The Graph: Could the 2024 ACA Open Enrollment Period break 18.5 million QHPs/BHPs? (updated)

As long-time readers know, every year during the ACA Open Enrollment Period (OEP) I have a tradition of regularly updating a graph tracking how many Americans have enrolled in on-exchange Qualified Health Plan (QHP) policies nationally. The Graph®, as I've come to call it, is how this entire website got started; the logo for ACA Signups even consists of a stylized version of the original version from the 2013 - 2014 OEP.

That first year I attempted to track every conceivable population--on-exchange QHPs, off-exchange QHPs, Medicaid expansion enrollment, SHOP (ACA small business exchange) enrollees) and even the amorphous "sub-26er" populations of young adults enrolled in their parents employer plans thanks to ACA provisions. Some of these were nearly impossible to accurately estimate, but I really tried my best.

Over the next year or two, I not only dropped the categories which I wasn't able to track properly, my tracking of the remaining ones became much more streamlined and sophisticated. Eventually I decided to stick with just two categories: On-exchange QHPs and those enrolled in the Basic Health Plan (BHP) programs in Minnesota and New York.

BHP policies aren't counted as QHPs by the Centers for Medicare & Medicaid Services (CMS), but after years of being ignored for some reason, they're finally being included in CMS's official enrollment data reports, though listed separately. I'm assuming CMS has finally started doing this because the BHP enrollment numbers are far too high to ignore these days...nearly 1.4 million people between the two states combined.

In any event, below I've posted the "blank" Graph template for the 2024 OEP. The dotted lines show the actual enrollment patterns from the 2023 OEP for QHP enrollees via the federal ACA exchange (HealthCare.Gov), QHP enrollees via the 19 state ACA exchanges (Covered California, Your Health Idaho and so forth), and BHP enrollees in Minnesota and New York.

During the 2023 OEP, a total of 16,357,030 people signed up for on-exchange QHPs, plus another 1,217,921 who enrolled in BHPs in MN/NY. In addition, 10,416 undocumented Colorado residents enrolled in QHPs via the state's unique OmniSalud program, for a grand total of 17,585,367 people...just under 17.6 million through the end of January. This marked an all-time high for ACA enrollment.

For 2024 OEP, I have no reason to assume that total enrollment will be any lower, and several reasons to assume it will be significantly higher:

  • First: 2024 OEP should have started off with the highest effectuated enrollment retention rate in history (ie, the number of those who signed up during last year's OEP who are still enrolled as of today). The percent of OEP enrollees still enrolled by February or March of the year has increased every year since 2015, and hit a high of 95.7% this year.
  • Third: While the ongoing Medicaid Unwinding process is bad news for millions of people impacted by having their Medicaid/CHIP coverage taken away due to clerical errors and/or having to jump through onerous procedural hoops, it's also important to note that a good chunk of this population has been shifting to (mostly heavily subsidized) ACA exchange coverage. As of the end of July, CMS reports that over 590,000 of the Unwinding population had moved to ACA exchange plans, and another 87,000 had enrolled in BHP plans.
  • Fourth: The implementation of strict Premium Alignment in Texas last year helped lead to a impressive 31% enrollment increase (nearly 570,000 people) year over year, the highest in the country. While most of that increase is likely baked in, it's also possible that some of the target population in Texas didn't know about the dramatically improved cost savings on ACA plans at the time but have found out about it over the past year. I could see TX enrollment jumping perhaps another 100K or so based on this alone (?).

Some of these Medicaid-to-ACA transfers would have happened anyway (people are constantly switching between Medicaid/CHIP and ACA plans throughout the off-season via Special Enrollment Periods as their income & circumstances change), but those are much higher "transfer in" numbers than typically happened prior to the end of the COVID Public Health Emergency's "Continuous Coverage" rule.

The Kaiser Family Foundation had estimated that at least 3.1 million people had been kicked off of Medicaid/CHIP via Unwinding as of mid-July. ~680K of them moving to QHPs/BHPs is roughly 22%. If you extrapolate that out to the ten million who KFF estimates had been "unwound" as of the end of October, that would be upwards of 2.2 million moving to ACA exchange plans (or BHP programs).

Now, I don't know how much higher 2024 OEP enrollment will end up being. It's not a simple matter of tacking an extra 2.2 million on to last year's 17.6 million (which would bring it up to 19.8 million total). That 2.2 million could be overstated, and not every current unwinding transferree is going to stay in an ACA exchange plan.

In addition, on the flip side, North Carolina is finally launching Medicaid expansion next month; around 280,000 of the NC OEP enrollees from last year earn less than 138% FPL, meaning they will start to be transferred over to Medicaid instead starting in December. This alone would drop the theoretical high water mark to no more than 19.5 million QHPs+BHPs combined nationally.

However, perhaps 19 million (~17.6 million QHPs + 1.4 million BHPs) is plausible.

UPDATE 11/08/23: Yikes...I made a mistake. As noted in my update to the Unwinding post, 680K was actually more like 12% of the total Unwinding population as of July, not 22%, so it would only extrapolate out to around 1.1 million, or half my prior estimate. 19 million is still conceivable but I'd say 18.5 million is a more realistic high-end projection.

Stay tuned...