Expectations of the ACA Re-Open Enrollment

At the Incidental Economist, Dr. Paul Shafer, a friend and frequent co-author, and I outline and review some of the research on advertising, outreach and extended enrollment periods on the ACA 2nd Open Enrollment Period (OEP) that started on February 15th and will run through May 15th.

As part of re-opening the Marketplace, the Centers for Medicare and Medicaid Services, which runs HealthCare.gov, has pledged to spend over $50 million on advertising and outreach. This is a radical departure from the Trump administration, which drastically cut back on advertising and enrollment assistance, leaving over a billion dollars of so-called “user fees” unspent. These user fees were collected from insurers that sold ACA plans and the fees were intended to support Healthcare.gov operations, advertising and outreach.  Yet the money just sat there as millions became and stayed uninsured.

These moves should be cheered loudly for what they symbolize, a return to an administration that wants to support and promote the ACA rather than sabotage it. A return to finding ways to help people get coverage, not make it harder….

We should not expect massive new enrollment increases from this Special Enrollment Period….

However, the support that a President and administration shows (or doesn’t) for a policy can have a notable impact. We have seen this in our own and others’ work studying the ACA. Before now, the shift had only gone one way—from supportive to negative—at the state and then federal level. Kentucky was one of the early success stories of the ACA with its state-based Marketplace (kynect) and adoption of Medicaid expansion. A new Republican governor, Matt Bevin, campaigned hard against anything to do with the ACA including the Medicaid expansion and shutting down kynect. After his election, the states canceled all television advertising for kynect in the middle of open enrollment, which led far fewer people to seek out information or signing up for health insurance online. Similarly, we found that applications submitted to HealthCare.gov dropped by about a quarter after President Trump took office in January 2017.

From both the ACA and COVID, we also know that partisanship matters a lot in how people behave. Advertising has modest effects on enrollment, depending on who is pushing it—states and the federal government seem to be more effective while insurers are mainly out for themselves. A supportive President and a lot more visibility leads us to believe that some of the millions of Americans who are eligible for Medicaid or subsidized Marketplace coverage will enroll, gaining access to telehealth visits, prescriptions, and whatever care they need as we work towards herd immunity and a return to “normal.”

The first week data has not been released yet. However, HealthSherpa, a private direct enrollment website that has a great interface and good people behind it that enrolled about 1 in 6 people that was enrolled in the ACA in 2021 released some interesting data:

Excited to announce that in the first week of the new Marketplace SEP, over 40,000 people enrolled through @healthsherpas – more than triple the volume in a typical SEP week. Particularly happy to share that the median net premium so far is $43.67. #GetCovered

— George Kalogeropoulos (@GeorgeK_HS) February 23, 2021

Assuming HealthSherpa is still getting 1 in 6 of all enrollments and their SEP pace is the same as the OEP pace, the first week nationally on Healthcare.gov and other channels would see 150,000 to 160,000 new enrollees who otherwise would not have normally have signed up for insurance.  That is more than I would have thought.

We should also expect an acceleration in enrollment in late March if and when the reconciliation bill that is currently working its way through the House and likely to be hitting the Senate next week as there should be a massive expansion of subsidies and consequently millions of more people will have access to zero premium plans if they can only navigate the challenges of awareness and enrollment.