From 2016 to 2018, 2.5 million people who were paying their entire Affordable Care Act premiums dropped out of the individual market.
The Trump administration's latest enrollment snapshot doesn't bring many surprises given the high price tag for premiums, but the numbers are stark. The exchanges saw a 40% drop in unsubsidized enrollment from 2016 to 2018, and the declines hit almost every state.
From 2015 to 2016, 23 states began to lose some of their unsubsidized insured. Ten of these states had double-digit declines.
The following enrollment year, 43 states saw a slide — most in the double digits. Arizona lost 73% of its unsubsidized enrollees, Oklahoma dropped about 60% and Minnesota 53%.
In a statement, CMS Administrator Seema Verma characterized the report as another sign that the ACA isn't working.
"As President Trump predicted, people are fleeing the individual market," she said. "Obamacare is failing the American people, and the ongoing exodus of the unsubsidized population from the market proves that Obamacare's sky-high premiums are unaffordable."
But ACA supporters took the opposite tack. For them the numbers, even with the declines, show people are still attracted to the individual market despite the high premiums, attributed to "sabotage" by the Trump administration and GOP lawmakers in Congress.
"It clearly shows that the American people still want the quality coverage that the Affordable Care Act provides," said Leslie Dach, chair of the liberal advocacy group Protect Our Care.
Christen Linke Young, a fellow with the USC-Brookings Schaeffer Initiative for Health Policy, said the size of the declines reflected in the new report didn't surprise her so much as the response of the Trump administration.
"The thing that I continue to find most surprising about all of this is how unsure they are about whether these are good news or bad news," Linke Young said of the new report.
Like Dach, Linke Young attributes the increases to the elimination of the individual mandate, expansion of short-term plans and cuts to enrollment marketing.
Premiums have risen steadily since the ACA exchanges launched in 2014. There was another spike in 2017 when Trump canceled cost-sharing reduction payments that under the law were supposed to offset co-pays for poorer people.
Last year after individual market insurers settled into "silver-loading" the cost-sharing reduction payments into the ACA's benchmark plans, premiums saw a slight decline.
Along with the documented enrollment slump, government-paid subsidies through premium tax credits have jumped for the subsidized by 114% since 2014. Average per-person federal spending on the exchanges has surpassed that for Medicaid expansion where people have fuller coverage.
Policy experts are staying cautious about predicting what this data forecasts for the individual market and its politics in the Democratic Party.
"I think the ACA did not solve every problem in affordability, and so you see the Democratic caucus on the Hill, and Democrats running for president continuing to have conversations about how to increase affordability," Linke Young said.
The Trump administration's report comes at a unique political time for Democrats' healthcare politics.
While Democrats rallied around the ACA last year as it faced a Republican challenge in the courts, liberals are no longer so united around the ACA now that the presidential primaries are well underway.
Insurer and hospital-backed coalition groups are waging a public relations battle to fend off any overhaul of Obamacare's insurance model that could damage their profits. House Democrats have passed proposals to expand the already-costly subsidies to more people, which could stop departures from the market.
But the leftward swing toward single payer has brought moderates on board with the public option to buy into Medicare or Medicaid.