Texas ACA enrollment down again for 2019
The window to sign up for health plans on the Affordable Care Act’s exchange closes Saturday, and it appears the number of Texans signing up for coverage will again be down, perhaps sharply.
There were roughly 6 percent fewer people in the state choosing plans from a comparable time from a year ago, according to figures from the federal Centers for Medicare and Medicaid Services. Nationally, there is about an 11 percent drop.
Adding to the uncertainty in the perpetually uncertain health care law known as Obamacare, just hours before enrollment was to end, U.S. District Court Judge Reed O’Connor in Fort Worth threw yet another curveball and ruled that the entire health care law was unconstitutional. The ruling Friday night was not completely unexpected and will most likely be appealed. It could end up before the U.S. Supreme Court.
At the heart of the issue before the federal judge was a challenge led by Texas Attorney General Ken Paxton filed in February and joined by 19 other states that argued that the law became unconstitutional when Congress last year reduced the tax penalty for not having health insurance to zero.
That new rule goes into effect Jan. 1, and many health care watchers have speculated it may have depressed enrollment for the coming year.
As of Dec. 8, the last week figures were available, a total of 542, 589 people in Texas had signed up for plans. That compares with 570,688 by Dec. 9, 2017.
“We’ve kind of resigned ourselves that we’re going to go backwards as a state,” said Ken Janda, CEO Of Community Health Choice, a Houston-area regional insurer.
Texas already leads the nation in the overall number and rate of uninsured. It also leads in the number of uninsured children, according to a recent report by Georgetown University’s Center for Children and Families who found that an estimated 835,000 Texas children were without health coverage in 2017.
Enrollment opened Nov. 1 and ran 6 weeks. It was the second year that the sign-up period was cut in half to 45 days. Before 2017, it was 90 days and ended Jan. 31.
The numbers do not yet reflect last-minute signups that typically spike the numbers in the final days. Nor do they account for automatic re-enrollment of those who are staying with current coverage. But going into the final week of the sixth-annual regular enrollment period, there is little doubt among health care watchers that the final tally will be down.
“I just don’t see how we can make up the difference,” said Janda, who said one of the most striking drop-offs is among new enrollees.
The slide began last year and appears to be continuing. In 2018, about 1.1 million Texans were enrolled in health plans purchased through the ACA exchange. That was down about 100,000 from the previous year.
Some see the declining numbers as especially ironic as the once highly volatile insurance market has been stabilizing. In Harris County, for instance, there were 33 plans available to individuals and families from 4 insurers which was virtually unchanged from the previous year. Such steadiness comes after years of eye-popping rate increases and insurers fleeing the exchange. But for 2019 premium price increases in mostly in the single-digits, or in the case of Blue Cross and Blue Shield of Texas plans, actually went down.
Still, for many middle and higher earners who do not qualify for federal subsidies to defray the plan costs, the monthly health insurance price-tag can feel crushing which may discourage enrollment.
Backers of the law are scrambling to explain the reasons behind the declines. Some say it may be an improving economy where more people get their health insurance through employers. Other say it’s the continued expansion of Medicaid in some states, which would cover those who might otherwise have signed up for plans through the exchange.
Take for instance Virginia, which is showing an enrollment decline by more than a third from this time last year. But the state also approved a Medicaid expansion. Other states, such as Kansas, are also showing steep declines in signups but its newly-elected governor made future Medicaid expansion a campaign promise.
Texas is one of 14 states that has said no to Medicaid expansion.
There are other political factors that could account for the declines, including an almost total lack of federally-funded advertising to remind people to sign up. In 2017, the Trump administration cut the advertising budget for ACA enrollment by 90 percent. The HuffPost reported Friday that the White House knew in advance that such a measure could mean a loss of more than 100,000 enrollees.
Similarly, grants were cut again this year to groups that help people navigate the enrollment process. Taken together it is plausible people simply did not know to sign up. A Kaiser Family Foundation poll last month showed that threequarters of people who buy individual plans or are currently uninsured did not know the dates of enrollment.
Another change under the Trump administration is the loosening of regulations over less comprehensive insurance plans which are starting to hit the market. While the plans may be cheaper than plans offered on the exchange, analysts worry they often do not offer as much coverage as people think they do.
“In addition to the uninsured we’re going to have a lot more under-insured in Texas,” said Melissa McChesney, a health policy analyst for the Austin-based Center for Public Policy Priorities.
Should those numbers rise, health care experts and insurers say the impact could be felt across the region, appearing as worse overall health outcomes when people delay or skip treatment, more pressure on charity clinics, a rise in emergency room visits and a spike in the already high uncompensated care cost which is passed on to taxpayers.
“If you don’t have insurance and have diabetes you can’t afford insulin,” Janda said.
Elena Marks, CEO of the Houston-based Episcopal Health Foundation, is also troubled by the numbers but also sees a glimmer of opportunity in the current climate.
The Trump administration, she said, has signaled willingness to let individual states be creative and craft their own solutions to getting health care to people and provide them with coverage. She would like to see Texas leaders use available federal funds to create “a Texas-designed solution.”
With the start of the Legislature only weeks away, she threw down the challenge. “This is a problem that Texas can and should solve.”