ACA enrollment assistance in the Biden era: More boots on the ground, more demand

A conversation with Shelli Quenga of the Palmetto Project in South Carolina -- an ACA enrollment assistor since 2013.

That’s a full appointment book

Last week I caught up with Shelli Quenga of the South Carolina-based nonprofit Palmetto Project, who has been an ACA enrollment assistor and enrollment project director since the ACA marketplace’s first Open Enrollment Period (OEP) in fall 2013.

In the Obama years, the Palmetto Project was South Carolina’s chief grantee under in the federally funded Navigator enrollment assistance program. When the Trump administration gutted the program’s funding*, Palmetto Project converted its enrollment assistance program to a nonprofit brokerage in advance of OEP 2019. At that point, the program was operating on a shoestring, with five employees. Now, Quenga told me, they are up to 11 employees, with a couple of more hires planned.

After 11 years on the front lines of marketplace enrollment assistance, Quenga has a deep understanding of how people find their way to coverage through the ACA — or fail to. Her reflections shed light on the dynamic of the enrollment explosion of the pandemic years — particularly in the ten remaining states (including South Carolina) that have refused to enact the ACA Medicaid expansion. Enrollment overall is up 87% since OEP 2020, 147% in nonexpansion states, and 167% in South Carolina, from 214,040 in 2020 to 571,175 in 2024. In 2024, enrollment growth was concentrated at the lowest subsidy-eligible income levels, up 61% nationally in the 100-138% FPL bracket. In South Carolina, enrollment at 100-138% FPL almost doubled in OEP 2024, from 133,787 to 253,158.

Among the key points:

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• Ignorance of the insurance available through the ACA’s programs is chronic; people only find their way toward what’s available when they lose other coverage.

• The more “boots on the ground” — the more robust the network of enrollment assistance — the more likely that people in need will find their way to appropriate coverage.

• In a nonexpansion state, where no federal aid is available to most adults who report income below the federal poverty level (FPL), knowledge of how eligibility works is power and can make the difference between free comprehensive coverage and no coverage.

An edited account of our conversation follows.

xpostfactoid: You have told me more than once that ignorance about the ACA marketplace is rife. Is that still true?

Quenga: Yes. This [coverage options provided by public programs] is still something you don’t need to know until you need to know. As long as you’re sailing along in an employer-sponsored plan, and it’s comprehensive coverage, you don’t need to understand how the ACA works and how enrollment works. When you’re in between jobs, or going back to school — in those times when you need to know, those who have had employer insurance still don’t understand. The need to continue advertising and marketing remains.

These days there are more ads on social media — YouTube, Facebook. We [the Palmetto Project] run ads on TV. But our major referral source is still word of mouth.

xpostfactoid: I suppose the word of mouth effect is cumulative, after eleven years?

Quenga: Yes. The number of people covered through ACA plans is bigger now — there’s a much bigger group of supporters who will say “call and get help.”

xpostfactoid: How have conditions changed under the Biden administration? (The Trump administration cut funding for the Navigator program, operating in states using the federal exchange, HealthCare.gov, from $63 million in 2016 to $10 million in 2018. The Biden administration raised Navigator funding to about $100 million in 2024.)

Quenga: I do think the increased navigator funding positively impacted enrollment in our state. We had a shell of navigator action under the previous administration. With more robust funding, we have more boots on the ground, which is what we need in a deeply rural, red state. We continue to work on the principle that President Obama referred to in the original navigator funding: a ‘no wrong door’ approach. No matter where a person enters with a question about health insurance, there are enough people on the ground to say, ‘I don’t know how it works, but someone at Palmetto Project does — or, the Primary Health Care Association [the state’s sole Navigator grantee] is funded, and they do.’ You want to have enough boots on the ground to create enough buzz so that no matter where a person enters, you’re just a few people away from getting the assistance you need. We do the same for services we don’t provide — for example we don’t help people appeal Social Security disability decisions, but we know the groups in who state who do provide that assistance.

xpostfactoid: What about people coming to the marketplace from the Medicaid unwinding (the resumption of Medicaid redeterminations and disenrollments after a 3-year pandemic-induced moratorium)? How do they react to marketplace offerings?

Quenga: They are surprised, but people have always been surprised — for example, that their college-age children are not eligible for Medicaid. There a lot of students in the coverage gap. A lot of colleges and universities dropped their health plans at the start of the ACA [e.g., before the Supreme Court made the Medicaid expansion optional for states in 2012], because they thought the ACA would cover students. When we didn’t expand Medicaid, the schools didn’t go back and add health insurance back in. We usually find a way to get these student into marketplace coverage.

xpostfactoid: You mean by estimating an income that’s over the 100% FPL threshold? (Quenga and I have discussed this at length before.)

Quenga: Yes. We play by the rules that are provided to us. Eligibility is based on projected income. We have a lot of cockeyed optimists around here.

xpostfactoid: Have you ever had an income projection challenged for being too high (e.g., over the 100% FPL eligibility threshold)?

Quenga: Occasionally the marketplace asks for proof of income, typically if the person has not filed taxes in years. Eligibility is still based on projected income, so we have a spreadsheet in which we put the twelve months of the year, what your projected income, expenses and net profit from your business will be, and submit that as proof of income. ‘I am self-employed as a childcare provider, landscaper, care provider for elderly people, and this is my projected income in coming months.’

xpostfactoid: Has year-round enrollment for people with income under 150% FPL [implemented in early 2022] had an impact?

Quenga: Absolutely. Robustly.

xpostfactoid: That makes for a busier off-season?

Quenga: It does. We get a lot more referrals from social workers, hospitals.

Trading out-of-pocket cost control for access to doctors and hospitals

We also discussed a trend to which I’ve devoted several posts this year: the decline in silver plan selection at low incomes, where Cost Sharing Reduction (available only with silver plans) raises the actuarial value of a silver plan to a roughly platinum level. At incomes up to 150% FPL, at least two silver plans in each rating area are available for zero premium. The average silver plan deductible in 2024 is $90 at incomes up to 150% FPL and $737 at incomes in the 150-200% FPL range — compared to $7,258 for bronze and $1,430 for gold. Differences in out-of-pocket maximums are equally stark (see the prior post for details). Yet silver plan selection rates at low income declined in 2023, and, as was revealed three days after my conversation with Quenga — fell further in 2024.

xpostfactoid: We spoke earlier this year about more people forgoing CSR by selecting plans in metal levels other than silver. Has this continued?

Quenga: Yes. We see a lot of selection for a bronze plan with a zero-dollar premium, primarily because Blue Cross, the carrier with the biggest network, is priced above benchmark — and has been undercut by insurers that will give you a plan with a very limited network or an HMO with more red tape. The tradeoff for paying less is having to jump through more hoops, a smaller network, driving much further to get to a specialist. Blue Cross has a zero-premium bronze [zero premium net of subsidy for low-income enrollees], and every hospital in the state is in-network. That bronze plan has flat co-pays [not subject to the deductible] for primary care, specialist care, and generic prescriptions.

xpostfactoid: Do you think it makes sense to go for that zero-premium bronze plan when the lowest-cost silver plans are also available for zero premium or very low premiums?

Quenga: It does, if they have no chronic conditions. If they do have chronic conditions, though — if they’re on any name-brand medications — Eliquis, Xarelto — then it usually makes sense to look at a narrow network plan, or an HMO that requires referrals, to keep prescription costs low. They need silver for the out-of-pocket maximum.” (At an income below 150% FPL, the OOP max for lowest-cost silver plan in Charleston, South Carolina in 2024 is $550. The lowest OOP max for a zero-premium bronze plan for a 40 year-old is $7,500.)

In 2024, 67% of South Carolina enrollees in the 100-150% FPL income range selected silver plans, compared to 76.4% in the 32 states using HealthCare.gov and 69% in South Carolina in 2023. In 2020, before cut-rate insurers moved into the state, silver selection in this income bracket was 76% (still low compared to other states; the HealthCare.gov average in that year was 87%)*.

In key respects, the South Carolina marketplace is representative of the program as it has evolved: an enrollment increase fueled by the 2021 subsidy boosts and driven largely by a population that should be in Medicaid; market penetration burning slowly through a fog ignorance about the marketplace; competition that generates sometimes perverse tradeoffs; and coverage that can include harmful gaps but that is far better than nothing, or the options that preceded the ACA. Shelli Quenga has seen it all, while overseeing a program that has helped thousands find their way to coverage over more than a decade.

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* In 2018, faced with the Trump Administration’s second round of Draconian funding cuts to the ACA Navigator program (from $63 million for OEP 2017 to $10 million for OEP 2019), the Palmetto Project, which had been the state’s chief Navigator grantee since 2013, converted its enrollment assistance program to a nonprofit brokerage. The program’s Navigator grant had been cut from $1.1 million for OEP 2017 to $500,000 for OEP 2018. For OEP 2019, total Navigator funding for the state dropped to $300,000.

** These percentages are derived from the Marketplace Open Enrollment Period Public Use Files for 2020, 2023 and 2024