should theoretically mean that the rest of the exchange enrollees are healthier on average.

Of course, there's all sorts of other crazy factors which will come into play, so this may not be noticeable next year...but if Maine drops from 32nd to 51st place in year over year performance next year, this will probably be the reason.