Week 7: New Sign-Ups Gain Ground to Overcome Trump Administration Obstacles
Enrollment On Par With Last Year, Proving HealthCare.gov is More Resilient Than Ever
Today, CMS released the Week 7 enrollment snapshot for the HealthCare.gov 2019–2020 Open Enrollment Period. Cumulatively, 8,303,850 people signed up for coverage through December 17. Total sign ups, when factoring in people that transitioned from the federal exchange to a State Based Exchange or Medicaid since last year, were down just 0.4%.
More new people signed-up for coverage than last year. This increase in new enrollment is despite cuts to the outreach and awareness budget, in-person assistance, technical challenges, expanded availability and proactive marketing of junk plans, and the repeal of the individual mandate that increased the ongoing uncertainty. Overcoming these obstacles means the marketplaces are more resilient than ever. If the administration simply did its job raising awareness about the availability of quality, comprehensive and affordable coverage, millions more people would be enrolled in coverage today.
There were important changes to who could purchase coverage on HealthCare.gov this year that had an impact on the year-over-year comparisons. Nevada transitioned to become a State-Based Exchange that will report sign-ups independently, so the equivalent 83,647 people who signed up for coverage in Nevada last year are not included in this CMS snapshot. Similarly, Medicaid expansion in Virginia and Maine transitioned people from HealthCare.gov to Medicaid. The Center on Budget and Policy Priorities estimates that combined these factors in Nevada, Maine and Virginia reduced the number of people purchasing coverage in the federal marketplace by about 110,000 people this year.
Last year, CMS reported 8,454,882 plans selections in the Week 7 snapshot (not the final snapshot). Factoring in the impact of Nevada, Maine and Virginia, the equivalent number of people who signed up for coverage last year was 8.34 million.
CMS added auto-renewals into the snapshot along with people who actively enrolled during the finals days of Open Enrollment. Combined, 6,241,376 people renewed coverage this year. Factoring in the changes in Nevada, Virginia and Maine (roughly 83,600 fewer people renewed), renewal is down 2% this year. Year over year renewals were dead even last year. At the same time the percentage of people who retained coverage from the February effectuated enrollment report to the end of Open Enrollment actually stayed the same year over year at 81%. Clean up (a final batch of enrollments and terminations factored in to the “final” snapshot by CMS) could impact this number.
CMS reported that 2,062,474 new people signed up for coverage this year. Factoring in the changes in Nevada, Virginia and Maine (roughly 26,300 new sign-ups), new people signing up for coverage is up 3% this year. Last year, the number of new people signing up for coverage was down 15% in Week 7, so this is a significant departure from the multi-year decline in new enrollment we’ve witnessed.
New enrollment was especially strong in the final 8 days of open enrollment continuing a multi-week trend. The strength of new enrollment this year is likely the product of multiple factors including: the widespread availability of low or zero dollar premium plans, rising number of uninsured people and\or changes to the distribution of prices that aren’t captured in the averages. For example, the Kaiser Family Foundation analysis found that 4.7 million people had access to a plan with $0 monthly premiums — 500,000 more people than last year.
Obstacles Slowing Enrollment
Technical issues on the site likely hurt sign-ups. When CMS announced the deadline extension, they reported that “over half a million” people signed-up on the final day. CMS cited this as evidence that HealthCare.gov was working, when the reality is it indicates that the technical issues users faced had a significant impact on enrollment. This sign-up total is far lower than December 15 deadline days in past years. For example in 2016 CMS publicly announced that over 670,000 had signed-up. The final day sign-up totals should have increased since then because of the shortened Open Enrollment period (just as they have weekly). In any case, this is a huge gap in final day sign-ups and indicates that technical issues on the final day were consequential. Based on similar reasoning that factors in this year’s enrollment totals, Charles Gaba estimates that over 110,000 people were impacted by the technical glitches. While the deadline extension certainly helped many of the people who were impacted, many others never learned about the extension.
The CMS snapshot released today, while close, is not the final snapshot for HealthCare.gov. CMS has not added in sign-ups from the call-center in-line extension. While we don’t know how many people signed up during this time, it’s likely significant because the phone number was the only vehicle to enroll for many people during the technical problems last Sunday. Additionally, CMS typically does some clean-up, adding and\or terminating enrollments, before releasing final numbers for the federal exchange. Last year, the clean-up removed 43k sign-ups in the final snapshot released on January 3, 2019 this year it’s possible the number will increase.
CMS Must Improve Communications
The way CMS handled the technical issues on the first and last day of Open Enrollment was unacceptable. When issues like these are flagged by people using the site, it is vital that CMS acknowledge the issue to users on the site and give people who are actively trying to enroll basic information about what is happening and what to do as a result (e.g. wait for a page to load, return to the site another time, etc.).
As technical issues impacted hundreds of thousands of people on both the first and last day of Open Enrollment, CMS’s silence about what was going on was deafening. CMS must commit to being transparent about what happened on the first day of Open Enrollment and last Sunday. CMS should explain what they did to fix each problem, the impact they had on enrollment, and what they will do to make sure it doesn’t happen in the future.
This year sign-ups in 11 HealthCare.gov states grew: Mississippi, Iowa, Florida, Delaware, Oklahoma, Nebraska, Utah, Texas, Georgia, North Carolina, and South Dakota. Sign-ups in 10 HealthCare.gov states shrunk by more than 5%: Virginia (Medicaid Expansion), Maine (Medicaid Expansion), West Virginia, Tennessee, Pennsylvania, Missouri, Illinois, Louisiana, and Ohio.
State-Based Exchanges Continue
Importantly, Open Enrollment is over in HealthCare.gov states, but continues in California, Colorado, Connecticut, District of Columbia, Massachusetts, Minnesota, New York, Rhode Island, and Washington. State-based exchanges, which report independently, were responsible for over 3 million enrollments last year. While HealthCare.gov sign-ups have declined for the last 4 years, collectively State-based Exchange enrollment has been steady or even grown.
So far this year, we’ve seen promising reports from State-based exchanges about Open Enrollment suggesting this trend might once again continue. Maryland reported its highest sign-ups in years. Covered California reported that new enrollment is up 16% so far this year. New York State of Health reported that so far sign-ups are “outpacing” last year.
Unfortunately, we have to wait until February for the complete national enrollment tally. The consequences of the administration’s efforts to undermine Open Enrollment are on vivid display in this graph from last year by Charles Gaba that shows the difference in sign-ups between HealthCare.gov states and State Based Exchanges.
The ongoing uncertainty created by Texas v. United States will hurt enrollment in states where Open Enrollment is still underway. But more importantly, the lawsuit endangers the existence of the Health Insurance Marketplaces and Premium Tax Credits among many other things. The Urban Institute released an excellent assessment of the implications for the lawsuit.