Shouldn't have 2nd-guessed myself: 19 - 19.5M QHPs & BHPs a distinct possibility after all?

Back on November 5th, just a few days into the 2024 Open Enrollment Period, I did some back-of-the-math number crunching and concluded that the odds were pretty good that total 2024 OEP ACA enrollment (including both exchange-based Qualified Health Plans, or QHPs, as well as enrollment in Basic Health Plans (BHPs) in New York & Minnesota only) would break 19 million people for the first time in the ACA's history.

This was based on some simple assumptions:

  • 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.

On the flip side, as I noted at the time, a couple hundred thousand current ACA exchange enrollees in North Carolina are being automatically transferred over to Medicaid thanks to the state finally enacting ACA expansion of the program, which would knock the 2024 exchange total down a bit.

However, a few days later I second-guessed myself and walked back my 19M+ projection a bit based on what seemed to be an overestimate of the Medicaid Unwinding population moving to exchange QHPs & BHPs; I modified my projection down to perhaps 18.5 million total (~17.2 million QHPs + ~1.3 million BHPs).

Today, however, I'm returning to my original 19M+ projection based on a few new pieces of data:

For starters, new enrollment is currently running 44% higher year over year nationally, with over 500,000 more people new to exchange plans having enrolled in the first month or so.

For another, as the table below shows, if you assume a similar ratio of renewing enrollees to the prior OEP's enrollment total (ie, in OEP 2023, 87.2% of OEP 2022's enrollees renewed), it would be 1.6 million higher year over year.

In that scenario, even if not a single additional new enrollee signed up after last week's CMS report (and obviously many more have), that would already mean 2.1 million more enrollees total year over year, bringing the total to at least 18.4 million QHPs. Throw at least 1.3 million or more BHPs on top of that and you're at 19.7 million. It's even conceivable that we could break 20 million, though that would be a pretty big stretch.

Looked at another way, on a state-by-state basis, at least 10 states have already exceeded their final 2023 OEP enrollment totals: New Mexico, Idaho, Massachusetts, Connecticut, Vermont, Virginia, Rhode Island, Washington State, Kentucky and Maryland are all anywhere from 0.2% to 22% higher than last year's final tally. Granted, this only adds up to a net increase of around 85,000 people, but it's still pretty impressive given that there's still a solid month for peole to sign up in each of them.

These states are averaging 6.4% higher year over year than last year's final total, and made up 8.2% of last year's total OEP enrollment. If every other state is actually at the same level with auto-renewals included, it would put total enrollment as of today at just over 17.4 million. By comparison, last year, with auto-renewals added to every state, 15.5 million had enrolled as of December 17th...1.9 million fewer. That would suggest total final 2024 OEP enrollment of at least 18.3 million or so. Again, throw in 1.3M or so BHPs and you'd be at 19.5 million, give or take.

Finally, the entire reason I backtracked from 19M to 18.5M in the first place was because at the time I revised my estimate of Unwinding > QHP transferees from 2.2 million to just 1.1 million. More recent data from August suggests that around 11% of the Unwinding population makes the move to QHPs, plus another 1.6% to BHPs. With KFF's Medicaid Unwinding tracker having reached nearly 12.6 million nationally, that would mean roughly 1.4 million moving to exchange plans and 200K moving to Basic Health Plans...exactly halfway between the two (1.6 million combined).

Again, all of this is still speculation until the next update from CMS, which I expect to be released sometime next week just ahead of the Christmas/New Year's break. I could be wrong, but it's looking very much like total 2024 OEP enrollment will be higher than I expected a month ago.