CMS’s week six open enrollment snapshot for the 2021 open enrollment period shows that more than 8.2 million consumers selected a plan in the 36 states that use HealthCare.gov. Of these, about 1.83 million were new consumers and about 6.4 million were renewing their coverage from last year.
Overall enrollment through HealthCare.gov increased by about 6.6 percent for the 2021 open enrollment period relative to the 2020 open enrollment period. Other analysis suggests that the increase may be even greater once Medicaid expansion is accounted for. This is the first and only year when HealthCare.gov enrollment has increased under the Trump administration, reversing a trend where enrollment declined each year beginning in 2016.
As noted above, there were two fewer states using HealthCare.gov for 2021 as New Jersey and Pennsylvania transitioned to their own state-based marketplaces. They follow Nevada, which transitioned to its own marketplace for 2020. Combined, New Jersey and Pennsylvania had accounted for about 7 percent of all HealthCare.gov plan selections (more than 578,000 plan selections) during the 2020 open enrollment period. In addition, Idaho, Nebraska, and Utah expanded their Medicaid programs in 2020. (The individual market generally contracts after a state expands its Medicaid program, as individuals whose income is between 100 percent and 138 percent of the federal poverty level migrate from marketplace coverage to the Medicaid program.)
Enrollment may tick up yet more because CMS’s data does not yet account for consumers who 1) enrolled in coverage between midnight and 5am ET on December 16; or 2) could still enroll after leaving their contact information at the call center due to high volume. This data also does not reflect enrollment in many state-based marketplaces whose deadlines are later, in December or January. As with prior years, CMS intends to release an updated snapshot on HealthCare.gov enrollment during the second week of January. A more detailed final open enrollment report (with data on enrollment in all states) is expected in spring 2021.
Unlike last year, there were no reported technical difficulties with HealthCare.gov, and less than five hours of planned maintenance were needed during the entire open enrollment period. CMS also reports that consumer satisfaction with the call center remained high.
Renewals Up, But New Enrollment Down
The data show a consistent surge as the December 15 deadline neared. Consistent with last year, more than half—about 4.4 million people (or 53 percent)—of all consumers who selected a plan did so from December 6 to December 15. This included more than 911,000 additional new consumers relative to the prior week. Even so, enrollment of new consumers is down relative to last year. New enrollment is critical to maintaining the health of the overall risk pool because new enrollees tend to be younger and healthier.
The final week of enrollment numbers are higher because this data includes individuals who were automatically renewed in 2021 coverage. Although new enrollment was down, this was offset by an 11 percent increase in renewals (via auto-reenrollment or active reenrollment). Renewals may be up because, as discussed more in the reports below, more people retained marketplace coverage in 2020 or enrolled through special enrollment periods (SEPs). Either way, having more people enrolled in marketplace coverage at the end of the year likely contributed to stable enrollment as a result of auto-renewal.
Based on an analysis from Get America Covered, enrollment grew by 5 percent or more in 16 states and fell by 5 percent or more in only 2 states. Enrollment grew the most in Texas (by 15 percent), Hawaii (by 13 percent), and Mississippi (by 12 percent). Enrollment fell the most in Kentucky (by 7 percent) and Louisiana (by 6 percent).
Marketplace Stability That Undercuts Those Challenging The Affordable Care Act In California v. Texas
The final data show the stability of the marketplaces, continued demand for comprehensive individual market coverage, and the importance of the marketplaces as part of the health care safety net during the COVID-19 pandemic. Higher enrollment is undoubtedly positive. But further gains likely could have been made if the Trump administration allowed a broad-based SEP in response to the pandemic or more aggressively advertised marketplace coverage options during this year’s open enrollment period. Doing so was important even before the pandemic, given the rising uninsured rate. These actions also would have complemented lower average premiums and higher insurer competition that CMS often touts.
Finally, the fact that enrollment remained stable cuts against one of the arguments in California v. Texas over the impact of the individual mandate penalty. The past three open enrollment periods (since the penalty has been set to $0) make it clear that the penalty was not driving enrollment nearly as much as expected, and none of the dramatic negative consequences predicted by the district court in Texas have come to pass.
Separately, CMS released 1) an updated 2021 landscape report with revised premium metrics (after some insurers modified the percent of their plans’ premiums attributable to essential health benefits); and 2) insurer-level enrollment data for the 2019 plan year for HealthCare.gov states.