Preliminary federal data indicates that enrollment in Affordable Care Act exchange plans has risen for the first time under the Trump administration.
CMS reported on Friday that more than 8.2 million people signed up or were automatically enrolled in a health plan for 2021 during HealthCare.gov's open enrollment through Dec. 15. Those totals don't include people who signed up for coverage in the 15 states that operate their own exchanges, which is up from 13 states last year. New Jersey and Pennsylvania left the federal HealthCare.gov marketplace this year to open their own state exchanges.
The increase comes as the nation deals with an economic downturn caused by the COVID-19 pandemic, uncertainty about the ACA's fate during an election year, and an increase in the number of private insurers in the marketplace.
Josh Peck, the former chief marketing officer for HealthCare.gov and co-founder of nationwide campaign Get America Covered, said the number of sign-ups rose 6.6% year over year, which represents the first increase in enrollment ever during the Trump administration. He credited the growth to individuals enrolling in ACA plans throughout the year due to emergency circumstances caused by COVID-19, rather than during open enrollment.
"When COVID-19 hit, it created this huge, incredible amount of turmoil in our economy," Peck said. "People lost jobs, lost health coverage, and many of them apparently signed up for Medicaid and also for the marketplace during the year. It's very unusual to have the growth come during the year."
More than 600,000 people had already enrolled in marketplace coverage before open enrollment for 2021 started, Peck said. He said the number of people renewing their coverage during open enrollment rose 10.5% year over year to 6.4 million people. Once Peck factored in those who enrolled in Medicaid expansion plans, he said he found that the marketplace is experiencing a 7.6% enrollment growth year over year.
Medicaid and the Children's Health Insurance Program are seeing similar rises. CMS on Monday reported 5.8 million more individuals enrolled in Medicaid from February to August 2020, and 33,000 adolescents joined CHIP's rolls. This reflects an 8.3% increase in the total number of enrollees for the combined programs.
"What we know now, with the growth of marketplace in conjunction with Medicaid, is that they frankly played a very, very important role in expanding the safety net," Peck said.
ACA plans may have been more attractive as premiums dropped. The average price of premiums dropped 8% since 2018, according to CMS.
Many exchanges also had more competition. CMS said only 10% of regions would have only one insurer offering a health plan, compared to 56% of regions for the 2018 plan year. Approximately 62.8% of regions in 2019 had three insurers or more participating in exchanges, according to the Urban Institute.
CMS Administrator Seema Verma credited the rise in enrollment to HealthCare.gov's updated user experience and the Trump administration's work bringing more private insurers in the exchange.
"We've opened more pathways to enroll by taking advantage of private sector and people are clearly finding the coverage they need at this critical time," Verma said in a statement.
While the number of available plans to individuals rose to more than 50 from 38 last year, Peck questioned whether more options would really lead more consumers to use the ACA. While competition improved, that doesn't mean consumers have cheaper or better quality plans to select from. He said Verma's reasoning fails to account for why more people signed up for coverage throughout the year, with an "unprecedented" number of individuals renewing their coverage for 2021.
"While the Trump administration is asleep at the wheel, the ACA is here to help people weather this storm," Peck said.
But the increase in enrollment could have been higher, Peck said. CMS slashed marketing and outreach funds as well as navigator grants in past years. It also didn't create a COVID-19 special enrollment period, though people could sign up via special enrollment if they lost job-based minimum essential health coverage or experienced another life event such as moving to a new zip code or getting married.
Total sign-ups in states using HealthCare.gov could be higher than reported. The tally does not include the final three hours of open enrollment or plan selections from people who left their contact information at the call center due to high volume.