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August 14, 2019

Exchange enrollment is down among unsubsidized buyers, CMS finds

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    About 10.6 million U.S. residents enrolled in Affordable Care Act (ACA) exchange plans by March 15 of this year, representing a less than 1% decrease when compared with the number of U.S. residents who were enrolled in exchange plans as of March 15 last year, according to CMS data released Monday.

    Cheat sheet: What you need to know about the ACA

    2019 enrollment snapshot

    CMS in the enrollment snapshot said the 10.6 million figure reflects the number of individuals who paid their first month's premium for coverage, which effectively completes the enrollment process.

    According to the data, the number of U.S. residents who completed the enrollment process by March 15 was down from the 11.4 million U.S. residents who had started the enrollment process by selecting exchange plans during the ACA's latest open enrollment period.

    According to CMS, 87% of U.S. residents who enrolled in exchange plans as of March 15 of this year received federal subsidies to help offset their premium costs—a figure that largely is unchanged from 2018. The snapshot stated that the average total monthly premium for exchange plans decreased by about 1%, from $597.20 in February 2018 to $594.17 in February 2019. CMS said the decrease in premiums resulted in the average federal premium subsidy decreasing by 1%, falling from $520 in 2018 to $514.01 this year.

    Exchange enrollment declined by 40% among unsubsidized US residents from 2016 to 2018

    However, CMS in a separate report released Monday noted that enrollment among U.S. residents who did not qualify for ACA subsidies decreased by 2.5 million—or 40%—from 2016 to 2018. CMS said the enrollment declines have coincided with increases in exchange plan premiums.

    For example, CMS found average monthly enrollment declined nationally by 7% between 2017 and 2018, as premiums increased by 26% during that period. CMS said the decrease occurred mostly among U.S. residents who did not qualify for federal subsidies, with enrollment declining by 24% among such individuals. In comparison, enrollment increased by 4% from among U.S. residents who qualified for subsidies from 2017 to 2018:

    According to the report, unsubsidized enrollment declined in 47 states between 2017 and 2018. CMS found that unsubsidized enrollment declined by more than 40% in 14 states, including Iowa, where unsubsidized enrollment declined by 85%.

    CMS in the report wrote, "While data from the Effectuated Enrollment report shows stability in exchange enrollment and premium trends, affordability remains a significant challenge for people who do not qualify for exchange subsidies."


    Randy Pate, a CMS deputy administrator and director of the agency's Center for Consumer Information and Insurance Oversight, last week told state insurance commissioners that exchange enrollment overall remains steady. Pate noted that some of the Trump administration's actions, including a  final rule that will allow U.S. workers to use employer-funded health reimbursement arrangements (HRAs) to purchase private health coverage, could help U.S. residents who do not qualify for ACA subsidies to enroll in health plans.

    CMS Administrator Seema Verma said the data show that the ACA "is failing the American people, and the ongoing exodus of the unsubsidized population from the market proves that Obamacare's sky-high premiums are unaffordable."

    But Leslie Dach, chair of the liberal advocacy group Protect Our Care, said premiums have increased and enrollment has declined as a result of a 2017 tax reform law that zeroed out the ACA's individual mandate penalty for being uninsured, reductions in funding for ACA enrollment outreach, and the administration's expansion of short-term health plans. According to Dach, the data "clearly shows that the American people still want the quality coverage that the [ACA] provides" (Sullivan, The Hill, 8/12; Luthi, Modern Healthcare, 8/12; Owens, "Vitals," Axios, 8/13; Lotven, Inside Health Policy, 8/12 [subscription required]).

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