West Virginia is a state whose population is disproportionally likely to benefit from the Affordable Care Act’s subsidized health insurance markets. It has a large population of people who need health insurance and who earn between 100% and 400% Federal Poverty Level (FPL). It has light to non-existent competition on Healthcare.gov so the stable equilibrium may not be converged pricing in every county which compresses the premiums spread.
However since 2017, the total share of Healthcare.gov enrollment that West Virginia supplies has gone down.
For the 2021 OEP, national enrollment increased. It increased on Healthcare.gov once we adjusted for two more states with 7% of the 2020 enrollment leaving the platform and going totheir own exchanges. However, West Virginia lost enrollment again.
There are two things going on, I think.
First, we have good evidence that partisanship matters. Republican leaning counties (and states) tend to have less enrollment at any given price point than a comparable Democratic leaning area. The elite messaging that conservative leaning partisans have heard is that the ACA is horrendous and should be avoided. That (probably) matters.
This obstacle can be overcome through superior pricing.
Here, West Virginia has made a policy choice. The state government has decided that they will not structure their market to provide increased affordability for subsidized buyers. Since 2018, Cost Sharing Reduction (CSR) subsidies are not paid directly by the federal government. Instead, the benefit must be provided and insurers can seek compensation through indirect means via the premium channel. The overwhelming majority (48) states currently have insurers “Silver load” CSR benefits onto the silver premiums. This increases the silver premiums relative to gold and bronze plans and produces larger than 2017 status quo counterfactual subsidies. That means a lot of people are either exposed to zero premium bronze plans OR see gold plans with significantly less cost sharing priced near silver plans. The value proposition in silver load states for people who don’t want to buy silver plans just got a whole lot better and people who bought silver plans in previous years sometimes move to non-silver plans.
Three states, West Virginia, Indiana and Mississippi, mandate a different CSR compensation scheme. These states require insurers to spread the CSR costs to all plans in a system known as Broad loading. Broad loading results in minimal changes in relative premium spreads compared to 2017 policy. Few people see a better deal now than they did under the Obama administration in these states.
The combination of partisan response and the deliberate embrace of broad loading’s inability to provide a different set of pricing facts and reality to counter-act that partisan response in West Virginia has resulted in a shrinking ACA market in the Mountaineer State.
satby
The three shittiest states to live in. Figures.
LosGatosCA
Three states, West Virginia, Indiana and Mississippi,
dnfree
My mother was from West Virginia so I always pay attention to news from there. It’s amazing how poor working people from coal-mining areas have always been taken advantage of by those responsible for their wellbeing, whether government or the miners union, corrupt for so many years. Anyone who has never seen the documentary “Harlan County, USA” from the 1970s should check it out. Harlan county is in Kentucky but it’s the same region. And they believed Trump was going to help them, too.
Ken
I’m wondering if this is one of those “we could cover more people and spend less money if we did X, but for ideological reasons let’s do Y” situations. Does silver loading increase or decrease the cost to the state?
David Anderson
@Ken: On first pass, Silverloading has no impact on the state budget (on a second, dynamic pass, it likely leads to slightly higher tax revenue as it is a federal transfer to local insurers, hospitals and doctors and on a third dynamic pass, it leads to less social welfare spending as insurance enables health which enables work…)
wvng
When I signed up for ACA coverage in the first year of operation, I met with a navigator to discuss options. We had a nice talk, during which I learned that she could not mention that this was Obama’s program (both exchanges and the expanded Medicaid that covered so many West Virginuans) or they wouldn’t sign up.
L85NJGT
There is decline in the state population due to out-of-state migration and high mortality in former coal producing regions. The mythology of rugged American individualism, self reliance and bootstrapping kills people.
WV Blondie
Anecdote is not evidence, and heaven knows most of what you talk about goes right over my head, David, but … I turned 65 and qualified for Medicare, which removed me from the Marketplace, and my husband, because of economic hardship and poor health, qualified for Medicaid, which also removed him from the Marketplace. (We’ll see what happens when his Medicaid eligibility expires, if it does, later this year – then he’ll be back to Obamacare.) So it seems to me there are other circumstances that could dampen enrollment, or am I mistaken?
David Anderson
@WV Blondie:
At the individual level, most definitely people will move in and out of the exchanges and into and out of other coverages (Medicare, Medicaid, work etc)
But at a state level, a lot of these things should roughly balance