Different Forces at Work Expected to Affect This Year's ACA Open Enrollment

There are 2 policy forces at work that will likely have the most impact on sign-ups for health insurance available on the individual marketplaces under the Affordable Care Act (ACA), according to a Health Affairs blog post.

Open enrollment, the sixth season for the ACA, begins Thursday and lasts for 6 weeks, November 1 to December 15, same as last year.

There are some policy changes that will likely increase enrollment, wrote the post’s author, David Anderson, MSPPM, a research associate at Duke University’s Margolis Center for Health Policy. But other changes may decrease enrollment.

The policy changes put in place by the Trump administration have already taken effect (or they were widely expected) and have been priced into the 2019 plans. It is the second open enrollment run by the administration.

While Republicans were unable to repeal the ACA outright, they were able to remove the individual mandate penalty and increase access to short-term, limited duration health plans and association health plans, which are not required to cover pre-existing conditions or all 10 essential health benefits, as originally envisioned under the ACA.

The administration did approve several states’ reinsurance waivers but ended cost-sharing reimbursement (CSR) payments to insurers to cover them for enrolling low-income people.

The response was to “silver-load” CSR costs, because the ACA’s premium subsidies are income-adjusted and set to a silver benchmark. The unintended consequence was that discounts were created for other metal levels, so some premiums for gold plans cost less than some silver plans, and some bronze plans were essentially free for those at the lowest income levels.

What will lead to a change in enrollment will be 2 different forces—relatively lower premiums for exchange plans, and the influence of the newer, non—ACA-compliant plans that cover mostly healthy people without chronic disease or other illnesses.

Anderson wrote that exchange plans are likely to be attractive to individuals who earn between 200% and 400% of the federal poverty level. But they will likely be a target of the lower-cost, non—ACA-compliant plans as well.

Policies Boosting Enrollment

The following factors are likely to boost enrollment on exchange plans:

• Silver-loading in more states, meaning some buyers will get more for their healthcare dollars.
• States using reinsurance waivers to lower premiums.
• More insurers entering or re-entering the market.
• “Catastrophic” plans that are easier to buy.

Policies Depressing Enrollment

• Short-term, limited-duration plans are expected to be priced such that they are attractive to healthy people who can pass medical underwriting and don’t qualify for subsidies. They are renewable for up to 3 years.
• Association plans, likewise, are expected to draw healthier people.
• In addition, without a financial penalty attached to the individual mandate, some people may just decide to go without insurance altogether and skip enrollment; this effect remains to be seen.

In addition, those shopping for insurance over the next 6 weeks will have fewer options for unbiased help or assistance if they are confused, as grants to nonprofits and other organizations that provided “patient navigators” were cut to $10 million this year. The grants were $63 million in 2016.

CMS Administrator Seema Verma said this summer that the old navigator program was not effective. CMS is allowing private agents and brokers—which also sell the cheaper, skinnier plans—to provide advice to consumers.

Hundreds of counties across the United States will not have any patient navigators this year, The New York Times reported.