New Jersey's disappointing 2019 ACA enrollment: Some perspective
Policymakers in New Jersey were disappointed by enrollment in the state's ACA marketplace in 2019, which came in 7.1% behind 2018 enrollment. In the 39 states using HealthCare.gov, the federal exchange, enrollment was down 3.8%, and in the 12 states (plus DC) that have their own exchanges, it's likely to come in flat (enrollment is not over in several of them).
The state had acted swiftly in the first half of 2018 to pass a state-based individual mandate and get a reinsurance program enacted by legislation and approved/funded by CMS. As a result, premiums were down an average of 9% in 2019, and 22% below where they would have been had no action been taken.
But base premiums affect only unsubsidized buyers, and in 2019 premiums in New Jersey were actually higher than in 2018 for most subsidized enrollees, as benchmark silver plan premiums, which determine subsidies dropped further than the average for all plans. For a 40 year-old with an income of $30k, the cheapest bronze plan cost 12-22% more in 2019 than in 2018 (varying by region) -- that is, $13-$25 more per month. Cheapest silver was also up slightly in most of the state. There's some hope that off-exchange enrollment will show some improvement, as that's where the benefit from lower premiums comes home. We'll know when the state publishes first-quarter off-exchange enrollment in the spring.
For what it's worth, Jersey's enrollment performance is smack in the middle of the cohort that may be most relevant: states that enacted the ACA Medicaid expansion but did not create their own exchanges and instead rely on HealthCare.gov. For reasons that remain somewhat murky, the expansion states on HealthCare.gov accounted for almost all the net enrollment loss, lagging not only states that run their own marketplaces but also nonexpansion states on HC.gov. Collectively 2019 enrollment in nonexpansion states on HC.gov was less than 1% below the 2018 total -- whereas in the expansion states on the platform (excluding Virginia and Maine, expanding in 2019), enrollment was down 7%.
Here's how enrollment shook out for states on HealthCare.gov that had expanded Medicaid as of 2018.*
Enrollment performance, 2019 vs. 2018: Expansion states on HealthCare.gov
STATE 2018 2019 2019 vs. 2018
Hawaii 19,799 20,193 102% Arkansas 68,100 67,413 99% Alaska 18,313 17,805 97% North Dakota 22,486 21,820 97% Arizona 165,758 160,456 97% Montana 47,699 45,374 95% Oregon 156,105 148,180 95% Kentucky 89,569 84,620 94% Pennsylvania 389,081 365,888 94% Michigan 293,940 274,058 93% Illinois 334,979 312,280 93% New Jersey 274,782 255,246 93% Iowa 53,217 49,210 92% Delaware 24,500 22,562 92% Nevada 91,003 83,449 92% New Mexico 49,792 45,001 90% New Hampshire 49,573 44,581 90% Ohio 230,127 206,871 90% Indiana 166,711 148,404 89% Louisiana 109,855 92,948 85% West Virginia 27,409 22,599 82%
New Jersey policymakers and activists may be disappointed that the state individual mandate apparently did not have its intended effect -- though we don't know what enrollment would have looked like in its absence. But the state suffers not only from the moderate premium hikes for subsidized buyers but from a lack of discounts generated by silver loading** that partially offset losses in 2018 and 2019 in many other states. That is, bronze plans are not particularly cheap, let alone free as they are for most low income enrollees in many states (or parts of states), and gold plans remain out of reach for most enrollees (whereas in many states they are cheaper than silver plans, or close in price).
Again, the state market's one advantage this year is reduced base (unsubsidized) premiums, which may drive improvement off-exchange -- or among the on-exchange unsubsidized, which we'll know when CSM releases a final report that breaks out enrollment by income.
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* I've omitted Virginia, which enacted an expansion effective this month, for which eligible people could enroll throughout open season, and Maine, where the incoming governor has just instructed her government to begin enactment, and where expectation of that step may have depressed enrollment.
** Silver loading refers to concentrating the cost of CSR subsidies (directly reimbursed to insurers by the federal government as stipulated by the ACA until Trump stopped payment in October 2017) in the premiums of silver plans, since CSR is available only with silver plans. Since premium subsidies, designed so that the enrollee pays a fixed percentage of income, are set to a silver plan benchmark (the second cheapest silver plan), inflated silver premiums create discounts for subsidized buyers in bronze and gold plans. And in states that allowed insurers to offer silver plans off-exchange with no CSR load, unsubsidized enrollees were protected from CSR costs, theoretically at least.