Giving a damn and ACA enrollment

Yesterday, the Centers for Medicare and Medicaid Services (CMS) released the final Open Enrollment Snapshot for the ACA individual health insurance markets.

The Centers for Medicare & Medicaid Services (CMS) reports that 14.5 million Americans have signed up for or were automatically re-enrolled in 2022 individual market health insurance coverage through the Marketplaces since the start of the 2022 Marketplace Open Enrollment Period (OEP) on November 1, 2021 through January 15, 2022. This includes 10.3 million plan selections in the 33 states using the HealthCare.gov platform for the 2022 plan year, where the OEP ran through January 15, 2022, and 4.2 million plan selections in the 17 states and the District of Columbia with State-based Marketplaces (SBMs) that are using their own eligibility and enrollment platforms, through January 15, 2022, which represents the end of the OEP for many of the SBMs.[1]  Total nationwide plan selections include 3.0 million consumers (21% of total) who are new to the Marketplaces for 2022, and 11.5 million returning consumers (79% of total) who had active 2021 coverage and made a plan selection for 2022 coverage or were automatically re-enrolled.

The first thought that I had on this number is WOW! This is a huge number and makes the previous peak year (2016) look anemic.

Secondly, the causal factors that led to this enrollment are intertwined and messy.  I think the following factors are likely to have had some play.

• Enhanced subsidies and increased affordability due to ARPA
• Extended Special Enrollment Period  (SEP)
• Increased health insurance salience
• Extended OEP into January
• An administration that made enrollment a priority by funding outreach and navigators.

The easiest answer for why enrollment increased is that plans got significantly cheaper for almost everyone.  Cheaper plans means more people buying plans.  The extended COVID related SEP made it real easy for people who were newly worried about insurance due to COVID to enroll.  Inertia through automatic re-enrollment made the SEP enrollments pretty sticky.  Extending OEP into January allowed for new folks to correct administrative errors as well as renewing folks to pick better for them plans.

The big thing that is on my mind is a “give a damn” factor.  Paul Shafer and I wrote a paper published in 2019 that looked at enrollment in the last two weeks of the 2017 OEP when there was a change in administration from a supportive to an oppositional presidential party.

Estimates indicate a population-weighted decline of over 700 applications per county-week during the final 2 weeks of the 2017 open enrollment period relative to 2016, corresponding to a nearly 30% decline in applications submitted. A more flexible event-study approach that better accounts for time shifting of enrollment across open enrollment periods found a similar decline of approximately 660 applications per county-week associated with the post-inauguration period (−24%).

I think (but can’t prove yet) that the opposite effect is in play. Increased marketing, increased navigator funding, and positive elite supportive messaging likely nudged people harder for coverage for OEP 2022 compared to OEP 2021 (which ended in December 2020). I am curious if there is a partisan valance on zip code or county enrollment growth — hypothesis more enrollment growth in Dem leaning geographies than GOP leaning geographies.

Giving a damn likely matters especially when that give a damn is tied into increased information provision and administrative burden decreasing measures.