Old n' Busted: 36M covered by the #ACA. New Hotness: 40M covered by the ACA.

Last spring, I noted that total enrollment in healthcare policies either specifically created by or expanded to more people by the Affordable Care Act had broken 36 million Americans:

The press release talks about "more than 35 million" being enrolled, but when you look at 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:

‡ 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.

With last week's report from the Centers for Medicare & Medicaid Services (CMS) touting the record-breaking 16.3 million Qualified Health Plan (QHP) selections during the 2023 Open Enrollment Period (OEP), it's time to take another look at the grand total.

For this, I'm assuming a similar 94% average effectuation rate as of February 1st (2 days from now) to the ASPE report from last year for QHP enrollees. Taken literally, that would mean 15,328,061 effectuated on-exchange ACA enrollees.

However, this data only includes OEP enrollment through January 15th (or the 14th in a few states). While 2023 OEP ended on the 15th in most states, the deadline was/is later in CA, DC, MA, NJ NY & RI...which means it's very likely that another 50,000 - 100,000 people will be added to the final QHP tally when the dust settles tomorrow (Tuesday, January 31st) evening. Even assuming the same 94% effectuation rate, that will still bring the effectuated QHP total to roughly 15.4 million.

Add to this the 1,217,517 confirmed Basic Health Plan (BHP) enrollees in New York and Minnesota and the subtotal comes to around 16.62 million QHPs + BHPs combined.

Next, we need to add Medicaid Expansion enrollees.

The most recent official Medicaid/CHIP enrollment data available for all states comes from the monthly Medicaid & CHIP Enrollment Trend Snapshot reports via CMS. The most recent of these is from September 2022, which isn't too out of date...but these reports (as well as the raw determinations / enrollment data which they're based on) don't separate out "Group VIII" (ACA Medicaid Expansion) enrollees, making them useless for my purpose today.

For that, the most comprehensive data comes from the quarterly Medicaid & Budget Expenditure System (MBES) reports, which separate out VIII Group enrollees, and even breaks those out between those newly eligible for Medicaid specifically due to ACA expansion as well as those who would have already been eligible for Medicaid prior to the ACA but who enrolled thanks to the ACA dramatically streamlining the enrollment process. The only problem here is that the MBES reports only run through March 2022, at which point the national ACA expansion total stood at 22,275,433.

We're up to 38.9 million Americans with ACA coverage already, and we're still missing a lot of Medicaid expansion enrollees.

How much has Medicaid expansion grown since last March? Well, that data isn't available for every state (at least it isn't easy to separate out from total Medicaid enrollment), but it's available for many of them:

*I'll have to double-check on Illinois...it's the only state so far where ACA expansion seems to have dropped since last March.

**Missouri and Oklahoma's actual expansion programs weren't implemented until July 2021 and were only partly ramped up as of March 2022.

Across these 19 states alone, ACA Medicaid expansion enrollment is up 788,245 people since last March, or 6.7% overall. If you remove Missouri and Oklahoma, it's still up 4.28% since then, and again, this is still as much as 8 months out of date depending on the state. Assuming Illinois is wrong, removing it as well puts expansion enrollment up 5.4% since last March.

Assuming these states are representative, it's safe to assume that Medicaid expansion is up at least 4.3% nationally since March 2022, or around an additional 960,000 people. If you go with the higher end estimate (+5.4%), it would be up over 1.2 million nationally.

That puts the grand total at somewhere between 39.9 - 40.1 million people with ACA-enabled healthcare covered nationally.

I should also note that there's likely another 2 - 3 million people enrolled in OFF-exchange individual market Qualified Health Plans, all of which are unsubsidized. You can argue as to whether or not these should "count" as being "ACA-enabled coverage" since the individual market already existed prior to the ACA, but the ACA required that these medical policies be significantly improved in terms of comprehensiveness and to have the same regulations as exchange-based policies including guaranteed issue, community rating, removal of annual/lifetime limits, maximum out-of-pocket cost caps and so forth.

If you count these, that puts the grand total of "ACA healthcare coverage" at somewhere between 42 - 43 million people.

It's important to keep in mind that this will likely become a high water mark for awhile starting this April, since that's the point that states are allowed to start "unwinding" Medicaid enrollees who normally would have been kicked off the program at some point over the past three years but who were kept enrolled due to COVID-19 pandemic legislation which required states to maintain continuous coverage of all enrollees unless they voluntarily chose to drop their Medicaid coverage.

Many of these people will shift from Medicaid over to an ACA exchange plan (which would still obviously mean ACA coverage), but an unknown number of others will shift over to either employer-based or some other type of healthcare coverage...while some, sadly, will likely end up falling through the cracks and end up with no coverage at all.

Even so, reaching 40 million covered is still an important milestone for the ACA.