Open Enrollment Succeeds Against the Odds, but Has the ACA Peaked?

The odds were long. At the start of the fifth open enrollment period for Affordable Care Act (ACA) marketplaces last November, there was every reason to believe that enrollment would fall off a cliff in 2018.

But Colorado’s state-based marketplace, Connect for Health Colorado, ended its open enrollment period on January 12 with 165,777 customers selecting health insurance plans on the individual market.

That’s down about four percent from last year’s total of 172,361 enrollees. Colorado’s uninsured rate has held steady since 2015 at about 6.5 percent, according to the Colorado Health Access Survey.

Here’s why that number is so impressive. In the past year:

• Premiums on the individual market jumped an average of 32 percent in Colorado.
• The Republican Congress and President Donald Trump spent most of 2017 deriding the ACA and trying to repeal it.
• Congress and Trump ended the year by repealing the individual mandate requiring most people to purchase insurance.
• Trump’s administration quit paying cost-sharing subsidies to insurance companies to provide discounted ACA coverage, an action that caused Colorado’s premiums to jump an average of six percent.
• Trump also cut back on advertising and outreach that has helped convince younger, healthy people to get coverage and improve the risk pool.
• The open enrollment period was 22 days shorter than last year.

Together, these factors created the greatest threat to stability in ACA markets since the act took effect in 2014. Yet in Colorado and around the country, ACA marketplaces racked up enrollment close to last year’s totals. What happened?

Here are a few theories.

First, as the president himself might say, there’s no such thing as bad publicity. The repeal debate in Congress kept the ACA in the news all year long. The threat of repeal only seemed to improve the law’s popularity, according to opinion polls throughout the year.

Second, the market forces and political attacks that pushed up prices had a paradoxical effect: They made coverage cheaper for a lot of people. ACA subsidies increase when insurance prices increase, so the price hikes for 2018 meant that most Colorado customers who qualified for subsidies could get significant discounts compared with last year. In some states, customers with subsidies could even get bronze plans for $0 a month.

Coloradans seem to have noticed. As of December 18, 75 percent of Connect for Health’s customers were getting subsidies, compared with 63 percent in 2017.

The pain of high prices will be borne by those who don’t qualify for subsidies — people who make at least four times the federal poverty level, or just under $50,000 for a single person.

The slight drop in enrollment for 2018 does raise a serious question for 2019. Are the ACA marketplaces’ best days behind them? Here are a few reasons to worry:

• There’s been no change in the fundamentals behind high prices: spiraling drug costs, expensive medical care, and individual market customers who frequently buy and drop coverage, making it hard for insurers to break even.
• The individual mandate will not be in effect in 2019.
• The Trump administration has left no doubt that it will take executive actions aimed at tearing down the ACA, rather than propping it up.

The successful enrollment period for 2018 is something to celebrate. But it might be the last celebration for the ACA for a while.

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