ACA exchange enrollment dropped by less-than-expected 3.7%

Some 11.8 million people signed up for coverage through the Affordable Care Act (ACA)’s insurance exchanges for 2018, down from 12.2 million the year before. Considering changes that were expected to depress enrollment—like HHS shortening the open enrollment period for Healthcare.gov and cutting its advertising budget by 90 percent—signups “remained generally stable,” according to a report from the National Academy for State Health Policy (NASHP).

The report combined enrollment figures from the federal exchange, where enrollment ended on Dec. 15, 2017, along with state-based exchanges that allowed customers to select plans as late as Jan. 31. In all, enrollment dropped by 3.7 percent nationwide, less than 7 to 13 percent decline predicted by S&P Global Ratings.

“For the first time we now have the full national picture of how the individual marketplaces did this year and it is a picture of remarkable stability,” Trish Riley, executive director of NASHP, said in a statement. “Despite all the uncertainty and challenges we have seen, particularly for consumers living in states supported by state-based marketplaces, we see millions of Americans continuing to benefit from the coverage they get in the individual market.”

In the 34 states using the federal marketplace, enrollment dropped by a larger 5.3 percent compared to 2017 and 10.5 percent compared to 2016. State-by-state, enrollment shifts ranged from a 23.5 percent drop in Louisiana to 4.5 percent increases in both Hawaii and Nebraska.

States which have their own marketplaces fared better. In the five state-based marketplaces using the Healthcare.gov platform, enrollment increased by an average of 1 percent. In the 12 fully state-operated marketplaces, enrollment ticked up just slightly by 0.1 percent, ranging from 6.3 percent drop in Vermont to a 12.1 percent increase in Rhode Island.

The difference, according to NASHP, was state-based exchanges used “effective communication”—since they didn’t cut their advertising budgets like HHS—to reach out to key populations who may be eligible for larger subsidies, shielding them from the double-digit premium increases seen across the country.

“In the end, insurance coverage and enrollment [are] a local issue and states all have different priorities and goals,” said Heather Korbulic, executive director of Nevada Health Link. “We worked hard to communicate the message in every corner of our state that we had affordable health insurance available despite the market uncertainty.”

What would help boost enrollment when sign-ups begin again later this year, according to leaders of state-based exchanges, is additional federal funding for reinsurance. After Minnesota instituted a reinsurance program, premiums dropped by as much as 13 percent and insurers have called for Congress to offer up to $15 billion to bring down costs for consumers.

“Minnesota is an example that reinsurance works to stabilize markets,” said Allison O’Toole, CEO of Minnesota’s exchange MNsure. “But Minnesota’s state-funded reinsurance program is just a band aid, and we need a long term federal reinsurance program to help Americans across the country.”