Enrollment in 2024 Marketplace health plans during open enrollment reaches record high

In the course of the open enrollment interval for 2024 well being protection, greater than 21.4 million folks enrolled in personal certified well being plans (QHPs) by the Marketplaces (exchanges) nationwide. ^{This was a 31% enhance over the earlier document excessive set in 2023, when 16.4 million folks enrolled in Market QHPs.}

Along with the 21.4 million QHP enrollments, one other 1.3 million folks enrolled within the Primary Well being Program (BHP) protection supplied through the Marketplaces in New York and Minnesota, for a complete of greater than 22.7 million enrollees.

There are a number of things that could possibly be driving the elevated enrollment in 2024, together with the “unwinding” of the pandemic-era Medicaid steady protection rule, the continued enhancement of ACA premium subsidies underneath the American Rescue Plan and Inflation Discount Act, in addition to state-specific components.

Medicaid unwinding

One important purpose for the 2024 enrollment progress is the Medicaid disenrollments that resumed in 2023 after being paused for 3 years in the course of the pandemic. States might resume disenrollments as early as April 2023, and all states have been working to redetermine eligibility for everybody enrolled in Medicaid.

As of April 19, 2024, greater than 20.3 million folks had been disenrolled from Medicaid/CHIP. ^{A few of these folks have transitioned to employer-sponsored protection or reenrolled in Medicaid or CHIP. Nevertheless, some have enrolled in substitute protection by the Marketplaces.}

In keeping with CMS knowledge (for HealthCare.gov ^{and right here for state-based Marketplaces), greater than 3.4 million individuals who had Medicaid/CHIP in March 2023 or a more moderen month had enrolled in Market QHPs by the top of December, together with greater than 257,000 who had enrolled in BHP protection.}

The roughly 3.4 million “unwinding” QHP enrollees account for about two-thirds of the roughly 5.1 million extra Market enrollments for 2024 versus 2023. (To make clear, it’s unlikely that everybody who transitioned from Medicaid to the Market in 2023 saved their Market protection for 2024, so we will’t say that every one roughly 3.4 million of the “unwinding” QHP enrollees are among the many extra roughly 5.1 million QHP enrollees for 2024. Nevertheless, the Medicaid unwinding is broadly thought to be a main driver of the enrollment enhance in 2024).

A good portion of the enrollment progress in 2024 was amongst lower-income enrollees, a few of whom might have been amongst these disenrolled from Medicaid attributable to an revenue that elevated above the Medicaid eligibility limits. For candidates with family incomes between 100% and 150% of the poverty degree, enrollment was greater than 54% larger in 2024 than it had been for 2023 Market plans.

On the upper finish of the revenue spectrum, enrollment was about 9% larger in 2024 than it had been in 2023 for enrollees with family revenue above 400% of the poverty degree. (Particulars of enrollment by revenue ranges might be seen within the state-level public use recordsdata for 2023 ^{and 2024.)}

Continued enhancement of ACA subsidies

Not solely is present Market enrollment at a document excessive, however Market enrollment has grown annually since 2021. ^{This has largely been because of the subsidy enhancements created by the American Rescue Plan (ARP), which have been prolonged by 2025 by the Inflation Discount Act (IRA).}

For 2024 protection, 19.7 million QHP enrollees – 92% of the roughly 21.4 million whole – are receiving advance premium tax credit (APTC). ^{The typical full-price Market premium is $605, however the common after-APTC premium – even accounting for the 8% of enrollees who pay full value – is simply $111/month. And almost 9.4 million enrollees are paying not more than $10/month for his or her protection, after APTC is utilized.}

Though the subsidy enhancements took impact in 2021, utilization of them has been steadily rising since then, serving to to drive enrollment larger annually.

Way forward for subsidy enhancements unsure

The subsidy enhancements will proceed for 2025 well being plans, however it would require a literal act of Congress to increase them previous the top of 2025. (To make clear, the essential ACA premium subsidies will proceed indefinitely; it’s solely the ARP/IRA subsidy enhancements which are scheduled to sundown on the finish of 2025.)

The Congressional Funds Workplace has projected that Market enrollments would drop by about 3.2 million folks in 2026 (in comparison with projected 2025 enrollment) if the APR subsidy enhancements are allowed to run out.

President Biden has known as on Congress to make the ARP’s subsidy enhancements everlasting. However there may be political division on this subject, and the Republican Examine Committee’s not too long ago printed price range proposal requires the ARP/IRA enhancements of premium tax credit to finish.

So whereas we will’t say what the long run holds, we do know that Market enrollment has reached an all-time excessive in 2024, pushed largely by improved affordability in addition to Medicaid disenrollments. And though open enrollment for 2024 protection has ended all over the place besides New York, shoppers in each state can nonetheless enroll in the event that they’re eligible for a particular enrollment interval.

State-by-state particulars

All however one state – and Washington, D.C. – noticed year-over-year Market QHP enrollment progress from 2023 to 2024. ^{Maine was the one exception, with a 1.3% lower in enrollment. Maine has clarified that this was attributable to a rise within the revenue limits for Medicaid eligibility for kids and younger adults, a few of whom have been capable of transition from Market plans to Medicaid beginning in late 2023.}

Washington DC’s year-over-year enrollment progress was solely 0.2%, ^{and 6 states – Alaska, California, Hawaii, Nevada, Oregon, and Wyoming – had enrollment progress underneath 10%.}

However the remainder of the nation noticed double-digit enrollment progress, together with a staggering 80.2% enhance in enrollment in West Virginia’s Market, and 6 different states the place the year-over-year enrollment progress exceeded 50%: Arkansas, Indiana, Louisiana, Mississippi, Ohio, and Tennessee.

Why enrollment in West Virginia spiked

In keeping with West Virginia’s Workplace of the Insurance coverage Commissioner, the sharp enhance in enrollment this yr was attributable to a mix of the continuing ARP/IRA federal subsidy enhancements and the Medicaid unwinding – each mentioned above – together with elevated outreach and training on the a part of insurance coverage carriers and enrollment assisters. This included the primary annual Cowl West Virginia Day that was held in early January.

But it surely’s additionally value noting that there have been some adjustments in pricing dynamics in West Virginia that may have had an affect. The state confirmed that the carriers proceed to set their very own CSR-defunding load, versus states like Texas ^{and New Mexico, the place state regulators set them.}

(CSR-defunding load refers to the truth that the federal authorities stopped reimbursing insurers for the price of cost-sharing reductions in late 2017, and carriers have been including the price to premiums since then. Typically, the price is added to Silver-level plans, which will increase Silver plan costs and thus additionally will increase premium tax credit score quantities, that are primarily based on the premium of the second-lowest-cost Silver plan.)

Nevertheless, a 50-year-old in Charleston, WV, incomes $40,000 in 2024 can get a Gold plan for as little as $124/month after subsidies, versus the lowest-cost Silver plan which is $151/month. ^{In different phrases, low-cost Silver plans are priced larger than low-cost Gold plans.}

This drives up subsidy quantities – that are primarily based on the worth of the second-lowest-cost Silver plan – and ends in Gold protection being comparatively extra inexpensive. In 2023, that was not the case. The bottom-cost Gold plan was $208/month for a 50-year-old Charleston, WV resident incomes $40,000, whereas the lowest-cost Silver plan was $190/month.

These pricing adjustments that in the end made protection extra inexpensive — mixed with Medicaid unwinding and the elevated Market outreach actions — resulted in a pointy enhance within the variety of West Virginia residents enrolled in Market plans.

How and why premiums fluctuate from state to state

Pricing dynamics fluctuate from one state to a different. This contains how the obtainable plans in a given space stack up in opposition to one another in value and CSR defunding masses. The larger the pricing distinction between the benchmark plan (second-lowest-cost Silver plan) and less-expensive plans, the extra inexpensive these lower-priced plans can be after the subsidy is utilized. And better CSR defunding masses imply larger costs for Silver plans and thus bigger premium subsidies.

There are additionally state variations in revenue, entry to Medicaid, authorities help for the Market, and many others. A number of states additionally provide extra state-funded subsidies, a few of that are newly obtainable or expanded as of 2024. With all that in thoughts, right here’s a state-by-state abstract of a number of the knowledge from the 2024 open enrollment interval:

Open enrollment knowledge highlights by state