HHS Offers Its Expectations For 2016 Open Enrollment

Implementing Health Reform. On October 15, 2015, the Health and Human Services Assistant Secretary for Planning and Evaluation (ASPE) released two issue briefs. The first addresses How Many Individuals Might have Marketplace Coverage at the End of 2016, while the second analyzes the Health Insurance Marketplace: Uninsured Populations Eligible to Enroll for 2016.

Projected Marketplace Enrollment For 2016

The headline of the reports is that HHS expects a total of 11 to 14.1 million individuals to select marketplace plans by the end of the 2016 open enrollment period, and between 9.4 to 11.4 million of those individuals to still have effectuated enrollment by the end of 2016.

ASPE reached these numbers by projecting that 7.3 to 8.8 million of the 9.1 million 2015 marketplace enrollees would reenroll for 2016; that approximately 0.9 to 1.5 million of 8.5 million individuals who are currently enrolled in the individual market outside the marketplace would move to marketplace coverage in 2016; and that 2.8 to 3.9 million of the 10.5 million remaining qualified health plan (QHP) eligible uninsured (see below) would enroll in 2016.

ASPE is further projecting a reduction of 1.6 to 2.7 million individuals from the number who will have selected plans as of the end of the 2016 open enrollment period over the course of 2016. The attrition figures are based on experience from the first two open enrollment periods and account for the excess in the number of individuals who leave the marketplace for employment-based or Medicaid coverage or who lose coverage because of nonpayment or data matching issues over those who sign up for marketplace coverage during special enrollment periods during 2016.

The ASPE And CBO Numbers Compared

HHS's goal of 10 million effectuated enrollees at the end of 2016 projects an increase of only about a million individuals from its current projected enrollment of about 9.1 million at the end of 2015. It is well below the 20 million individuals that the Congressional Budget Office has projected will be covered through the marketplaces by 2016. ASPE explains that this difference is due to the fact that the CBO anticipated a larger number of individuals moving from employer coverage and from the out-of-the-marketplace individual coverage to the marketplaces than has in fact occurred.

In fact, recently released Census figures for 2014 found 175 million Americans covered by employer-based coverage, an increase over 2013 and well above the 149 million projected for 2016 by the CBO. And, according to ASPE, 8.5 million individuals retain individual coverage outside the marketplaces, many of whom are no doubt covered by transitional plans which can continue into 2017 or grandfathered plans.

At least two states, New York and Minnesota, have also established Basic Health Plan programs that will reduce marketplace enrollment in those states. The bottom line is that the CBO's projection of 29 million remaining uninsured in 2016 is comparable to the number of uninsured who would remain if ASPE's projections prove accurate.

A Profile Of The Remaining Uninsured Population

ASPE believes, based on recent survey data, that 17.6 million previously uninsured individuals have become insured since 2010 under the ACA. The second ASPE issue brief describes the remaining uninsured population. This brief draws from a number of sources, including the National Health Interview Survey.

Of the remaining uninsured, approximately 49 percent are likely QHP eligible. About 12 percent of the remaining uninsured live in Medicaid expansion states and have incomes that would make them eligible for Medicaid (below 138 percent of FPL). About 11 percent live in states that have not expanded Medicaid and have incomes below 100 percent of FPL. They can purchase marketplace coverage but are not eligible for financial assistance. About 7 percent are children with family incomes below 250 percent of FPL and should be eligible for CHIP. Approximately 21 percent of the remaining uninsured are not eligible for marketplace coverage because they are undocumented aliens.

ASPE projects that 10.5 million Americans are eligible for QHP marketplace coverage for 2016. Of this "likely QHP-eligible uninsured population:"

• 48 percent have incomes between 100 and 250 percent of FPL, and thus would qualify for premium tax credits and cost-sharing reduction payments. Only 22 percent have incomes above 400 percent of FPL and thus do not qualify for any assistance. The QHP-eligible population are more likely than the general nonelderly population to have incomes below 399 percent of FPL and less likely to have income above 400 percent of FPL.
• 57 percent are men, compared to half of the general nonelderly population.
• Almost half of the QHP-eligible population have education beyond high school, but they are more likely than the general nonelderly population to have only a high school diploma.
• They are slightly more likely (61 percent) to be White or Black (14 percent) than the general nonelderly population; they are slightly less likely to be Hispanic or Asian.
• The QHP-eligible population are more likely to be between the ages of 18 and 34 (over 46 percent) and less likely to be under 18 or between 55 and 64 than the general nonelderly population.
• About 70 percent are employed (the same as the general nonelderly population) but they are more likely to be unemployed (11 percent) and less likely to be out of the labor force (17 percent) than the general nonelderly population.
• The QHP-eligible population are much more likely to live in nonmetropolitan areas (19 percent) than the general nonelderly population (14 percent).
• About 63 percent are not married, a much higher percentage than the general population (46 percent).
• The QHP-eligible population are less likely to rate their health as excellent (34 percent versus 40 percent) and more likely to rate it as good (28 percent versus 22 percent) than the general nonelderly population, although no more likely to rate it as poor (8 percent).
• Only half have a usual source of care, compared to over 86 percent of the general nonelderly population.

What Do We Know About The Attitudes And Experiences Of The Uninsured?

The ASPE brief also summarizes information from a number of surveys examining the attitudes and experiences of the uninsured. These surveys cover the uninsured generally, not just the QHP-eligible population.

• Nearly 80 percent of the uninsured have less than $1,000 in savings and half have less than $100. Only 26 percent say they are doing well financially.
• Half had difficulty affording food and housing in the past year.
• Many say they would pay down their debt, put money in savings, or make home or car repairs before buying health insurance.
• Only 28 percent of those with ongoing medical care needs believe they are getting all or most of the care they need.
• They are much less likely (33 to 74 percent) to receive a check-up or preventive care visit than those with employer-sponsored insurance, and more likely (21 percent to 4 percent) to be unable to afford prescription drugs.
• 33 percent have postponed care and never received it and 34 percent of these did so because they could not afford it.

Most (75 percent) of the uninsured think that having health insurance is important and only 20 percent do not want insurance, but:

• Many do not know that free or low-cost coverage is available to them through Medicaid or the marketplaces.
• Of those who believe coverage is too expensive, 42 percent appear eligible for premium tax credits and 14 percent for Medicaid.
• About half of those who sought coverage in 2014 but did not enroll because they understood that they were not eligible for assistance seem to be eligible for premium tax credits or Medicaid.
• About 40 percent of the uninsured are unaware of the individual responsibility penalty (which will be the greater of 2.5 percent of income or $695 per adult and $347.50 per child for 2016) and 40 percent who were uninsured in 2014 were unsure if they would pay it. (7.5 million Individuals owed the penalty in 2014).

Reaching The Remaining Uninsured

CMS is using its understanding of the remaining uninsured population and of their attitudes and experience to better target enrollment efforts for 2016. This includes greater use of electronic and social media to reach young adults and greater use of in-person assistance for individuals who are hard to reach through conventional channels. CMS will emphasize the availability of financial assistance and the potential penalties of going uninsured. It will focus its efforts on particular parts of the country where the level of uninsurance is high.

CMS plans to release more information on its 2016 enrollment efforts soon.

The ASPE Report And ACA Replacement Proposals

The information released by ASPE is of interest also for putting recent ACA replacement proposals in perspective. Presidential candidate Jeb Bush, for example, has proposed replacing the ACA's means-tested tax credits with fixed-dollar tax credits. It seems apparent, however, that most of the remaining uninsured have incomes low enough that fixed-dollar tax credits would be unlikely to make health coverage affordable to them. Even if the tax credit were sufficient to allow them to purchase a catastrophic policy, the uninsured would not be able to afford the cost-sharing that coverage would impose.

Proposals to extend tax subsidies for health savings accounts may benefit the wealthy, who can use them to shelter retirement savings from taxes, but are useless to low-income individuals who are unable to hold even $100 in savings. Proposals that would replace the ACA's preexisting condition underwriting ban with a continuous coverage requirement would impose a very heavy penalty on many of the uninsured who are unable for financial or other reasons to maintain continuous coverage—a penalty potentially much higher than that imposed by the individual mandate.

from Health Affairs Blog http://ift.tt/1VV9Rqo