Health Coverage Under the Affordable Care Act: Current Enrollment

March2023

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ISSUEBRIEF 1

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HP‐2023‐08

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HealthCoverageUndertheAffordableCareAct:

CurrentEnrollmentTrendsandStateEstimates

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Basedon2022andearly2023enrollmentdata,morethan40millionpeopleare

currentlyenrolledinMarketpl aceorMedicaidexpansioncoveragerelatedto

provisionsoftheAffordableCareAct(ACA),thehighesttotalonrecord.

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KEYPOINTS

 MarketplacesandMedicaidexpansion,programscreatedbytheAffordableCareAct(ACA),have

enrolledmillionsofAmericansinparticipatingstatessincetheirimplementationin2014.

 Nearly15.6million

consumerswereenrolledinMarketplaceplansasofFebruary2023(acrossall

50statesandtheDistrictofColumbia),and18.8millionpeople(across38participatingstatesand

theDistrictofColumbia)werenewlyenrolledinMedicaidviatheACA’sexpansionofeligibilityto

adultsasofSeptember2022.



1.2millionindividualswereenrolledinearly2023intheACA’sBasicHealthProgramoption,and

4.6millionpreviouslyeligibleadultsgained coverage undertheMedicaidexpansionbySeptember

2022duetoenhancedoutreach,stream linedapplications,andincreasedfederalfundingunder

theACA.

 Acrossthesecoverag egroups,atotal of

40.2millionAmericanswereenrolledincoveragerelated

totheACAbasedon2022andearly2023enrollmentdata,thehighesttotalonrecord.This

represents9.3millionmorepeopleenrolledthanin2021(a30%increase)and27.6millionmore

peopleenrolledthanin2014(a219%increase,or

morethantriple).

 ThisbriefupdatesourestimatereleasedInAprilof2022wherewefoundmorethan35million

peoplehadgainedcoverageundertheACA.Ourcurrentestimateof40.2millionrepresentsmore

than4millionpeoplegainingcoverageoverthepastyear.



Surveyresultsindicatethatall50statesandtheDistrictofColumbiahaveexperiencedsubs tantial

reductionsintheuninsuredratesince2013,thelastyearbeforeimplementationoftheACA.

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_______________________

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Atotalof16.4millionconsumers madeplanselectionsasofJanuary2023andanestimated15.6millionconsumers effectuated

enrollment(paidapremiumorotherwisecompletedenrollment).SeenotesforTable1formoreinformation.

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March23,2023

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March2023 ISSUEBRIEF 2

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BACKGROUND

TheAffordableCareAct

(ACA),passedin2010,broughtthelargestexpansionofcoverageintheU.S.health

caresystemsincethecreationofMedicareandMedicaidin1965.Acomprehensivehealthcarereformlaw,

theACAexpandedhealthinsurancecoveragetomillionsofAmericansthroughtwomainpathways:

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•Providingpremiumtaxcredits

toconsumerswithincomesbetween100%and400%ofthefederal

povertylevel(FPL)tolowerthecostofindividualmarkethealthinsurancepurchasedthroughnewstate

Marketplaces;

†

and

•ExpandingMedicaideligibilitytoadultswithincomesupto138%FederalPovertyLevel(FPL),in

participatingstates(aftertheSupremeCourtmadetheexpansionastateoptionina2012ruling).

‡

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TheACAalsoinvestedinoutreachandmarketingtohelpeligibleindividualsenrollincoverageandstreamlined

theapplicationprocessforMedicaid,andtheBiden‐HarrisAdministrationmadestrengtheningMedicaid,the

Marketplaces,andtheACAakeypriority.SinceimplementationoftheACA,thenumberofuninsured

Americanshasfallen

significantly.Between2013and2021thenumberofpeoplewithouthealthinsurance

droppedby38percent,fallingfrom45.2millionto28.2million.

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ThisIssueBriefpresentscurrentestimatesofenrollmentinhealthinsurancecoverageobtainedthroughthe

ACAMarketplacesandtheMedicaidexpansionandthesubsequentreductionsinstate‐leveluninsuredrates

sincetheACAwasimplementedin 2014.ThisbriefupdatesourestimatereleasedinAprilof2022wherewe

found

thatabout35millionpeoplegainedcoverageundertheACA.

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METHODS

ForbothMarketplaceandMedicaidexpansionenrollment,wepresentthemostrecentadministrativedata

withstate‐by‐statetotalsfromtheCentersforMedicare&MedicaidServices(CMS),aswellashistorical

nationaltotalsfortheyears2014‐2023.

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TherearetworelatedmeasuresofMarketplaceenrollment.Thefirstisplan

selections,andthesecondis

effectuatedenrollment.Attheendofopenenrollmentperiods,CMSreleasesplanselections,whicharethe

numberofpeoplewhohaveselectedaplan;CMSfollowslaterwithdataoneffectuatedenrollment,which

capturesthenumberofpeoplewhohavepaidtheirfirstmonth’spremium

(ifapplicable).Inthisreport,

MarketplaceenrollmentestimatesreflecteffectuatedenrollmentcountsfrombothStateswithMarketplaces

usingtheHealthCare.govplatformandthosewithState‐basedMarketplaces.Effectuatedenrollmentfor2023

isnotyetavailablebutwasestimatedfromstateFebruary2022effectuatedratesappliedtothenumberof

peopleselecting

Marketplaceplansduringthe2023OpenEnrollmentPeriod.Thisbriefuseseffectuated

enrollmentsothatouroverallcoverageestimatescanbecomparedovertimeusingthesamemethodasASPE

usedinpreviousestimatesofACA‐relatedcoverage.



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Medicaidenrollmentesti matesarestate‐reportedcountsofunduplicatedindividualsenrolledinthestate’s

MedicaidprogramthroughtheMedicaidBudgetandExpenditureSystem(MBES).ThemostrecentMedicaid

_______________________

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†

Individualswithincomesabove400%FPLcanpurchasecoveragethroughtheMarketplacesbutdidnotoriginallyqualifyforpremium

taxcreditsubsidies.UndertheAmericanRescuePlanandextendedbytheInflationReductionAct,individualswithincomesabove

400%FPLarenowpotentiallyeligibleforsubsidies.

‡

TheACAestablishedaMedicaideligibilitylevelof133%FPLforchildren,pregnantwomen,andadultsasofJanuary

2014,andincludedastandardincomedisregardoffivepercentagepointsofthefederalpovertylevel,whicheffectively

raisesthislimitto138%FPLMedicaid.ACAMedicaidexpansiontoadultswithincomesupto133%FPLisastateoption,

andasofFebruary2023,39statesandtheDistrictofColumbiahadadoptedMedicaidexpansion.

March2023 ISSUEBRIEF 3

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enrollmentdataarefromSeptember2022.ForstatesthathaveexpandedMedicaid,theenrollmentdata

providespecificcountsofthenumberofindividualsenrolledinthenewexpansionadulteligi bility group,

referredtoasthe“adultgroup,”withseparatetotalsforthosewhobecamenewlyeligibleundertheACA

expansion,as

wellasthosewhowouldhavebeeneligibleforcoveragepriortotheACAbutarenowpartofthe

adultgroup.StateMedicaidexpenditurereportsaregenerallysubmittedtoCMSwithin30daysfollowingthe

endofeachquarter.Somestates,however,submittheirexpenditurereportslater;accordingly,these

results

shouldbeconsideredpreliminary.

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MinnesotaandNewYorkhavealsoimplementedtheBasicHealthProgram(BHP)optionundertheACAto

coverindividualswithincomesbetween138‐200%FPL.WereportannualaverageBHPenrollment,asreported

toCMSbythestates.

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Notethatwerefertotheestimates

belowas“2023estimates”ofACAcoverage,thoughsomeofthestatistics

arefromlate2022,sincethosearethemostrecentlyavailablenumbers.

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EstimatesonuninsuredratesbystatecomefromtheAmericanCommunitySurvey(ACS),thelargestnational 

surveyofhouseholds.TheCensusBureausurveysalmost300,000households

eachmonthfortheACSand

collectshealthinsuranceanddemographicdata,alongwithothertypesofinformation.Uninsuredratesforthe

fullstatepopulationofallagescomefromtheACS’spublicdatatablesfor2013and2021(themostcurrent

yearofACSdataavailable),whichweusedto

comparestate‐by‐statechangesinuninsuredratessincethe

implementationoftheACA.

4,5



FINDINGS

NationalACA‐relatedenrollmentfor2014‐2023arepresentedinTable1andFigure1.Moredetailed

informationoneachsourceofcoverageisdescribedbelow.



AsofFebruary2023,anestimated15.6millionconsumershadenrolledandeffectuatedhealthinsurance

coveragethroughtheMarketplaces.Anestimated18.8millionnewly‐

eligibleadultswereenrolledinMedicaid

coveragethroughtheadultgroupcreatedbytheACAexpansionbasedonthemostrecentlyavailabledata,as

showninTable1.Anadditionalestimated4.6millionpeoplewereenrolledintheMedicaidexpansionadult

groupundertheACAwhowouldhavebeeneligibl efor

MedicaidbeforetheACA.TheACAsimplifiedMedicaid

enrollmentfortheseindividualsandmadepermanentunderfederallawsomestate‐specificcoverage

expansionsthatpre‐datedtheACA(e.g.,coverageunderasection1115demonstrationproject).Todate,39

statesandtheDistrictofColumbiahaveadoptedtheACAMedicaid

expansionofcoveragetoadults;South

Dakotahasnotyetbegunenrollingindividualsinitsexpansion,andotherstatesincludingNorthCarolinaare

consideringproposalstoexpandbuthavenotyetfinalizedthem.



MedicaidandCHIPenrollmentincreasedby21.1millionenrolleesfromFebruary2020toNovember2022,or

an

increaseof30percent;mostofthiscoverageincreaseoccurredinMedicaid.

Medicaidenrollment 

increasedunderthecontinuousenrollmentprovisionintheFamiliesFirstCoronavirusResponseActof2020

(FFCRA),whichpreventedstatesfromdisenrollingmostMedicaidenrolleesduringtheCOVID‐19publichealth

emergency(PHE)asaconditionforreceivingatemporary6.2percentagepointincreaseinthefederal

Medicaidmatch

rate.

This,alongwithrecentMedicaidexpansionsinstatesincludingMaine,Virginia,Idaho,

Utah,Nebraska,Utah,andMissouri,contributedtomoreindividualsgainingcoverageduringthePHE.



Twostates–MinnesotaandNewYork–haveimplementedtheBasicHealthProgram(BHP)optionunderthe

ACA,withenrollmenttotalingapproximately1.2

millioninearly2023.



March2023 ISSUEBRIEF 4



Takentogether,theseresultsindicatethatoverallenrollmentinMarketplacecoverage,Medicaidexpansion,

andtheBasicHealthProgramfor2023wasapproximately40.2millionpeople,thehighestenrollmenttotal

sincetheACAwasenacted.Thisrepresents9.3millionmorepeopleenrolledthanin2021(a30%increase)

and27.6millionmore

peopleenrolledthanin2014(a219%increase,ormorethantriple).Since2022,4.2

millionmorepeoplegainedACA‐relatedcoverage,withmostofthecoveragegainsapproximatelyevenlysplit

betweenMarketplaceandMedicaidexpansiongains.



Table1

ACA‐RelatedEnrollment:Marketplace,Medicaid,andtheBasicHealth

Program(BHP),2014‐2023







Notes:

*Marketplaceeffectuatedenrollmentfiguresfor2014and2015areasof12/31/2014and3/31/2015respectively,versusFebruary

coverageasof3/15for2016‐2021.Marketplaceenrollmentdatafor2014‐2015arelowerqualityduetothemanualpayment

processingsysteminplacefor

thoseyears.2014and2015Marketplaceenrollmentfiguresarepublishedhere:

https://www.cms.gov/Research‐Statistics‐Data‐and‐Systems/Statistics‐Trends‐and‐Reports/MarketplaceProducts/Effectuated_Quarterly_Snapshots.

February2016‐2022dataarefromtheCCIIOEnrollmentPaymentSystemandbeginningin2017havebeenpublishedintheEffectuatedEnrollment

Snapshotfortherespectiveyear.

**EffectuatedMarketplaceenrollmentfor2023wasestimatedapplyingtheFebruary2022stateeffectuatedratestothe16.4millionpeoplewhomade

planselectionsduring

the2023OpenEnrollmentPeriod,https://www.cms.gov/files/document/health‐insurance‐exchanges‐2023‐open‐enrollment‐

report‐final.pdf.

#Medicaidenrollmentdata,2014‐2021,arefromtheFebruarymonthlyenrollment(everenrolledduringthemonth)fortheexpansion

adulteligibilitygroup,asreportedbystatesthroughtheMedicaidBudgetandExpenditureSystem(MBES).2022and2023Medicaidenrollment

dataarefromSeptember2021andSeptember2022monthlyenrollmentreports

respectively,asthisisthemostrecentavailablemonthlyenrollment

countfromMBES.PublishedreportsanddetaileddatainformationforMedicaidenrollmentdata,includingcaveats,canbefoundat:

https://www.medicaid.gov/medicaid/national‐medicaid‐chip‐program‐information/medicaid‐chip‐enrollment‐data/medicaidenrollment‐data‐collected‐

through‐mbes/index.html

ⴕBHPprogramsdidnotstartuntil2015.BHPenrollmentdataarebasedonaveragemonthly(forMinnesota)orquarterly(forNew

York)projectedenrollmentsubmittedbythestatestoCMSinadvanceoftheapplicablequarterandareroundedtothenearestthousand.BHP

enrollmentdatafor2021isthrough

May2021.BHPenrollmentdatafor2022isthroughMarch2022.BHPenrollmentdatafor2023isprojectedforthe

secondquarterof2023forNewYorkandJune2023forMinnesota.



Year Marketplace

Enrollment*

MedicaidExpansion

Group,

Newly‐Eligible#

MedicaidExpansion

Group,

PreviouslyEligible

BHP

Enrollmentⴕ

TOTAL

ACA‐Related

Enrollment

2014 6,337,860 4,214,218 2,047,055 0 12,599,133

2015 10,187,197 9,103,944 3,002,271 358,000 22,651,412

2016 11,115,044 11,135,415 3,473,065 654,000 26,377,524

2017 10,330,759 12,229,576 3,524,856 772,000 26,857,191

2018 10,643,786 12,338,135 3,305,210 798,000 27,085,131

2019 10,579,744 12,201,118 3,247,188 833,000 26,861,050

2020 10,673,516 12,300,921 3,241,535 866,000 27,081,972

2021 11,227,111 14,849,998 3,890,934 961,000 30,929,043

2022 13,807,669 16,781,800 4,261,277 1,135,190 35,985,936

2023 15,567,000** 18,765,611 4,648,343 1,239,503 40,220,457

March2023 ISSUEBRIEF 5



Figure1.ACA‐RelatedEnrollment:Marketplace,MedicaidExpansion,

andtheBasicHealthProgram,2014‐2023



Table2presentsthemostrecentenrollmentestimatesbystateforMarketplaceandMedicaidexpansion

coverage.Table3presentsuninsuredratesin2013(beforetheACA)and2021(themostrecentstate

uninsureddata).Figure2illustratesthepercentagechangeintheuninsuredratefrom2013‐2021foreach

state.Nationally,

theuninsuredratehasdecreased5.9percentagepoints(from14.5%to8.6%)sincetheACA

coverageprovisionswereimplementedin2014.Allstatesexperiencedreductionsintheiruninsuredrates,

with11states–California,Kentucky,Louisiana,Michigan,Montana,NewHampshire,NewYork,Oregon,

RhodeIsland,Washington,andWestVirginia,all

ofwhichexpandedMedicaid–reducingtheiruninsuredrate

byatleasthalf.Theuninsuredratein2021variedwidelyacrossthecountry.Massachusettshadthelowest

uninsuredrateat2.5%andexperiencedoneofthesmallerrelativereductionsundertheAC Abecauseithad

alreadyimplementedlargecoverageexpansionsprior

to2014.Texas,whichhasnotexpandedMedicaid,had

thehighestuninsuredrateinboth2013 (22.1%)and2021(18.0%).StatedecisionsregardingtheACAMedicaid

expansionareamaindriverofvariabilityincoverageratesacrossstates.TheCensusBureau’sgold‐standard

estimatesoftheuninsuredpopulation,whichcome

fromtheACS,arenotyetavailablefor2022.



5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

35,000,000

40,000,000

45,000,000

2014 2015 2016 2017 2018 2019 2020 2021 2022 2023

MarketplaceEnrollment MedicaidExpansionGroup,Newly‐Eligible

MedicaidExpansionGroup,PreviouslyEligible BHPEnrollment

TOTAL

March2023 ISSUEBRIEF 6



Table2:MarketplaceEnrollmentandMedicaidExpansionEnrollmentbyState



State

Marketplace Marketplace MedicaidExpansion MedicaidExpansion Total

PlanSelections

Effectuated

Enrollment

NewlyEligible PreviouslyEligible ACA‐Related

January2023* February2023+ September2022# September2022# Coverage

Alabama 258,327 245,000 N/A N/A 245,000

Alaska 25,572 24,000 71,602 2 95,604

Arizona 235,229 222,000 190,742 517,200 929,942

Arkansas 100,407 93,000 326,906 15,599 435,505

California 1,739,368 1,718,000 4,910,970 30,486 6,659,456

Colorado 201,758 180,000 594,987 7,352 782,339

Connecticut 108,132 92,000 332,700 31,003 455,703

Delaware 34,742 33,000 14,685 78,706 126,391

DistrictofColumbia 14,768 13,000 89,169 44,973 147,142

Florida 3,225,435 3,106,000 N/A N/A 3,106,000

Georgia 879,084 825,000 N/A N/A 825,000

Hawaii 21,645 20,000 30,643 150,021 200,664

Idaho 79,927 78,000 126,920 0 204,920

Illinois 342,995 322,000 902,256 99,111 1,323,367

Indiana 185,354 175,000 572,082 0 747,082

Iowa 82,704 79,000 192,323 62,490 333,813

Kansas 124,473 118,000 N/A N/A 118,000

Kentucky 62,562 57,000 627,546 0 684,546

Louisiana 120,804 115,000 750,379 0 865,379

Maine 63,388 60,000 83,831 21,530 165,361

Maryland 182,166 168,000 451,214 0 619,214

Massachusetts 232,621 201,000 0 476,916 677,916

Michigan 322,273 306,000 967,247 60,396 1,333,643

Minnesota

 118,431 112,000 297,797 0 505,419

Mississippi 183,478 169,000 N/A N/A 169,000

Missouri 257,629 243,000 260,132 0 503,132

Montana 53,860 52,000 117,275 0 169,275

Nebraska 101,490 96,000 64,901 1,355 162,256

Nevada 96,379 93,000 362,226 0 455,226

NewHampshire 54,557 52,000 91,146 488 143,634

NewJersey 341,901 330,000 740,380 0 1,070,380

NewMexico 40,778 32,000 296,146 0 328,146

NewYork

 214,052 198,000 432,535 2,088,587 3,863,003

NorthCarolina 800,850 767,000 N/A N/A 767,000

NorthDakota 34,130 33,000 33,108 1,686 67,794

Ohio 294,644 278,000 862,854 223 1,141,077

Oklahoma 203,157 193,000 334,632 0 527,632

Oregon 141,963 133,000 598,132 108,818 839,950

Pennsylvania 371,516 358,000 1,078,203 64,957 1,501,160

RhodeIsland 29,626 30,000 98,299 0 128,299

SouthCarolina 382,968 365,000 N/A N/A 365,000

SouthDakota 47,591 46,000 N/A N/A 46,000

Tennessee 348,097 330,000 N/A N/A 330,000

Texas 2,410,810 2,283,000 N/A N/A 2,283,000

Utah 295,196 287,000 131,599 935 419,534

Vermont 25,664 25,000 0 75,920 100,920

Virginia 346,140 330,000 685,404 0 1,015,404



March2023 ISSUEBRIEF 7



Table2:MarketplaceEnrollmentandMedicaidExpansionEnrollmentbyState,(cont’d)



State

Marketplace Marketplace MedicaidExpansion MedicaidExpansion Total

PlanSelections

Effectuated

Enrollment

NewlyEligible PreviouslyEligible ACA‐Related

January2023* February2023+ September2022# September2022# Coverage

Washington 230,371 203,000 803,639 18,624 1,025,263

WestVirginia 28,325 26,000 239,001 0 265,001

Wisconsin 221,128 213,000 N/A N/A 213,000

Wyoming 38,565 37,000 N/A N/A 37,000

Guam N/A N/A N/A 5,488 5,488

PuertoRico N/A N/A N/A 667,162 667,162

VirginIslands N/A N/A N/A 18,315 18,315

Total 16,357,030 15,567,000 18,765,611 4,648,343 40,220,457



Notes:

*2023planselectionsfromstateswithHealthCare.govMarketplacesfortheOpenEnrollmentPeriodofNovember

1,2022toJanuary15,2023.DatesthroughwhichdataarereportedvaryforStateBasedMarketplaces.health‐

insurance‐exchanges‐2023‐open‐enrollment‐report‐final.pdf(cms.gov).Statetotalsdonotaddupduetorounding.

+

EffectuatedMarketplaceenrollmentfor2023wasestimatedapplyingtheFebruary2022stateeffectuatedratesto

the16.4millionpeoplewhosigned‐upforcoverageduringthe2023OpenEnrollmentPeriod,health‐insurance‐

exchanges‐2023‐open‐enrollment‐report‐final.pdf(cms.gov).

#MedicaidData:September2022enrollmentofnewlyeligiblepopulationasreportedontheCMS‐64.Awaiting

statereporting,enrollmentreasonablenessreviewisinprogress.Enrollmentonlyapplicableforstatesthathave

expandedtheirMedicaidprogramstoadultswithincomesupto138%FPL(the“adultgroup”).Forthestatesthat



havenotexpandedMedicaidtheirenrollmentisnotedas“N/A.”MassachusettsandVermontalreadyoffered

subsidizedcoveragetothosewithincomesbelow138%FPL,sotheyarelistedashaving0newly‐eligibleadults,

eventhoughtheyhaveimplementedtheACA’sMedicaidexpansion.

Minnesotatotalincludesanestimated95,622BasicHealthPlanenrolleesasofJune2023.

NewYorktotalincludesanestimated1,143,881BasicHealthPlanenrolleesasofApril‐June2023.



Table3:UninsuredRatesfor2013and2021



State

UninsuredRate%^

2013 2021

Alabama 13.6 9.9

Alaska 18.5 11.4

Arizona 17.1 10.7

Arkansas 16.0 9.2

California 17.2 7.0

Colorado 14.1 8.0

Connecticut 9.4 5.2

Delaware 9.1 5.7

DistrictofColumbia 6.7 3.7

Florida 20.0 12.1

Georgia 18.8 12.6

Hawaii 6.7 3.9

Idaho 16.2 8.8

Illinois 12.7 7.0

Indiana 14.0 7.5

Iowa 8.1 4.8

Kansas 12.3 9.2

Kentucky 14.3 5.7



March2023 ISSUEBRIEF 8



Table3:UninsuredRatesfor2013and2021(cont’d)



State

UninsuredRate%^

2013 2021

Louisiana 16.6 7.6

Maine 11.2 5.7

Maryland 10.2 6.1

Massachusetts 3.7 2.5

Michigan 11.0 5.0

Minnesota 8.2 4.5

Mississippi 17.1 11.9

Missouri 13.0 9.4

Montana 16.5 8.2

Nebraska 11.3 7.1

Nevada 20.7 11.6

NewHampshire 10.7 5.1

NewJersey 13.2 7.2

NewMexico 18.6 10.0

NewYork 10.7 5.2

NorthCarolina 15.6 10.4

NorthDakota 10.4 7.9

Ohio 11.0 6.5

Oklahoma 17.7 13.8

Oregon 14.7 6.1

Pennsylvania 9.7 5.5

RhodeIsland 11.6 4.3

SouthCarolina 15.8 10.0

SouthDakota 11.3 9.5

Tennessee 13.9 10.0

Texas 22.1 18.0

Utah 14.0 9.0

Vermont 7.2 3.7

Virginia 12.3 6.8

Washington 14.0 6.4

WestVirginia 14.0 6.1

Wisconsin 9.1 5.4

Wyoming 13.4 12.2

Total 14.5 8.6

UninsuredRates:AmericanCommunitySurvey,“HealthInsuranceCoverageStatusandTypeofCoveragebyState

andAgeforAllPeople”,2013,2021:https://www.census.gov/data/tables/time‐series/demo/health‐insurance/acs‐

hi.2013.html.

March2023 ISSUEBRIEF 9



Figure2:RelativeReductionintheUninsuredRatebyState,2013to2021



CONCLUSION



TheACA’smultipleprogramshaveledtoanhistoricexpansionofhealthcoverage,withanestimated40

millionpeoplecurrentlyenrolledincoveragerelatedtothelaw.Gainshaveaccelerate dsince2021,

concurrentwitheffortsbytheBiden‐Harrisadministrationtoexpandcoverage.Theseeffortsinclude:

enhancedsubsidiesforMarketplace

coverageundertheAmericanRescuePlanandlaterextendedbythe

InflationReductionAct;robustoutreacheffortstosignupeligibleindividualsforcoverage;andongoing

supportforstateMedicaidexpansions.



UndertheConsolidatedAppropriationsAct,2023theMedicaidandCHIPcontinuousenrollmentprovisionfor

theCOVID‐19publichealth

emergencywillcometoanendonMarch31,2023.ASPEpreviouslyestimated

that15millionenrolleescouldlosetheirMedicaidorCHIPcoveragebasedonhistoricalpatterns,thoughmany

willbeeligibletoobtainalternativecoverage.

About8.2millionMedicaidenrolleesareestimatedtoleave

MedicaidduetolossofMedicaideligibilityandanother6.8millionareestimatedtoloseMedicaidcoverage

despitestillbeingeligible( “ administrativech urning”).HHSisworkingwithstatestominimizeadministrative

churningtoreducethenumberofMedicaidandCHIPenrollees

whoremaineligiblebutfailtocompletethe

redeterminationapplication.Ofthe8.2millionMedicaidenrolleesestimatedtoloseMedicaidorCHIP

eligibility,5millioncanlikelytransitiontoothercoverage,primarilyemployerhealthplans,and2.7million are

expectedtobeeligibleforMarketplacepremiumtaxcredits(1.7millionof

the2.7millionareexpectedtobe

eligibleforzero‐premiumMarketplaceplans).TheAdministrationclosedthe“familyglitch”sothatstarting

withthe2023Marketplaceplanyear,familymembersofapersonwhoisofferedemployer‐basedinsurance

thatisonly“affordable”forself‐onlycoverage,andnotthe

wholefamily,maybeeligiblefortaxcreditsonthe

MarketplacesforthefirsttimetohelpthefamilyenrollinaMarketplaceplanwithsavings.





Ofnote,estimatesofACA‐relatedcoveragepresentedinthisIssueBriefareaconservativeestimateofthe

law’simpactonhealthinsurancecoverageforseveralreasons.First,theeffectuatedenrollmentestimatefor

theMarketplaceisamoreconservativeestimatethanplanselections.Second,thetotaldoesnotincludethe



March2023 ISSUEBRIEF 10



provisionoftheACAthattookeffectin2010allowingyoungadultstoremainontheirparents’plansuntilage

26,whichpreviousresearchestimatedledtomorethan2millionyoungadultsgaininginsurance;this

provision,likemanyotherprivateinsurance marketreformsintheACA(suchasbanninglifetime

limitson

medicalexpensesandguaranteedissueforthosewithpre‐existingconditions), hasbecomeembeddedinthe

healthinsurancesystem,makingupdatedestimatesofthenumbersofAmericansbenefitingfromtheACA

moredifficult,butitnonethelessremainsanimportantpartoftheACA’simpact.

Third,thestreamliningof

Medicaidapplications,enhancedoutreach,andexpandedeligibilityledtoincreasedenrollmentevenamong

childrenandparentswhowereeligibleforMedicaidthroughtraditionalpre‐expansionpathways,a

phenomenonreferredtoasthe“welcomemat”effect.

Thus,40.2millionlikelyunderestimatesthetotal

effectoftheACA.





March2023



ISSUEBRIEF 11



REFERENCES



AsamendedbytheHealthCareandEducationReconciliationActof2010.

CensusBureau,AmericanCommunitySurveyTablesforHealthInsuranceCoverageStatusandTypeofCoveragebyState

andAgeforAllPeople.Accessedat:https://www.census.gov/data/tables/time‐series/demo/health‐insurance/acs‐

hi.2013.html.

HealthCoverageUndertheAffordableCareAct:EnrollmentTrendsandStateEstimates.OfficeoftheAssistantSecretary

forPlanningandEvaluation,U.S.DepartmentofHealthandHumanServices.June2021.Accessedat:

https://aspe.hhs.gov/reports/health‐coverage‐under‐affordable‐care‐act‐enrollment‐trends‐state‐estimates.

LeeA,ChuRC,PetersC,andSommersBD.HealthCoverageChangesUndertheAffordableCareAct:Endof2021Update.

(IssueBriefNo.HP‐2022‐17).OfficeoftheAssistantSecretaryforPlanningandEvaluation,U.S.DepartmentofHealthand

HumanServices.April2022.Accessedat:https://aspe.hhs.gov/reports/health‐coverage‐changes‐2021

‐update.

CensusBureau,AmericanCommunitySurvey,HealthInsuranceCoverageStatusandTypeofCoveragebyStateandAge

forAllPeople.Accessedat:https://www.census.gov/data/tables/time‐series/demo/health‐insurance/acs‐hi.2013.html.

LeeA,RuhterJ,BosworthA,PetersC,DeLewN,SommersBD.ChangesinHealthInsuranceCoveragefrom2019to2021:

GeographicandDemographicPatternsintheUninsuredRate(IssueBriefNo.HP‐2023‐01).OfficeoftheAssistant

SecretaryforPlanningandEvaluation,U.S.DepartmentofHealthand

HumanServices.January2023.Accessedat:

https://aspe.hhs.gov/reports/changes‐health‐insurance‐coverage‐2019‐2021.

CentersforMedicareandMedicaidServices.November2022MedicaidandCHIPEnrollmentTrendsSnapshot.Accessed

at:https://www.medicaid.gov/medicaid/national‐medicaid‐chip‐program‐information/downloads/november‐2022‐

medicaid‐chip‐enrollment‐trend‐snapshot.pdf.

MedicaidCMS‐64FFCRAIncreasedFMAPExpenditureDataCollectedthroughMBES.Medicaid.gov.Accessedat:

https://www.medicaid.gov/medicaid/financial‐management/state‐budget‐expenditure‐reporting‐for‐medicaid‐and‐

chip/expenditure‐reports‐mbescbes/medicaid‐cms‐64‐ffcra‐increased‐fmap‐expenditure‐data‐collected‐through‐

mbes/index.html.

OfficeoftheAssistantSecretaryforPlanningandEvaluation,U.S.DepartmentofHealthandHumanServices.Unwinding

theMedicaidContinuousEnrollmentProvision:ProjectedEnrollmentEffectsandPolicyApproaches.(IssueBriefNo.HP‐

2022‐20).August2022.Accessedat:https://aspe.hhs.gov/reports/unwinding‐medicaid‐continuous‐enrollment‐provision.

MarketplaceOpenEnrollmentFactSheet.CentersforMedicareandMedicaid.

https://www.cms.gov/files/document/102622‐landscape‐and‐window‐shopping‐508.pdf.

Uberoi,N.,Finegold,K.,&Gee,E.(March3,2016).HealthinsurancecoverageandtheAffordableCareAct,2010‐2016.

Washington(DC):DepartmentofHealthandHumanServices,OfficeoftheAssistantSecretaryforPlanningand

Evaluation.Accessedat:https://aspe.hhs.gov/system/files/pdf/187551/ACA2010‐2016.pdf.

Hudson,J.andMoriya,A.“MedicaidExpansionforAdultsHadMeasurable‘WelcomeMat’EffectsontheirChildren”.

HealthAffairs,September2017.



HP‐2023‐08

March2023



ISSUEBRIEF 12



HP‐2023‐08



U.S.DEPARTMENTOFHEALTHANDHUMANSERVICES



OfficeoftheAssistantSecretaryforPlanningandEvaluation



200IndependenceAvenueSW,Mailstop447D

Washington,D.C.20201



FormoreASPEbriefsandotherpublications,visit:

aspe.hhs.gov/reports



SUGGESTEDCITATION

OfficeoftheAssistantSecretaryforPlanningandEvaluation,U.S.

DepartmentofHealthandHumanServices.HealthCoverage

ChangesUnder

theAffordableCareAct:CurrentEnrollmentand

StateEstimates.(IssueBriefNo.HP‐2023‐08).March2023.



Allmaterialappearinginthisreportisinthepublicdomainand

maybereproducedorcopiedwithoutpermission;citationasto

source,however,isappreciated.



DISCLOSURE

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printed,published,orproducedand

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