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CMS: Enrollment in unsubsidized ACA plans declined by 45%

October 13, 2020

Topics: Quote of the Day

Centers for Medicare and Medicaid Services, October 9, 2020


This report provides data on enrollment trends for people who purchased on- and off-Exchange individual market health insurance plans, both with and without federal advanced premium tax credit (APTC) subsidies. These data are based on an analysis of individual market plans that participated in the risk adjustment program established under section 1343 of the Patient Protection and Affordable Care Act (PPACA) and Health Insurance Exchange effectuated enrollment data. The data provided in this report include state-specific, average monthly enrollment covering plan years 2014 to 2019. Over that period, average monthly enrollment in the individual market—including both subsidized and unsubsidized enrollment—peaked in 2016, reaching 14.5 million. Enrollment then declined by 10 percent in 2017, 7 percent in 2018, and 3 percent in 2019. Enrollment among the unsubsidized, who do not receive APTC subsidies, saw a considerable decline of 9 percent from 2018 to 2019, compared to a decrease of 1 percent in APTC subsidized enrollment. From its peak in 2016, unsubsidized enrollment declined by 2.8 million people by 2019, a 45 percent drop nationwide. From 2016 to 2019, unsubsidized enrollment declined by more than 70 percent in Arizona, Georgia, Iowa, Missouri, Nebraska, New Hampshire, Oklahoma, Tennessee, and West Virginia.

Key Findings

This report provides data on individual health insurance market enrollment trends for people who purchase health insurance with (subsidized) and without (unsubsidized) advanced premium tax credits (APTC).

  • From plan years 2016 to 2019, unsubsidized enrollment declined by 2.8 million people, representing a 45 percent drop nationally. At the state level, the percentage change in unsubsidized enrollment over this period ranged from a 4 percent drop in Rhode Island to a 90 percent drop in Iowa.
  • The most recent year of enrollment data shows that average monthly enrollment across the individual market nationally decreased by 3 percent between 2018 and 2019.
  • Eighty percent of the decrease in enrollment between 2018 and 2019 occurred among people who did not receive APTC subsidies. Unsubsidized enrollment declined by 9 percent, compared to only a 1 percent decrease in subsidized enrollment, from 2018 to 2019.
  • Though unsubsidized enrollment continued to decline in 2019, the rate of decline was substantially lower than the 24 percent drop in 2018 and the 20 percent drop in 2017. This lower rate of decline occurred as premium rates leveled off in 2019, after increasing by double-digits in 2017 and 2018.
  • Looking at state-level enrollment trends between 2016 and 2019 also shows the link between enrollment and premium trends. States with larger declines in unsubsidized enrollment tended to experience a larger increase in average premiums.
  • Review of state-level data also shows that trends in declining enrollment began from 2015 to 2016 for 10 states. Declining enrollment occurred in 44 states from 2016 to 2017, 43 states from 2017 to 2018, and 39 states from 2018 to 2019.
  • Average monthly enrollment in the subsidized portion of the market grew substantially in comparison to the unsubsidized market. The subsidized portion of the market was 140 percent larger than the unsubsidized portion in 2019, up from 122 percent larger in 2018 and 61 percent in 2017.



By Don McCanne, M.D.

To no surprise, as premiums increased in the plans offered through the ACA exchanges, the enrollment by individuals who received no subsidies (advanced premium tax credits) declined by 45%. They found the premiums to be simply unaffordable.

In contrast, the percentage of enrollees who received subsidies increased dramatically (though the actual numbers enrolled didn’t increase much – see Figure 3 at link above). In 2015, the subsidized enrollment was 24% larger than the unsubsidized enrollment, whereas, by 2019, the subsidized enrollment had grown to 140% larger.

When it was decided to reject a universal public insurance program and instead enact an exchange (market) of private insurance plans to help fill the void in coverage, the authors of the legislation rejected the efficiency and effectiveness that had already been demonstrated in our Medicare program and instead relied on the fragmented and highly dysfunctional private insurance model – a model that has not served us well.

It is understandable why people would accept private insurance when the government is providing generous subsidies for its purchase. Likewise, it is also certainly understandable why the private plans would be rejected when the enrollees were required to pay the full unaffordable premiums. Why would they want to pay hard-earned money for a private plan that had unaffordable deductibles, limited provider networks, and wasteful, costly administrative excesses? A more pertinent question is why would Congress insist on offering such a defective model of health care financing when we could have an efficient, equitable, affordable, single payer Medicare for All program that includes everyone?

The near future looks grim. Both presidential candidates have rejected the single payer model, and the likely victor has suggested more of the same, with perhaps an increase in subsidies and the addition of a private-style option which has been mislabeled as Medicare.

Our clearly dysfunctional system is working poorly for too many of us and not at all for far too many more. Why would we simply want to throw more subsidies at it when all of us could have a far better deal through a single payer program of Medicare for All?

Joe Biden keeps saying to us, “Here’s the deal.”

It’s time for us to say, “No! Here’s the deal we demand.”

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About the Commentator, Don McCanne

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Don McCanne is a retired family practitioner who dedicated the 2nd phase of his career to speaking and writing extensively on single payer and related issues. He served as Physicians for a National Health Program president in 2002 and 2003, then as Senior Health Policy Fellow. For two decades, Don wrote "Quote of the Day", a daily health policy update which inspired HJM.

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