ACA Implementation—Monitoring and Tracking Factors That Contributed to Low Marketplace Enrollment Rates in Five States in 2015 October 2015 John Holahan, Linda J. Blumberg, Erik Wengle, Ian Hill, Rebecca Peters and Patricia Solleveld With support from the Robert Wood Johnson Foundation (RWJF), the Urban Institute is undertaking a comprehensive monitoring and tracking project to examine the implementation and effects of the Patient Protection and Affordable Care Act of 2010 (ACA). The project began in May 2011 and will take place over several years. The Urban Institute will document changes to the implementation of national health reform to help states, researchers and policymakers learn from the process as it unfolds. Reports that have been prepared as part of this ongoing project can be found at www.rwjf.org and www.healthpolicycenter.org. The quantitative component of the project is producing analyses of the effects of the ACA on coverage, health expenditures, affordability, access and premiums in the states and nationally. INTRODUCTION In September 2015, the U.S. Department of Health and Human review of materials documenting enrollment efforts in these Services (HHS) released data indicating that an estimated 9.9 states. This paper focuses on the experiences of five states— million people have obtained coverage in qualified health Colorado, Iowa, Minnesota, Washington, and West Virginia 3 — 1 plans (QHPs) throughout the country. The results (Table 1) that had low marketplace enrollment by the end of the second show that 92 percent of the population projected by the Urban open enrollment period (OE2) relative to projections. 2 Institute to enroll in 2015 was enrolled. But underneath this encouraging national number was considerable variation The Urban Institute’s Projections and among the states. At the high end, Florida enrolled 143 percent Estimates of Marketplace Enrollment Rates of Urban Institute 2015 projections. Maine and Vermont had The Urban Institute uses a detailed microsimulation model to enrollment of 129 percent and 137 percent respectively. estimate the impact of the Affordable Care Act (ACA) on health In other words, those states were well ahead of predicted insurance coverage. The model enables researchers to estimate enrollment in the second year of the reforms. At the other anticipated enrollment in QHPs in every state when the law is end of the spectrum, Hawaii and Minnesota had very low fully implemented. 4 Because new health coverage programs enrollment rates relative to projections of 31 and 36 percent generally take several years to reach their full enrollment levels, respectively. High and low enrollment rates also cut across the model assumes a “ramp-up” in enrollment from 2014 to geographic regions and the type of marketplace in the state 2016: one-third of full projected enrollment in 2014; two-thirds (e.g., whether it is a federally-facilitated marketplace (FFM), of full enrollment in 2015; and full enrollment in 2016. state-based marketplace (SBM), state partnership marketplace or state plan management marketplace). The HHS data release mentioned above provided data on the number of consumers who had “effectuated enrollment,” In light of these varied enrollment outcomes, we identified five meaning that they had paid at least the first month’s premium, states that, based on its projections (explained below), had not just selected a plan at the end of the application process. high enrollment rates in 2015 and five states that had relatively A total of 9,949,000 consumers had effectuated enrollment low enrollment rates in 2015. Researchers conducted in-depth and were enrolled in a marketplace plan as of June 30, 2015, interviews with diverse stakeholders in each state including: a 15 percent drop from the 10,858,000 consumers who had state officials; health plans; health care provider organizations; selected a plan at the end of open enrollment. 5 Table 1 shows brokers and agents; consumer advocates; and marketplace effectuated enrollment in all states and calculates effectuated assisters, to ascertain what factors may have contributed to enrollment as a percentage of the Urban Institute’s 2015 these different enrollment outcomes. The Urban Institute is enrollment projections. releasing two papers analyzing the enrollment outcomes in those states’ marketplaces based on those interviews and ACA Implementation—Monitoring and Tracking 2 b a ACA Implementation—Monitoring and Tracking 3 a NOTES: ** Insufficient data supplied; n.a. = not applicable; APTC = Advanced Premium Tax Credit. a Rhode Island is not included in the enrollment subcategories because the relevant data were not available. b https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-09-08.html Table 1 shows that several states, including Arkansas, Iowa, with household income between 100 percent and 400 percent Colorado, Nevada, New Mexico, Minnesota, Washington, of the federal poverty level (FPL) (consumers with household North Dakota, Ohio, and West Virginia, had enrollment rates income between 138 and 400 percent FPL in Medicaid relative to projections well below the national average. In this expansion states) are eligible to receive APTCs on a sliding scale, paper, we focus on Colorado, Iowa, Minnesota, Washington, with the amount of the tax credit decreasing with the rise in and West Virginia. Two of these—Iowa and West Virginia— their income level. Figure 1 displays the five states’ effectuated used Healthcare.gov in 2015 and Colorado, Minnesota, and enrollment rates as a percentage of enrollment projections Washington used their own Information Technology (IT) for all consumers, for consumers receiving tax credits, and for platforms for enrollment. consumers not receiving tax credits. In 2015, HHS also released data showing how many consumers who selected plans and effectuated coverage received advanced premium tax credits (APTC) to partially offset the cost of premiums in the marketplace. Under the ACA, consumers ACA Implementation—Monitoring and Tracking 4 Figure 1. 2015 Effectuated Enrollment by Category, as Percentage of Urban Institute Projections Total Receiving Tax Credits Not Receiving Tax Credits NOTE: Rhode Island is not included in the Receving Tax Credits vs not breakouts for “States Using Their Own It Platform “or the “US Total “ due to a lack of relevant data from HealthSource RI. Summary of Findings from the Five Low The second issue that was consistent across states is that of Enrollment States affordability. For those individuals with very low incomes, coverage is easily affordable either because of Medicaid or The key findings for the five low enrollment states are as because of substantial tax credits and cost-sharing reductions. follows. First each of the low enrollment states had pre- But the financial assistance phases out as incomes increase. ACA uninsurance rates that were near the average for In virtually all five states studied, high premiums for higher the nation of 17.3 percent; if not well below. 6 These states did wage groups were thought to be making coverage not have the opportunity that states with high uninsurance unattainable for many. Premium contributions increase rates, e.g. Florida or Texas, had to make inroads with a large pool rapidly as income increases and tax credits are tied to the of uninsured people. For states like Minnesota and Iowa, 2013 second lowest cost silver plan, a coverage tier with substantial uninsurance rates were quite low, 9.5 percent and 9.7 percent deductibles and other cost-sharing requirements. The respectively, and progress was very challenging. Each of the combination of higher premiums relative to income and high five states, including West Virginia, had a large and successful cost-sharing obligations create an affordability issue at higher Medicaid expansion. Thus each lowered their uninsured income levels e.g. above 250 percent FPL. In Minnesota and rates over the 2014 to 2015 period by a considerable margin. Iowa, premiums were low enough that the Advanced Premium Those who now remain uninsured may be disproportionately Tax Credits (APTC) did not apply to some with incomes in the comprised of those who are ideologically opposed to the upper income part of the eligibility range (i.e., the full premium law, as well as the young and healthy, and the immigrant was lower than the percent of income cap that applied); as a population. In each case, these groups have proven difficult to result, some respondents reported that individuals did not see reach. that the ACA was helping them. ACA Implementation—Monitoring and Tracking 5 Each of the states with their own IT platforms reported The lack of insurer participation in Iowa and West Virginia problems that have created difficulty and have negatively was cited as a reason for low enrollment. Individuals were not affected enrollment. There are examples of individuals who happy with the limited choice of insurers and blamed the lack went through the enrollment process but then discovered there of competition for higher prices. Insurers in less competitive was no record of coverage when they went to providers. There markets did relatively little to market aggressively. This was were problems with the backend transmission of information also true of the Mountain areas of Colorado where insurance is from the marketplace to insurers. There have also been extremely expensive. problems at the 2015 renewal period where individuals were auto enrolled into their 2014 plans and had difficulty