David Anderson (@bjdickmayhew) is a health insurance researcher at Duke University Margolis Center for Health Policy. Paul Shafer (@shaferpr) is an Assistant Professor at the Boston University School of Public Health
In the first week of his term, President Biden showed his commitment to supporting Americans having access to affordable health insurance coverage by signing an executive order re-opening HealthCare.gov enrollment for three months starting February 15. Even though millions have lost health insurance during the COVID-19 pandemic because of lost hours or lost jobs, nearly half of uninsured adults haven’t even looked for Marketplace or Medicaid coverage. They assume that it would cost too much for Marketplace coverage or that they wouldn’t qualify for Medicaid, with two-thirds knowing little or nothing about financial help being available to make insurance affordable. There is a big hill to climb in getting the word out to say the least.
As part of re-opening the Marketplace, the Centers for Medicare and Medicaid Services, which runs HealthCare.gov, has pledged to spend over $50 million on advertising and outreach. This is a radical departure from the Trump administration, which drastically cut back on advertising and enrollment assistance, leaving over a billion dollars of so-called “user fees” unspent. These user fees were collected from insurers that sold ACA plans and the fees were intended to support Healthcare.gov operations, advertising and outreach. Yet the money just sat there as millions became and stayed uninsured.
These moves should be cheered loudly for what they symbolize, a return to an administration that wants to support and promote the ACA rather than sabotage it. A return to finding ways to help people get coverage, not make it harder.
Why is this so important? Well besides the fact that there is a very real pandemic still going on, health insurance is critical to making health care affordable for Americans. Being uninsured means significant barriers in accessing health care. Medicaid expansion under the Affordable Care Act decreased the mortality rate among adults in expansion states by over 9 percent and outreach to those in violation of the now-defunct individual mandate also showed reduced mortality attributable to gaining coverage.
We should not expect massive new enrollment increases from this Special Enrollment Period.
The traditional open enrollment period ended less than two months ago (December 15, 2020) for HealthCare.gov and many state-based Marketplaces were open even longer. This year saw the first increase in enrollment under the Trump administration, presumably due to the economic crisis induced by the pandemic leaving more people without employer-based insurance. The state-based Marketplaces, like those in California, New York, Massachusetts, and Maryland, had extensively promoted special enrollment periods due to COVID and already had longer open enrollment periods than HealthCare.gov.
However, the support that a President and administration shows (or doesn’t) for a policy can have a notable impact. We have seen this in our own and others’ work studying the ACA. Before now, the shift had only gone one way—from supportive to negative—at the state and then federal level. Kentucky was one of the early success stories of the ACA with its state-based Marketplace (kynect) and adoption of Medicaid expansion. A new Republican governor, Matt Bevin, campaigned hard against anything to do with the ACA including the Medicaid expansion and shutting down kynect. After his election, the states canceled all television advertising for kynect in the middle of open enrollment, which led far fewer people to seek out information or signing up for health insurance online. Similarly, we found that applications submitted to HealthCare.gov dropped by about a quarter after President Trump took office in January 2017.
From both the ACA and COVID, we also know that partisanship matters a lot in how people behave. Advertising has modest effects on enrollment, depending on who is pushing it—states and the federal government seem to be more effective while insurers are mainly out for themselves. A supportive President and a lot more visibility leads us to believe that some of the millions of Americans who are eligible for Medicaid or subsidized Marketplace coverage will enroll, gaining access to telehealth visits, prescriptions, and whatever care they need as we work towards herd immunity and a return to “normal.”
