Old n' Busted: 31M covered by the #ACA. New Hotness: 36M covered by the ACA.

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Last June, the U.S. Health & Human Services Dept. confirmed my estimate that total enrollment in healthcare policies either specifically created by (or expanded to more people by) the Affordable Care Act had broken 31 million Americans:

Today, the U.S. Department of Health and Human Services (HHS) released a new report that shows 31 million Americans have health coverage through the Affordable Care Act – a record. The report also shows that there have been reductions in uninsurance rates in every state in the country since the law’s coverage expansions took effect. People served by the health Marketplaces and Medicaid expansion have reached record highs.

HHS's breakout was fairly close to mine, though they had enrollment a bit higher in some categories and a bit lower in others:

And there it is:

  • 11.3 million effectuated exchange enrollees
  • 14.8 million newly-eligible Medicaid enrollees
  • 3.9 million previously-eligible/streamlined Medicaid enrollees
  • 1.0 million BHP enrollees
  • 31.0 million total

As I noted at the time, however, Medicaid expansion data in the HHS report only ran through December 2020, so it didn't include any additional increases from January - June. Meanwhile, the "effectuated exchange enrollment" only ran through February...meaning it didn't include any of those who had signed up during the re-opened Enrollment Period which started on 2/15 at that point.

In conjunction with my colleague Andrew Sprung of Xpostfactoid, I crunched some additional numbers and concluded that the grand total as of June 2021 was actually more like 34 million people:

  • Effectuated ACA exchange enrollment: ~12.4 million
  • Off-Exchange ACA policy enrollment: 1 - 2 million (?)
  • ACA Medicaid expansion enrollment: ~19.8 million
  • ACA Basic Health Plan enrollment: ~1.0 million
  • TOTAL: 34.2 - 35.2 million

...or over 10% of the total U.S. population.

Well, moments ago, the Centers for Medicare & Medicaid posted a new press release about a new report from the HHS's Assistant Secretary for Planning & Evaluation (ASPE) which has updated ACA-specific enrollment data current as of October 2021 - March 2022:

New Reports Show Record 35 Million People Enrolled in Coverage Related to the Affordable Care Act, with Historic 21 Million People Enrolled in Medicaid Expansion Coverage

Today, the U.S. Department of Health and Human Services, through the Office of the Secretary for Planning and Evaluation (ASPE), released a report showing new estimates for coverage related to the Affordable Care Act (ACA), concluding that the total enrollment for Medicaid expansion, Marketplace coverage, and the Basic Health Program in participating states has reached an all-time high of more than 35 million people as of early 2022. The ASPE findings build on a report from the Centers for Medicare & Medicaid Services (CMS) showing a record-breaking 21 million people in more than 40 states and territories gained health care coverage thanks to the ACA’s expansion of Medicaid to low-income adults under 65. More than two million people gained coverage as a result of Medicaid expansion under the Biden-Harris Administration, ensuring health care coverage for underserved communities during the COVID-19 Public Health Emergency.

The ASPE report also describes new estimates from the National Health Interview Survey, showing that the uninsured rate in the fourth quarter of 2021 was at nearly an all-time low of 8.8% for the full population (similar to the 8.9% rate in the third quarter of 2021), compared to 10.3% in the fourth quarter of 2020.

“With a record-breaking total of over 35 million people who now have health coverage, thanks to the Affordable Care Act, America’s uninsured rate is nearing an all-time low,” said Health and Human Services Secretary Xavier Becerra. “Today’s historic reports show we are delivering on our commitment to bring health care coverage to as many people as possible. We will continue to push for comprehensive ACA coverage and Medicaid expansion and work with states to make comprehensive health care accessible and equitable for families across the country.”

The success of Medicaid expansion nationwide highlights a path to affordable, comprehensive, person-centered care for the 12 states (Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming) that have yet to expand their Medicaid programs. Additional state expansion would also be a key step to advance health equity: of the nearly four million uninsured Americans who could gain coverage if these states expanded their Medicaid programs, more than half are people of color. Oklahoma and Missouri, which expanded Medicaid coverage in 2021, saw an enrollment increase of more than 276,300 and 146,600 individuals, respectively.

“Medicaid is a lifeline to better health and care for millions of people—including the millions who gained coverage thanks to expansion under the Affordable Care Act,” said CMS Administrator Chiquita Brooks-LaSure. “Medicaid expansion is key to improving maternal and infant health outcomes, addressing longstanding health disparities, and connecting people to needed essential care. Nearly four million additional people could benefit from this coverage if Medicaid is expanded in all states. We can’t leave them behind.”

Today’s CMS report details key connections to coverage under the adult group created by the ACA for people with incomes up to 133% of the federal poverty level. In 2021, that translated to $17,130 for a single person and $35,245 for a family of four. Since the ACA became law in 2010, 38 states, the District of Columbia, and three U.S. territories have expanded Medicaid coverage to the adult group, resulting in more than 21 million people getting Medicaid coverage.

“We remain committed to ensuring people have access to quality, affordable, comprehensive, and person-centered health care coverage and the peace of mind that comes with it,” said Dan Tsai, CMS Deputy Administrator and Director of Center for Medicaid & Children’s Health Insurance Program (CHIP) Services.

Medicaid expansion also closes essential coverage gaps for women, who make up more than half of the total adult group for Medicaid expansion. Efforts to extend Medicaid and CHIP coverage for pregnant and postpartum individuals to a full year after pregnancy are also important tools to address disparities.

For information on opportunities for more states to expand Medicaid through the ACA, visit Medicaid.gov. Medicaid.gov also provides additional details on the data; a breakdown of enrollment by state or U.S. territory is also available here.

For the ASPE report on the uninsured and ACA-related enrollment, please visit here.

The press release talks about "more than 35 million" being enrolled, but when you look at the data in the actual data, it's almost certainly over 36 million as of today. Here's how they break it out:

  • Effectuated ACA exchange enrollment as of March 2022: 13,640,412
  • Medicaid Expansion (newly eligible) as of October 2021: 16,781,800
  • Medicaid Expansion (previously eligible) as of October 2021: 4,261,277
  • Basic Health Plan enrollment as of March 2022: 1,135,190
  • TOTAL: 35,818,679

Notice that even without delving further, the total is already over 35.8 million.

However, there's two important dates to look at here: First, the Medicaid Expansion totals are only up to date as of last October, a good 6 months ago.

Secondly, here's what it says regarding the effectuated ACA exchange enrollment as of March 2022:

‡ Effectuated enrollment for 2022 was estimated applying the February 2021 average effectuated rate of 94% (as of 3/15/2021) to the 14.5 million people who signed-up for coverage during the 2022 Open Enrollment Period.

In other words, ASPE is assuming that roughly the same percentage of those who selected ACA exchange plans during the 2022 Open Enrollment Period (OEP) were still enrolled as of February as those who selected ACA exchange plans during the 2021 OEP. They're assuming that around 6% of the 14.5 million had dropped their coverage.

Normally this would be a reasonable assumption...but I'm willing to bet that the attrition rate as of February 2022 was lower than it was in February 2021, because of one critical difference: The American Rescue Plan (ARP) wasn't introduced in the House until February 24th, didn't pass the Senate until March 6th and wasn't signed into law until March 11, 2021.

Until it was passed & signed (and for several months after that in many cases), ACA enrollees had absolutely no idea that their premiums were about to drop dramatically. As far as they knew at that time, their plans and expenses would be roughly the same for the rest of 2021 as they had been in 2020. Any decisions enrollees made about keeping or dropping their exchange coverage were made with that mindset.

In February 2022, it's a completely different situation. For one thing, 89.3% of ACA exchange enrollees are receiving tax credits vs. the 84.6% of those who enrolled during the 2021 OEP. Assuming identical total enrollment, that'd be ~680,000 more people.

In addition, the vast majority of the millions of enrollees who would have been receiving tax credits regardless are receiving far more generous subsidies this year than they were as of last January/February. Yes, the expanded ARP subsidies were made retroactive to January 2021...but they didn't know that at the time.

In other words, my guess is that the ACA exchange effectuated enrollment total as of March 2022 was likely several hundred thousand higher than the ASPE report estimated.

Combine this with what I assume has been continued growth in Medicaid expansion enrollment (for instance, the Medicaid expansion report from last October puts Oklahoma's total at 197,000 but today's press release has it at over 276,000), I think I'm on very safe ground in estimating that total ACA-related coverage is now well over 36 million Americans.