A picture is worth 1,000 words and all that.

I've done my best to label every state/territory, which obviously isn't easy to do for most of them given how tangled it gets in the middle.

Nearly 1 out of every 7 residents of North Dakota and Rhode Island have tested positive for COVID-19 to date.

More than 1 out of every 8 residents of South Dakota has tested positive to date.

More than 1 out of every 9 residents of Iowa, Utah, Tennessee, Arizona, Nebraska, Oklahoma, New Jersey and South Carolina.

More than 1 out of 10 in Arkansas, Alabama, New York, Kansas, Indiana, Delaware, Mississippi, Idaho, Illinois, Georgia, Florida, Wisconsin, Nevada, Montana and Minnesota.

More than 1 out of 20 in every state & territory EXCEPT Guam, Maine, Oregon, Vermont, zU.S. Virgin Islands, Hawaii, N. Mariana Islands & American Samoa.

As I noted last night, the healthcare provisions of the upcoming American Families Plan could be in jeopardy, due primarily to (wait for it) the liberal and progressive wings of the Democratic party squabbling over whether to pass ACA 2.0 or to beef up Medicare instead. Aside from the fact that this is likely a false choice (there seem to be several options available to pay for both, or at the very least to pay for large portions of each), this has also led to various factions of Democrats to move more assertively to ensure their priorities are included.

The New Democrat Coalition (NDC) consists of 94 mainstream House Democrats, including many of those who first took office after the 2018 midterms to help flip control of the House.

Another quick Connecticut update...I've received the following Special Enrollment Period (SEP) QHP selection numbers for the past three years, and they're pretty telling:

SEP Enrollment for the 2/15 – 4/15 Timeframe:

• 2019 - 1,817
• 2020 - 4,250
• 2021 - 5,890

That averages out to:

• 2019: 30/day
• 2020: 70/day (2020 was a leap year)
• 2021: 98/day

2020 isn't really a good comparison year, since COVID had already started ravaging the U.S. by mid-March and Connecticut also launched a COVID SEP from March 18th - April 17th last year as well. The spring of 2019, however, didn't have anything special going on, so that's a perfect pre-COVID comparison year: The 2021 COVID SEP racked up 3.26x as many new enrollees as you'd typically expect to during the off-season for the same time period.

A week or so ago, Access Health CT's COVID Special Enrollment Period ended...but they also announced that they're re-launching a new SEP starting on May 1st anyway. This amounts to them taking a 2-week pause to reprogram/retool their website to take advantage of the expanded ACA subsidies under the American Rescue Plan.

At the time, they were only allowing current exchange enrollees to switch plans mid-year via a cumbersome process of calling into the exchange directly. Today it sounds like that's been changed:

Access Health CT American Rescue Plan Act Policy

The Biden Administration's first major bill was, of course, the American Rescue Plan, which actually consisted of perhaps a dozen smaller bills which were debated and passed out of a bunch of different House/Senate committees individually before being merged together into the larger package bill.

The next major legislative effort in the works is supposed to be an even larger omnibus infrastructure bill, broken into two major sections: "The American Jobs Plan" and "The American Families Plan". The "Jobs Plan" is supposed to include so-called "hard infrastructure". Here's the summary of the major bullets according to the White House website:

It's been nearly a month since I posted my final estimate of the official national and state-level tally for the 2021 Open Enrollment Period (OEP). At the time, I pegged the final total at just barely over 12.0 million QHP selections nationally...the first time an ACA OEP had hit that threshold since the end of the Obama Administration (this seems fitting for obvious reasons).

Earlier today, the Centers for Medicare & Medicaid (CMS) issued the official 2021 OEP report, as well as the accompanying Public Use Files (PUFs) which break the data out in all sorts of ways. Let's dig in!

First, the topline numbers: 

The data below comes from the GitHub data repositories of Johns Hopkins University, except for Utah, which comes from the GitHub data of the New York Times due to JHU not breaking the state out by county but by "region" for some reason.

Important:

• Every county except those in Alaska lists the 2020 Biden/Trump partisan lean; Alaska still uses the 2016 Clinton/Trump results (the 2020 Alaska results are only available by state legislative district, not by county/borough for some reason...if anyone has that info let me know)

• I define a "Swing District" as one where the difference between Biden & Trump was less than 6.0%. FWIW, there's just 187 swing districts (out of over 3,100 total), with around 33.7 million Americans out of 332 million total, or roughly 10.2% of the U.S. population.

• For the U.S. territories, Puerto Rico only includes the case breakout, not deaths, which are unavailable by county equivalent for some reason.

With those caveats in mind, here's the top 100 counties ranked by per capita COVID-19 cases as of Thursday, April 20th, 2021 (click image for high-res version).

• Blue = Joe Biden won by more than 6 points
• Orange = Donald Trump won by more than 6 points
• Yellow = Swing District (Biden or Trump won by less than 6 points)

Quick: Run a Google search for "Obamacare" or "Health Insurance" and see what the first listings which come up are. The odds are pretty high that the first listing won't be HealthCare.Gov, Pennie.com, CoveredCA.com or any of the other state-based ACA exchanges. In fact, the first link which comes up probably won't even be for Blue Cross Blue Shield, Molina or Centene (the actual health insurance carriers themselves).

It's far more likely that the most prominent sites to come up in Google's paid search listings will be third-party health insurance brokers. If you click on the link, you may be taken to a legitimate health insurance broker authorized to sell on-exchange ACA policies...or you may be taken to a fly-by-night quasi-legal outfit which either pushes junk plans or simply resells your contact info to fourth-party scammers. In many cases, they may even include the terms "Obamacare" or "ACA" baked into their names:

I've noted before that enrollment in Michigan's ACA Medicaid expansion program, "Healthy Michigan", has risen sharply over the past year since the COVID-19 pandemic hit; it's up by over 1/3 since last February.

However, it's also worth noting that non-ACA Medicaid enrollment has also jumped significantly since the pandemic arrived. I've dug into data from the Centers for Medicare & Medicaid, the Kaiser Family Foundation and Michigan's Health Dept. archives and put together the graph below, showing that non-ACA Medicaid enrollment has risen from around 1.66 million Michiganders in February 2020 to over 1.92 million today, a 16% increase.

Combined, total Medicaid enrollment is up by around 21% to over 2.82 million as of April 2021.

I should also note that in addition to this, 267,000 Michiganders enrolled in ACA exchange coverage during the 2021 Open Enrollment Period, of which a good 90% (240,000)paid their first monthly premium based on past ACA data. At the time I noted that around 83% were subsidized, or perhaps 200,000.

Around half the 50 states (+DC) expanded Medicaid under the Affordable Care Act starting in 2014. Since then, roughly half of the remaining states have also done so, either via executive order by the Governor, a new state legislature coming around or, most frequently, via statewide ballot initiative.

Idaho is an example of the latter: In November 2018, voters in Idaho (along with Utah and Nebraska) passed a ballot proposal to fully expand Medicaid under the ACA. After some legal wrangling, the state officially launched Medicaid expansion starting in January 2020, with more than 35,000 Idahoans signing up within the first few days of being allowed to do so.