Disappointment runs thick around 2017 open enrollment for the Affordable Care Act’s exchanges, likely the last go-around for the health insurance marketplaces.  Foes of the ACA claim it’s a further sign that the markets are unsustainable. ACA advocates point to the new administration’s actions undercutting open enrollment it its final days.

Healthcare.gov enrolled 9.2 million people, a 400,000-person decline, albeit a completely unsurprising one. Throughout much of open enrollment, numbers kept pace with the previous year, sometimes exceeding it. But this time, exchanges lacked the crush of people signing up at the last moment.

The biggest rush of enrollees always arrived in open enrollment’s final days. A cutback at that critical juncture could have let the deadline slip past those on the fence about buying coverage. Almost the entire margin of decline comes from the final weeks – in 2016, 690,000 people enrolled in the final week, while 376,000 enrolled in the final two weeks of 2017 open enrollment.

Along with President Donald Trump’s executive order and the cancelation of up to $5 million in exchange advertising in open enrollment’s final days, ACA skepticism and hostility still reigns in most healthcare.gov states. Given the rhetoric surrounding a replacement, previous enrollees might have decided to skip coverage or wait to see what replacement emerges.

The demographics of people who didn’t buy coverage in 2017 skew younger and healthier. People with health conditions will buy coverage no matter the cost. Younger, healthier people will skip buying coverage until necessary.

Exchange business has already proven unprofitable for many insurers. Enrollment of fewer younger, healthier enrollees could lead more insurers to decide to dump their exchange business.

Results were more mixed among state-run exchanges. When states controlled exchange marketing, the numbers generally held steady or increased for 2017. If the inevitable ACA replacement retains some provision for state-run exchanges, these states are the most likely to continue.

Not every state-run exchange increased – Maryland Health Connection lost 3 percent, enrolling 157,000, although local factors such as an insurer’s last-minute withdrawal from the exchange likely played a role.  Access Health CT, another successful exchange, saw its enrollment drop.

Washington Health Plan Finder enrollment increased 13 percent to 222,000. Connect for Health Colorado exceeded 2016 enrollment by 12 percent, surpassing 200,000 enrollees. A late surge in enrollment led Colorado to extend open enrollment until February 3. Nevada Health Link’s ticked up slightly to 89,000 lives.

Idaho, which already had one of the nation’s highest percentages of exchange eligibles enrolled in a plan, exceeded 100,000 lives for the first time.

Idaho could be a model if exchanges survive under ACA replacement. The Republican-controlled state built a low-cost exchange that has seen high enrollment and no loss in exchange competition.

Some of these exchanges will endure through an ACA repeal.

But with the majority of states using healthcare.gov, underperforming enrollment indicates the eventuality of change for most enrollees.


Follow Bill Melville at @BillMelvilleDRG


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