How States Can Drive Down Uninsured Rates
Prior to the COVID-19 pandemic, there were 27.5 million Americans without health insurance, an unacceptable number that was exacerbated as the pandemic reached its peak. Determined to ensure that low- and middle-income Americans had access to health insurance when they needed it the most, the federal government implemented several policies that led to 5.2 million additional individuals attaining coverage since 2020 and a historic national uninsured rate of eight percent — compared to 2016’s prior low of nine percent according to a recent report by the U.S. Department of Health and Human Services (HHS).
It is an achievement that health officials should strive to maintain as we approach this year’s open enrollment period (the window in which Americans can purchase insurance through the Affordable Care Act (ACA) healthcare marketplaces). The open enrollment window runs from November 1st to January 15th in most states. The HHS report noted the increase in insured individuals was partly driven by the continuous enrollment provision in Medicaid and the enhanced health insurance subsidies contained in the American Rescue Plan Act (ARPA). Under the latter, individuals within a certain income range were able to purchase health insurance on HealthCare.gov — the federal marketplace — with temporary subsidies, saving roughly $700 on average. The subsidies were set to expire at the end of this year, but fortunately, the Inflation Reduction Act, signed recently by President Biden, included an extension of the subsidies through 2025. Without that extension, many low-income Americans would have once again found themselves priced out of many of the plans offered, potentially leading them to drop coverage all together. The Kaiser Family Foundation estimated around a 10 percent increase in premiums in 2023 if they had expired.
The HHS report also noted that, “Medicaid enrollment has grown under the continuous enrollment provision passed by Congress as part of the COVID-19 pandemic response, as well as several states’ recent Medicaid expansions.” Continuous enrollment is tied to the Public Health Emergency (PHE) declared in January of 2020 that has been extended every three months since. As long as the PHE remains in place, states are required to keep individuals enrolled in Medicaid without reprocessing their eligibility. With states yet to receive the required 60-day notice that the PHE will terminate or expire, it is expected to extend into the new year.
When the states do resume eligibility determinations, it is estimated that almost 15 million individuals — including 5.3 million children enrolled in the Children’s Health Insurance Program (CHIP) — could lose their coverage. The extension of the ARPA subsidies could establish the federal or state healthcare marketplace as an alternative for those who are no longer eligible for Medicaid and subsequently lose their coverage when the PHE is no longer in effect. HHS expects 2.7 million individuals are expected to qualify for those premium subsidies. With this expected change to coverage, this year’s open enrollment and special enrollment periods take on much more significance, given the potential for the number of uninsured Americans to spike once continuous enrollment expires.
The Centers for Medicaid and Medicare (CMS) has provided states guidance on how to manage the changes that will go into effect when the PHE ends. The goal at both the federal and state level is to ensure that as many people as possible retain health insurance either by renewing their Medicaid coverage or transitioning to Marketplace coverage. COVID-19 remains a part of our everyday lives with Biden administration officials preparing for the potential that 100 million Americans will be hit with COVID this fall and winter, underscoring the need for Americans to continue to have access to affordable healthcare. The open enrollment period — coinciding with the expected spike in cases — provides an opportunity to make that a reality.
The extension of both policies affords states time to think through how they can maintain and even increase enrollment levels. With many consumers likely unaware that they could lose their Medicaid insurance, state public health officials could develop and execute marketing and communications plans on the continued affordability of health care insurance and all available options. States which have not done so should also consider conducting a cost-benefit analysis of transitioning from the ACA federal marketplace to a state-based exchange, which would not only bring cost savings, but more control over their open enrollment periods. Several states have already made this transition which further fortifies their health insurance markets and protects their residents while allowing them to leverage their autonomy to drive policymaking.
It has taken time and effort to reach this point and we don’t want to lose any ground. States have an opportunity to develop plans now that will help keep their residents covered and maintain — or even lower — the nation’s uninsured rate.
Heather Korbulic is the Senior Policy and Strategy Lead at GetInsured, where she engages local, state, and federal health care policy leaders in developing strategies for technology-driven improvements to the provision of health care and other public benefits. She was previously the executive director of Nevada’s health insurance marketplace, the Silver State Health Insurance Exchange.
