Affordable Care Act & Medicaid Reform in Wisconsin: Enrollment and Coverage Trends, Plans and Premiums Chartpack March 2018 Trends in insurance coverage Pre- and Post-ACA Premiums and Plans Purpose: To allow Wisconsin residents to track the progress of both the federal health reform law and Wisconsin’s entitlement reforms. The chartpack culls through different reports from the federal and state governments to provide an accessible format. UW Population Health Institute – Wisconsin Health Insurance Coverage Chartpack 2018 Page 1 Governor’s Health Insurance Coverage Goal “Through Governor Walker’s Entitlement Reform Plan, all Wisconsinites have access to affordable health care coverage. People living in poverty have coverage through Medicaid while individuals and families above the poverty level have access to affordable private health care coverage through the federal Health Insurance Marketplace. Approved as part of the 2013-15 state budget, this plan is projected to reduce the number of uninsured in our state by 224,580, or roughly half, while strengthening the state’s safety net for Wisconsin's neediest residents.” Governor Walker’s Entitlement Reform Plan Wisconsin Department of Health Services https://www.dhs.wisconsin.gov/initiatives/entitlement-reform.htm Last Revised: November 22, 2017 UW Population Health Institute – Wisconsin Health Insurance Coverage Chartpack 2018 Page 2 Wisconsin’s Medicaid Reforms and the ACA: Fact Summary FPL=Federal Poverty Level Insurance Coverage  About 5.3% of Wisconsin residents were uninsured in 2016, down from 9.1% in 2013  Uninsured decreased by about 216,000 from 2013 to 2015, a reduction of about 42% across the total population. Persons <138% FPL most likely to be uninsured: 10.1% compared to 3.8% for persons >200% FPL.  But those above 200% FPL account for 49.6% of all uninsured persons in Wisconsin.  Most of the gains in insurance coverage occurred through the ACA Marketplace and increases in employer-sponsored insurance. The State has nearly but not fully met the Governor’s 2015 goal of reducing the uninsured by 224,580. Medicaid and BadgerCare Trends  Parent and caretaker BadgerCare enrollment has declined by 37% since September 2013. Most of this reflects the entitlement reforms that took effect in April 2014 that removed eligibility for adults over 100% FPL.  Most children enrolled in Medicaid are below 100% FPL. Children in poverty experienced an 8% decrease in enrollment between September 2013 and January 2018.  Enrollment of adults without dependent children (“childless adults”) has increased nearly eight-fold since 2013, with current enrollment at 148,857. ACA Marketplace Summary Data  For the 2017 coverage year, 242,863 Wisconsin consumers selected ACA Marketplace plans during the twelve-week open enrollment period. During the 2018 open enrollment period, reduced from twelve to six weeks, 225,435 Wisconsin consumers selected plans – 7% fewer than the 2017 period.  Details are not yet available about the characteristics of the 2018 consumers who selected plans.  In 2017, 87% of Wisconsin consumers who selected an ACA Marketplace plan went on to actually pay the first month’s premium, resulting in 211,025 actual plan enrollments in the first half of the 2017 calendar year.  For consumers who effectuated enrollment in 2017, 82% received federal financial assistance to reduce premiums (Advance Premium Tax Credit (APTC)), while 51% received federal Cost-Sharing Reductions that reduce deductibles, and co-payments.  In 2017, 74% of consumers selecting ACA plans were reenrollees, while 26% were new to ACA Marketplace plans. Among the re-enrollees, three-quarters were “active re-enrollees” rather than simply relying on the auto-reenrollment process.  Consumers ages 18-34 make up 25% of those who selected a 2016 Marketplace plan. Insurance Plans and Premiums  For consumers receiving a federal premium subsidy (APTC) for 2017 ACA plans, the average subsidy was $403/month.  Wisconsin in 2018 has 11 Insurance carriers offering health plans through the ACA Marketplace. UW Population Health Institute – Wisconsin Health Insurance Coverage Chartpack 2018 Page 3 Medicaid/BadgerCare and HealthCare.Gov MarketPlace Coverage, Wisconsin, January 2018 Coverage Program Total Enrollment Percent of Statewide Population BadgerCare Children 417,981 32% of children BadgerCare Adults (parents, caretaker, childless adults) 288,497 8% of adults Other BadgerCare - Pregnant Women, Youths Exiting Foster Care, Income Extensions, Express Enrollment 78,930 Total BadgerCare 785,408 Elderly/Blind/Disabled 222,608 Other Coverage 179,433 Total Medicaid 1,187,499 Total Consumers Effectuating Enrollment in ACA Marketplace Plans, first half of CY2017 211,025 14% of Total Population 21% of total population 6% of population 300% FPL. *Note: subgroups add to 297,392 persons for whom poverty status is determined 18 to 64 years, 252,268 But persons above 200% FPL account for nearly half (49.6%) of all uninsured persons in Wisconsin. ≥ 300% FPL, 26.5% 200299% FPL, 23.1% <100% FPL, 22.6% 100-199% FPL, 27.8% Data Source: 1 UW Population Health Institute – Wisconsin Health Insurance Coverage Chartpack 2018 Page 8 Pre- and Post-ACA Medicaid/BadgerCare Enrollment  In Wisconsin, total BadgerCare enrollment increased by 33,509 persons (4.5%) from 2013-2018, due to the increased eligibility for adults without dependent children (“childless adults”).  Enrollment of childless adults has increased nearly eight-fold since 2013, to nearly 150,000 BadgerCare members.  Parent and caretaker BadgerCare enrollment has declined by 37% since September 2013. Most of this reflects the changes that took effect in April 2014 that removed eligibility for adults over 100% FPL. BadgerCare Plus 751,899 785,408 33,509 16,774 Childless Adults Parents/Caretakers 82,420 148,857 132,083 139,640 222,060 428,277 417,981 Children 10,296 200,000 100,000 0 100,000 200,000 Sep-13 300,000 Jan-18 400,000 500,000 600,000 700,000 800,000 900,000 Change 2013-2018 Data Source: 2 UW Population Health Institute – Wisconsin Health Insurance Coverage Chartpack 2018 Page 9 Children’s Pre- and Post-ACA Medicaid/BadgerCare Enrollment  Children’s enrollment overall has declined 2.4% since 2013.  Family income for most children enrolled in Medicaid is below 100% FPL.  That coverage group experienced a 8.2% decline in enrollment since 2013. 428,277 Total -10,296 417,981 8,188 > 250% FPL -1,796 6,392 11,923 200-250% FPL 16,109 4,186 45,193 150-200% FPL 47,013 1,820 65,970 100-150% FPL 9,955 75,925 297,003 0-100% FPL -24,461 -50,000 272,542 0 50,000 100,000 150,000 200,000 Sep-13 250,000 Jan-18 300,000 350,000 450,000 500,000 Change Note: This does not include changes in coverage extensions under “Transitional Medical Assistance” (TMA) UW Population Health Institute – Wisconsin Health Insurance Coverage Chartpack 2018 400,000 Data Source: 2 Page 10 HMO Managed Care Enrollment, BadgerCare Members, January 2018  As of January 2018, about 700,000 BadgerCare Members were enrolled in 15 Managed Care Organizations statewide.  UnitedHealthcare and Children’s Community Health Plans together enroll about 38% of BadgerCare members. GROUP HEALTH COOP SOUTHCENTR 5,236 TRILOGY HEALTH INSURANCE 9,897 PHYSICIANS PLUS INSURANCE CO 9,950 MERCY CARE INSURANCE COMPANY 12,531 INDEPENDENT CARE (ICARE) 15,518 QUARTZ 30,183 MHS HEALTH WISCONSIN 32,085 NETWORK HEALTH PLAN 33,235 DEAN HEALTH PLAN INC 37,683 GROUP HEALTH COOP EAU CLAIRE 49,018 SECURITY HEALTH PLAN OF WISC 54,940 MOLINA HEALTHCARE 58,940 ANTHEM BLUE CROSS BLUE SHIELD 79,591 CHILDRENS COMM HEALTH PLAN 126,322 UNITEDHEALTHCARE COMMUNITY PLAN 141,665 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 160,000 Data Source: 3 UW Population Health Institute – Wisconsin Health Insurance Coverage Chartpack 2018 Page 11 Wisconsin Individual Market Health Insurance: Overall Enrollment Trend  ACA-compliant single risk pool (includes both on- and off-exchange): Subject to all ACA provisions, such as coverage of essential health benefit package and no annual or lifetime benefit limits.  Grandfathered Individual/Individual Association Market (policies issued on or before March 23, 2010): Not subject to most provisions of the ACA.  Transitional Individual/Association Market (policies issued between March 24, 2010 and December 1, 2013). Subject to limited provisions of the ACA. 300,000 261,033 250,000 200,000 277,080 274,279 51,449 34,171 6,204 11,771 86,842 18,469 150,000 213,860 100,000 233,904 155,722 50,000 0 2014 2015 2016 Transitional Individual/Association Market Grandfathered Individual/Individual Association Market Data Source: 9 ACA-Compliant Single Risk Pool UW Population Health Institute – Wisconsin Health Insurance Coverage Chartpack 2018 Page 12 Plan Selections: Open Enrollment Trend 2016-18  Plan selections remained strong for 2018, despite the enrollment period reduction from 12 to 6 weeks.  Effectuated enrollment refers to those consumers who pay select a plan and pay their first month premium to activate their coverage.  In 2017, 87% of Wisconsin consumers who selected an ACA Marketplace plan went on to effectuate their enrollment, resulting in 211,025 actual plan enrollments in the first half of the 2017 calendar year. Open Enrollment Plan Year (Enrollment Period Length) Number of Plan Selections OE 2016 (12 weeks) 239,034 OE 2017 (12 weeks) 242,863 OE 2018 (6 weeks) 225,435 2017 ACA Plans (2018 detail not yet available) Number of Plan Selections Percent of Plan Selections Effectuating Coverage through 06/30/17 211,025 87% Consumers with Premium Subsidies (APTCs) 173,959 82% Consumers with Cost-Sharing Reductions (CSRs) 107,942 51% 2017 Plan Selections: Enrollment Mode New Consumers, 26.3% Reenrollees, 73.7% Active Reenrollees, 55.0% Automatic Reenrollees, 18.8% UW Population Health Institute – Wisconsin Health Insurance Coverage Chartpack 2018  Of those selecting ACA plans in 2017, 74% were re-enrollees, while onequarter were new enrollees.  Most re-enrollees actively re-enroll, with an enrollment assister or directly via Healthcare.gov, rather than relying on the autoreenrollment process. Data Source: 4, ,5,6, 7 Page 13 Wisconsin Plan Premiums and Subsidies (Advance Premium Tax Credits-APTC)  Premiums began rising substantially for 2017 plans, with an uncertain federal policy environment.  Nonetheless, ACA premium subsidies (APTC) shield consumers with incomes < 400% FPL from the premium increases, because the subsidy increases when the premium rises.  In 2017, 69% of Wisconsin ACA marketplace consumers had an option to select a plan with monthly premium lower than $100/month. Monthly Premium, Average Benchmark Plan, 40-year old Percent change Monthly Premium, Average Lowest Cost Plan, 27-year-old Percent change 2014 2015 2016 2017 2018 $298 $306 $319 $368 $569 -- 3% 4% 15% 55% $195 $198 $207 $250 $342 -- 2% 5% 21% 37% 27-year-old with household income of $25,000 (~210% FPL) Family of four with household income of $60,000 (~125% FPL) Benchmark premium before subsidy (APTC) APTC (premium subsidy) amount Monthly premium after subsidy (APTC) Benchmark premium before subsidy (APTC) APTC (premium subsidy) amount 2017 $302 $161 $141 $1,094 $690 $404 2018 $468 $329 $139 $1,695 $1,296 $399 Monthly premium after subsidy (APTC) Data Source: 6, 10, 11. 12 UW Population Health Institute – Wisconsin Health Insurance Coverage Chartpack 2018 Page 14 Wisconsin ACA Plan Selections: Open Enrollment 2017 Plan Selections by Income Range Other FPL, 14.6% >300%≤400% FPL , 13.6% ≥100% to ≤150% FPL , 25.8%  Consumers ages 18-34 make up about 25% of ACA plan selections.  Consumers with incomes less than 200% FPL make up about 47% of ACA plan selections. Plan Selections by Age Group, 2017 Age ≥65, 0.4% >250% to ≤300% FPL , 9.7% >200% to ≤250% FPL , 14.6% Age < 18, 6.8% Age 18-25, 8.7% >150% to ≤200% FPL , 21.6% Age 55-64, 34.4% Age 45-54, 19.3% Age 26-34, 16.3% Age 35-44, 14.2% Data Source: 5 UW Population Health Institute – Wisconsin Health Insurance Coverage Chartpack 2018 Page 15 Data Source: 5 UW Population Health Institute – Wisconsin Health Insurance Coverage Chartpack 2018 Page 16 Number of insurance carriers offering plans in Wisconsin, by county, for 2018 through the ACA Marketplace Data Source: 8 UW Population Health Institute – Wisconsin Health Insurance Coverage Chartpack 2018 Page 17 Number of Counties by Number of Insurers offering Plans through the ACA Marketplace  27 Wisconsin counties have at least three insurance carriers offering ACA plans.  34 Wisconsin counties have two carriers offering ACA plans  11 counties have only one insurance carrier offering ACA plans 40 34 35 30 Number of counties Insurers Offering Plans, 2018 Aspirus Arise Children’s Community Health Common Ground Dean Health Plan Group Health Coop Health Partners Medica MercyCare Network Health Security Health Gunderson/Unity/Quartz 25 20 20 15 11 10 4 5 3 0 1 insurer 2 insurers 3 insurers 4 insurers 5 insurers Data Source: 8 UW Population Health Institute – Wisconsin Health Insurance Coverage Chartpack 2018 Page 18 REFERENCES 1. American Factfinder. Demographic and Uninsurance data from U.S. Census, American Community Survey (ACS) 2013-16 http://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml 2. Wisconsin Department of Health Services. Medicaid/BadgerCare as of January 2018. https://www.forwardhealth.wi.gov/wiportal/Tab/42/icscontent/Member/caseloads/enrollment/enrollment.htm.spage 3. Wisconsin Department of Health Services. Forward Health Monthly HMO Enrollment Reports. https://www.forwardhealth.wi.gov/WIPortal/content/Managed%20Care%20Organization/Enrollment_Information/Reports.htm.spage 4. CMS, US DHHS. 2016 Marketplace Open Enrollment Period Public Use Files. https://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/Marketplace-Products/2016_Open_Enrollment.html 5. CMS, US DHHS. 2017 Marketplace Open Enrollment Period Public Use Files. https://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/Marketplace-Products/Plan_Selection_ZIP.html 6. CMS, US DHHS. First Half of 2017 Average Effectuated Enrollment Report. 12-13-2017. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-12-13-2.html 7. CMS. Final Weekly Enrollment Snapshot for 2018 Open Enrollment Period. 12-28-2017. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-12-28.html 8. Wisconsin Office of the Commissioner of Insurance. Individual Health Insurance Carriers in Wisconsin – 2018 https://oci.wi.gov/Pages/Consumers/ProviderMap2018.aspx 9. Wisconsin Office of the Commissioner of Insurance. Comprehensive Health Insurance Enrollment Reports. Last Updated July 31, 2017. https://oci.wi.gov/Pages/Companies/CompHealthEnrollment.aspx 10. U.S. DHHS, ASPE Compilation of State Data on the Affordable Care Act, December 2016. https://aspe.hhs.gov/compilation-state-dataaffordable-care-act 11. U.S. DHHS. ASPE Research Brief. Health Plan Choice and Premiums in the 2018 Federal Health Insurance Exchange. October 2017. https://aspe.hhs.gov/system/files/pdf/258456/Landscape_Master2018_1.pdf 12. Kaiser Family Foundation. State Health Facts. Marketplace Average Benchmark Premiums, 2014-2018. https://www.kff.org/healthreform/state-indicator/marketplace-average-benchmark-premiums/ UW Population Health Institute – Wisconsin Health Insurance Coverage Chartpack 2018 Page 19 Health Policy Programs Donna Friedsam, Director uwphi.pophealth.wisc.edu @UWHealthPolicy UW Population Health Institute – Wisconsin Health Insurance Coverage Chartpack 2018 Page 20