Rich Daly / January 26, 2016
Jan. 26—Enrollment in government-run insurance marketplaces will reach 13 million in 2016, while Medicaid enrollment will reach 77 million, according to new projections from the Congressional Budget Office (CBO).
The new CBO predictions differ sharply from the nonpartisan legislative scorekeeper’s previous enrollment expectations. Specifically, the 2016 marketplace enrollments are 8 million fewer than CBO predicted for this year in its March 2015 baseline.
The revised 2016 projections bring CBO enrollments in line with the actual sign-ups that the marketplaces created by the Affordable Care Act (ACA) have garnered over the last two years, which were far below the CBO projections.
The new marketplace totals are similar to the 2016 enrollment goals of the Obama administration, which predicted a year-end enrollment range of between 9.4 million and 11.4 million. If the marketplace sign-ups follow the pattern of the last two years, enrollments could reach the CBO total during the year and then taper to the administration’s year-end projection.
The average number of people enrolled in Medicaid in a given month was expected to increase from 76 million in 2015 to 77 million in 2016. The CBO previously projected Medicaid and CHIP would have 50 million enrollees in 2016.
The vastly larger Medicaid enrollment came even though 19 states have not agreed to widen the program’s eligibility to the full extent authorized by the ACA. The agency now expects Medicaid enrollments to reach 85 million by 2026.
Enrollment Challenges
The agency also revised its 2015 marketplace totals to 9.5 million from a previous projection of 11 million. The reduction was due almost entirely to a lower-than-expected number of enrollees who do not receive subsidies. Similarly, the new projections deleted 4 million from the 6 million unsubsidized enrollees who previously were expected to sign up for 2016 coverage.
The sharp reductions in unsubsidized enrollees reflected the administration’s ongoing challenges in attracting them to the marketplaces.
“Most of the unsubsidized people who are no longer expected to purchase insurance through an exchange are expected to purchase insurance directly from an insurer instead,” according to CBO.
The persistent enrollment challenges among the unsubsidized also were evident in 2016 mid-enrollment data from the administration that reported only 3 percent of enrollees at that point earned more than 400 percent of the federal poverty level, the threshold below which premium subsidies are offered.
Among subsidized enrollments, a decrease of 4 million relative to CBO’s earlier projections could reflect affordability challenges even when federal assistance is offered.
The Kaiser Family Foundation (KFF) estimated in an October report that about 19 million uninsured could qualify for subsidized or unsubsidized coverage.
“For these individuals, outreach and education about coverage and financial assistance may be important to continuing coverage gains that were seen in the first two years of full ACA implementation,” the report stated.
Some uninsured people found marketplace plan coverage was too expensive, even with financial assistance. For example, a 2014 KFF survey of the uninsured found the most common reason that adults lacked coverage was cost, with nearly half (48 percent) saying they were uninsured because coverage was too expensive.
Enrollment numbers also may be stymied by frustrated former policyholders who dropped coverage because they could not afford to use it, according to insurance researchers. For instance, a 2015 survey from left-leaning Families USA found a quarter (25.2 percent) of adults who bought insurance on their own went without medical tests or treatments, prescription drugs, or doctor visits because of cost.
Hospital Impacts
The latest CBO numbers did not include an updated projection of the uninsured rate, which is used to calculate the 2017 Medicare disproportionate share hospital payment cut required by the ACA. Hospital advocates have raised concerns that reductions in the uninsured rate have been less than CBO projected, and therefore the related cuts to hospitals should be reduced.
In March, CBO plans to release updated marketplace enrollment and subsidy projections that incorporate actual 2015 enrollment and early data on 2016 enrollment.
Hospitals also have focused ongoing attention on their inability to provide subsidies to help marketplace enrollees afford coverage.
The American Hospital Association (AHA) continued to push the Centers for Medicare & Medicaid Services (CMS) to require marketplace insurers to accept third-party premium payments and cost-sharing payments from hospitals, hospital-affiliated foundations, and other charitable organizations, just as they are required to accept them from the Ryan White HIV/AIDS program.
CMS previously has barred such financial assistance for enrollees, unless it was provided through a charitable organization that made the assistance available to any applicant in the area.
“Not only does it undermine one of the core objectives of the ACA—making affordable insurance coverage available to the uninsured—it also adversely impacts those who need it most: the poor and sick,” Ashley Thompson, a senior vice president for AHA, wrote in a Jan. 15 letter to CMS urging a change in the policy.
Source: HFMA