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With nearly all the 2023 open
enrollment period data now tallied, it appears that something curious is
happening in states that run their own Affordable Care Act exchanges:
Enrollment levels are on track to decline compared to 2022. That trend
follows years in which state-based marketplaces (SBMs) outperformed states
using the HealthCare.gov platform in terms of year-over-year enrollment
growth, and it comes as HealthCare.gov states are reporting a significant
signup surge compared to 2022.
Medicaid expansion states
have fewer potential enrollees
- Among the 33
HealthCare.gov states, enrollment is up 19% in 2023 compared with 2022.
However, signups in the SBMs are lagging the 2022 total by about 3% as
of Jan. 15 — most exchanges’ cutoff for enrolling in 2023 plans. And
although some enrollment data isn’t yet tallied, the decline is unlikely
to disappear, David Anderson, a Ph.D. candidate at the Duke University
Margolis Center for Health Care Policy, tells AIS Health.
- All 12 states
that haven’t expanded Medicaid under the ACA use HealthCare.gov. That
automatically gives many HealthCare.gov states a bigger potential pool
of exchange-plan customers. Still, even after the Medicaid expansion
difference was factored in, SBMs generally had “as good or better”
enrollment than HealthCare.gov states during the Obama administration,
Anderson notes, and they outperformed HealthCare.gov states by quite a
bit during the Trump administration.
- SBMs also have
“consistently dosed” their residents with enrollment outreach and
advertising, and the fact that a state runs its own exchange “is a
pretty good marker of state political support for the marketplaces,”
Anderson says. “So seeing enrollment go down for the SBM states is
weird.”
Federal marketplace states
could be ‘catching up’
- Charles Gaba,
the founder of ACASignups.net — a site that has been live-tracking ACA
enrollment since the exchanges launched in 2013 — points out that
enrollment in SBM states is not uniformly down this year. Idaho, for
example, saw a 9% year-over-year increase. Further, he notes that the
enrollment growth in HealthCare.gov states shrinks to around 8% if only
states that haven’t expanded Medicaid are counted.
- Those two
caveats aside, Gaba tells AIS Health that “I think there’s a couple
things going on” that could explain the overall enrollment decline in
SBM states. It’s possible that states that run their own exchanges have
“overperformed in the past,” he suggests, and therefore states that use
the federal marketplace have recently begun to catch up.
- Gaba adds that
one major question mark is the amount of the total eligible pool of
enrollees in each state that has already enrolled in an ACA marketplace
plan. “If it turns out that some of the [SBM] states have had a much
faster economic recovery…then that means more people with employer
coverage. If some of them are up to 70[%] or 80% of their addressable
market anyway, they might have just…hit their ceiling” of eligible
people who opt into marketplace coverage.
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