Oh, yeah: #ACA enrollment is at an all-time high right now almost any way you slice it.

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With this morning's confirmation of my post from Saturday that over 1 million more people have enrolled in ACA exchange coverage via HC.gov during the ongoing COVID Special Enrollment Period, I was reminded of a headline I wrote back in March:

Exclusive: Official 2021 #ACA Open Enrollment Period Hits 12.0 Million QHPs For First Time Since 2017

At the time I only had estimated 2021 Open Enrollment Period (OEP) data for several states, but my estimate was confirmed a couple of weeks ago when the Centers for Medicare & Medicaid Services (CMS) issued the official 2021 OEP report, which states that the official total number of ACA Qualified Health Plan (QHP) selections for 2021 was 12,004,365 people.

The all-time high for OEP enrollment was the 2016 OEP, during which 12,681,874 QHPs were selected...which also happened to be the last Open Enrollment Period which was fully controlled by the Obama Administration. President Obama and his team were still in office for most of the 2017 OEP, but the Trump Administration took the reins towards the end...and immediately pulled the plug on the marketing/outreach campaign during the critical final 11 days. Enrollment dropped off by over 465,000 people.

At first glance, this would appear to indicate that 2021 ACA enrollment is still some 680,000 shy of the 12.68 million high water mark of 2016...but there's several big numbers missing from both years.

First, there's also the Basic Health Plan (BHP) programs in Minnesota and New York. As Louise Norris explains:

Under the ACA, most states have expanded Medicaid to people with income up to 138 percent of the poverty level. But people with incomes very close to the Medicaid eligibility cutoff frequently experience changes in income that result in switching from Medicaid to ACA’s qualified health plans (QHPs) and back. This “churning” creates fluctuating healthcare costs and premiums, and increased administrative work for the insureds, the QHP carriers and Medicaid programs.

The out-of-pocket differences between Medicaid and QHPs are significant, even for people with incomes just above the Medicaid eligibility threshold who qualify for cost-sharing subsidies.

The Basic Health Program (BHP) – section 1331 of the ACA — was envisioned as a solution, although most states did not establish a BHP. Under the ACA (aka Obamacare), states have the option to create a Basic Health Program for people with incomes a little above the upper limit for Medicaid eligibility, and for legal immigrants who aren’t eligible for Medicaid because of the five-year waiting period.

Only two states have enacted a BHP so far: Minnesota and New York. Combined, the two had 456,261 residents enrolled in their BHP programs as of the end of the 2016 OEP...but for 2021, the total is more than twice as high: 975,337 people.

Some may quibble about whether or not BHP enrollees should "count" as or not, but they're still private individual market healthcare policies enabled by and subsidized by the Affordable Care Act, and at the end of the day, it's another 975,000 Americans enrolled in healthcare coverage via the ACA.

Adding BHPs to the mix gives you:

  • 2016: 13,138,135
  • 2021: 12,979,702...still about 158,000 short.

The next thing to look at is Special Enrollment Period (SEP) enrollees. While most people are only eligible to enroll in ACA exchange coverage during the official OEP, anyone who experiences a Qualifying Life Experience (QLE) such as losing their existing healthcare coverage due to job loss, moving to another state, getting married/divorced, giving birth/adopting a child, turning 26 and having to leave their parents policy and so forth is eligible for a 60-day SEP regardless of the time of year.

BEFORE the COVID pandemic hit, typically around 5,800 people would enroll via SEPs each and every day nationally. CMS confirmed that 266,434 enrolled via 36 HealthCare.Gov states alone from 2/15 - 4/30 in 2019, for instance, or around 3,552/day...and again, that doesn't include 14 states or DC. There's no obvious reason why 2019's national SEP enrollment rate would be that much different from 2016's; at 5,800/day it would be 435,000 for the same time period, but let's call it as high as 500,000 to err on the safe side.

We know that 673,141 more people have enrolled via SEPs via HealthCare.Gov alone during that same time period this year. When you include California, New York, Pennsylvania, New Jersey, Washington State and the other 10 state-based exchanges, I'm confident that the total 2021 SEP enrollments as of this writing are around 1.5 million...or a full 1.0 million higher than for the same period in 2016.

  • 2016: 13,638,000 (estimated)
  • 2021: 14,479,000 (estimated)

This puts 2021 enrollment around 840,000 ahead of 2016.

"But wait!" you're saying. "What about people who don't pay their first monthly premium, or who drop coverage after the first month or so, or who get their accounts cancelled due to residency verification issues or whatever?" After all, people are constantly dropping ACA coverage for similar reasons to why they sign up for it (getting a job with benefits; turning 65 and moving to Medicare, marrying someone with employer-based coverage; etc).

Well, that's where effectuated enrollment reports come into play. CMS also occasionally releases reports listing how many people are actually enrolled in effectuated ACA exchange policies month to month, as well as the average who are enrolled for the quarter or half-year. The most recent effectuation report is from last winter, and it happens to include the average monthly effectuations for the first half of 2016: 10,403,478 people.

In other words, back in 2016, perhaps 10% of those 12.68 million who selected QHPs never paid their first premium (~1.3 million), and another 1.5 million dropped their coverage after anywhere from 1-5 months, give or take...partly cancelled out by ~500K SEP enrollees. Put another way, effectuated QHP enrollment was 18.0% lower than the official OEP number. Add the BHP enrollees back in and you're at around 10.86 million.

So what about 2021? Well, if you assume a similar pattern, that would put effectuated QHP enrollment at around 9.85 million...except again that would assume similar SEP enrollment to 2016. Even if you assume only 900,000 extra SEP enrollees (to account for the typical 10% non-payment rate), adding those and the BHP number gives you something very close to:

  • Spring 2016: 10,860,000 (estimated)
  • Spring 2021: 11,725,000 (estimated)

...or around 865,000 higher.

This also assumes that the attrition rate is still similar in 2021 to what it was in 2016 (i.e., an ~18% net drop from the OEP total until February or March)...but the retention rate has gradually increased over the years. Hell, as of March 2020 it was 10.7 million people effectuated versus 11.4 million total QHP selections, and this year nearly 600,000 more people selected plans during OEP right off the bat.

You also have to remember that OVER HALF of the ~1.5 million SEP enrollees this spring signed up after the expanded subsidies under the American Rescue Plan went into effect. CMS says 469,000 out of 940,000 via HC.gov did so (50%), and the expanded ARP subsidies went live on April 1st or later in most other states as well. Given the massive improvement in affordability thanks to the ARP, retention of ACA enrollment has almost certainly increased since then; it's likely that total effectuations are at least 900,000 higher as of early May 2021 than they were in May 2016.

To be fair, there's another relevant number not discussed above: OFF-exchange ACA-compliant coverage.

CMS had previously stated that "average monthly enrollment in the individual market—including both subsidized and unsubsidized enrollment—peaked in 2016, reaching 14.5 million." Since effectuated on-exchange ACA enrollment for the first half of 2016 was 10.4 million, that means total off-exchange ACA-compliant enrollment was 4.1 million at the time. Covered California recently released a report estimating around 1.5 million people who are currently enrolled in off-exchange ACA plans nationally as of 2021.

When you add these to the mix, the #1 spot shifts back to 2016:

  • Spring 2016: 14,960,000 (estimated)
  • Spring 2021: 13,225,000 (estimated)

...or around 1.74 million fewer.

However, there's one other critically important population: ACA Medicaid Expansion.

According to the Medicaid Budget and Expenditure System (MBES), total Medicaid enrollment via ACA expansion as of March 2016 was 14,195,800 people. Of those, 11,199,442 (around 79%) were newly eligible due specifically to the ACA (that is, some people were already eligible for Medicaid under pre-ACA law in some states).

Unfortunately, the published MBES database only runs through June 2019; as of that month, those numbers had only increased slightly, to 14.83 million total and 12.0 million ACA-specific respectively. In addition, three more states have expanded Medicaid since then (Idaho, Nebraska and Utah), adding another ~220,000 to the total.

However, I do have hard data for Medicaid expansion enrollment for most states since then, thanks to a combination of my own ongoing state-level research and that of Andrew Sprung of Xpostfactoid. Based on his and my own data and analysis, I estimate total ACA Medicaid expansion enrollment as of March 2021 at roughly 20.5 million people and ACA-specific ("newly-eligible") enrollment at around 16.6 million people.

(And before anyone claims that Medicaid expansion "doesn't count"...that's nonsense. Aside from it being the one of the most important provisions of the ACA, part of the reason for the decline in QHP enrollment over the years has been due to more states expanding Medicaid under the ACA...because anyone earning 100 - 138% FPL gets shifted from exchange plans to Medicaid as soon as their state expands the program. In fact, if the 12 remaining "holdout" states were to finally expand Medicaid under the ACA, a whopping 2.4 million Americans would shift from subsidized ACA plans to Medicaid.)

In any event, this brings the grand total to roughly:

  • Spring 2016: 26,160,000 (estimate)
  • Spring 2021: 29,825,000 (estimate)

That's 3.67 million more people currently enrolled, as of this writing, in fully active, comprehensive, effectuated ACA-specific healthcare coverage as of May 2021 vs. May 2016, whether via ACA QHPs (on- or off-exchange), BHPs or Medicaid expansion.