A record number of Americans — 13.6 million — have signed up for health plans through the Affordable Care Act’s marketplaces for 2022, after Congress lowered the cost of Obamacare insurance, the Biden administration boosted advertising and the pandemic disrupted many Americans’ employer-provided coverage.
The Covid-19 public health emergency helped usher in an era of greater generosity and expanded outreach to the uninsured that many of Obamacare’s original authors had long called for.
The increased enrollment, covering at least 2 million more Americans than in any previous year, was particularly pronounced in red states like Georgia and Texas that have high rates of uninsurance and declined to expand Medicaid to cover their poorest adults.
“What a great day it is to really see how the programs are working as they are intended,” Chiquita Brooks-LaSure, the administrator for the Centers for Medicare and Medicaid Services, which manages the marketplaces, told reporters on a conference call.
The Biden administration has invested heavily in promoting the availability of insurance subsidies under the Affordable Care Act. It also quadrupled the network of professionals available to help people enroll. But Ms. Brooks-LaSure said she thought the main driver of the enrollment increase was the lower prices most Americans would pay.
A stimulus bill passed by Congress in March made many more Americans eligible for financial assistance in buying Obamacare plans. For most people with low incomes, comprehensive coverage is currently available for no premium. Middle class people earning higher incomes became eligible for subsidies for the first time.
Taken together, the policies have represented an expansion and a reimagining of the Affordable Care Act, what some policy experts have called Obamacare 2.0. The enrollment numbers suggest that these changes have substantially increased enrollment in the program, counteracting coverage declines from falling employment during the pandemic.
But those gains may be fragile. The enhanced subsidies are scheduled to expire at the end of 2022. Democrats in Congress hope to extend them through 2025 as part of their large social spending and climate bill, but that legislation is currently stalled in the Senate.
“The only cloud on the horizon is the current uncertainty with the Build Back Better Act now being in limbo,” said Peter Lee, the executive director of California’s marketplace, Covered California. “Because if the subsidies that are expanded under the American Rescue Plan aren’t continued, the sad truth is hundreds of thousands of Californians will drop coverage after next year, and millions of Americans will drop coverage across the country.”
Federal health officials said that enrollment gains were most pronounced in states that have not expanded their Medicaid programs, where Americans with incomes just above the poverty level qualify for Obamacare plans instead of Medicaid. Enrollment in Georgia grew by a third from last year, and enrollment in Texas increased by more than a quarter. The Build Back Better package would also create new insurance options for poorer residents of those states.
Laura Colbert, the executive director of Georgians for a Healthy Future, a consumer advocacy group that also helps sign Georgians up for coverage, said the big enrollment boost this year came thanks to increased subsidies and advertising — but also a new state reinsurance program that helped lower premiums and attract more insurers into the state’s marketplace. She, too, worried about what will happen if the subsidies expire.
“If nothing else consumers are price sensitive, and an expiration of the enhanced subsidies will definitely lead to fewer enrollments,” she said. “When extra help is in place, people really appreciate it. But when it goes away, they are often more frustrated by it than they appreciated the help in the first place.”
Other factors probably helped drive the recent enrollment boom. The economic disruptions of the pandemic mean that some Americans who lost job-based coverage may be purchasing their own plans now. And the increased investment in advertising probably attracted many customers who had always had access to good deals but been unaware that financial help was available. Research on the uninsured has found that more than half would qualify for free or subsidized health care.
“The messaging angle here is also really important to even get people to the door,” said Cynthia Cox, the director of the program on the Affordable Care Act at the Kaiser Family Foundation, which has studied the population. “And the subsidies make it more appealing to walk through the door to actually sign up.”
The administration also established a long “special enrollment period” related to the pandemic through the spring and summer. Millions of new customers signed up for insurance then and are renewing now.
Enrollment remains open until Jan. 15 in most states for those who want coverage that would begin in February. A handful of states that operate their own marketplaces will continue to allow sign-ups later in January.