Biden Order to Reopen Obamacare Markets Drives States to Follow

President Joe Biden’s order to reopen the federal Obamacare market is putting pressure on states with their own exchanges to follow suit, opening the door for more consumer choice as people who are uninsured move to get coverage amid the pandemic.

The executive action could also lead to a surge in state Medicaid enrollment as people who now turn to the exchanges find out they qualify for the low-income health program.

Biden signed an executive order Thursday to allow people to sign up for insurance from Feb. 15 through May 15. The order applies only to the federal HealthCare.gov website, and not the 15 states that run their own sites. Several of those states are allowing enrollments now for different time periods, and the administration expects them to match the federal open enrollment timeline. But those states must each make that call individually.

“We expect that when HHS opens up their enrollment period, most or all states exchanges would do the same,” a White House official said on a press call announcing the order.

Colorado, California, and the state of Washington’s exchanges announced Thursday they will reopen for individual health insurance between February and May. Minnesota’s health insurance exchange said in a statement it will share more about its plans in the coming days.

The 15 states that operate their own exchanges in 2021 could play a crucial role in signing more people up for Affordable Care Act plans. People who lost employer-sponsored insurance already qualify for a special enrollment period—meant for those who experience life changes such as job loss, moving, or having a baby—through HealthCare.gov, but it’s a harder process to go through.

Reopening both the federal and state exchanges means people who were uninsured even before the start of the public health emergency can enroll. By broadly reopening HealthCare.gov, people can sign up for coverage without meeting special qualifications, such as loss of coverage, the official said.

The official also said the administration is committed “to engage in robust outreach here, which will reach people in the states served by HealthCare.gov, but will also reach people in the states that are not.”

State Enrollment Periods

Most of the states that have their own exchanges are run by Democrats and extended their open enrollment in 2020, except for Republican-leaning Idaho.

Six states currently are extending open enrollment for 2021, according to Christina Cousart, senior policy associate with the nonprofit National Academy for State Health Policy.

Exchanges in California, the District of Columbia, and New Jersey are open until Jan. 31., Massachusetts until March 23, and New York until March 31. Covered California announced Thursday it will hold a special enrollment period from Feb. 1 through May 15. D.C. exchange director Mila Kofman said she expects the city’s exchange to stay open throughout the pandemic under a health emergency declaration.

Enrollment on Maryland’s exchange is open until March 15, and the state is looking at extending the period.

Colorado will reopen its exchange for individual health insurance from Feb. 8 through May 15. Washington state is also holding a special enrollment from Feb. 15 through May 15.

The 15 states operating exchanges in 2021 signed up 3.7 million people in 2020, Cousart said. Data isn’t yet available in the states for 2021. HealthCare.gov enrolled about 8.3 million people for 2021, according to the Centers for Medicare & Medicaid Services.

The White House official didn’t have projections for how many would be enrolled through the new period, but said that “millions of uninsured people” can benefit from coverage through the ACA.

The official noted that outreach will be critical for “people who have been eligible all along but may not have been aware of the opportunity to sign up for coverage.”

The outreach campaign will likely include past efforts used by the Obama administration, such as paid advertising, direct outreach to consumers, and partnerships with community and stakeholder organizations, the official said.

Medicaid Surge

The executive order and coming outreach could boost Medicaid enrollment because people who lost their jobs during the economic downturn will learn that they now qualify for coverage, said Matt Salo, executive director of the National Association of Medicaid Directors.

“Most people aren’t continuously monitoring whether their income has fallen below 138 percent of the poverty level,” he said. “So it’s not surprising that some may be unaware that they’ve become Medicaid eligible.”

People who shop for coverage on the exchanges are redirected to Medicaid if they qualify for that program.

An analysis released Thursday by the Urban Institute found that despite declines in employer-sponsored health insurance, 47% of uninsured adults hadn’t tried to enroll in Medicaid or Children’s Health Insurance Program (CHIP) coverage, nor looked for information on ACA marketplace plans.

However, a boost in sign-ups could put a squeeze on state budgets, Salo said. Medicaid enrollment already surged during the first six months of the pandemic by 9.1%, according to CMS figures.

States cover around a third of overall Medicaid costs, although the state share for the Medicaid expansion population is just 10%. Congress increased the federal share of most Medicaid costs by 6.2 percentage points in the Families First Coronavirus Response Act, which has been a lifesaver for state budgets, Salo said.

Acting Health and Human Services Secretary Norris Cochran signaled last week that that increase in the federal share will remain in place at least through 2021.

Team Effort

Randy Pate, who was in charge of HealthCare.gov under President Donald Trump as director of the Center for Consumer Information and Insurance Oversight, expressed doubt that reopening the exchanges would bring in large numbers of enrollees.

“We didn’t see big numbers of people come in” during extended state enrollment periods in 2020, Pate said. “The vast majority of those people that came in were probably already eligible for a special enrollment period,” he said.

He also noted it may be costly to reopen HealthCare.gov.

“You have to get not just the federal government, but also all the insurance companies, agents and brokers, the web brokers, the navigators, the assisters, everybody sort of geared up to do something like this,” he said.

Meanwhile, the America’s Health Insurance Plans lauded the action.

“We applaud the call for a targeted special enrollment period that is accompanied by robust consumer outreach and education, which will provide an additional opportunity for hardworking Americans to obtain comprehensive coverage for themselves and their families,” AHIP President and CEO Matt Eyles said in a statement.

Reconsidering Rules

The executive order also announces a broad effort by the Biden administration to reconsider “rules and policies that limit Americans’ access to health care,” according to a White House statement.

Those policies will likely include a Trump-era rule that allows states to largely bypass HealthCare.gov and sign up people through web brokers. The new administration will also likely examine regulatory actions that extended the duration of short-term health plans—which don’t comply with ACA prohibitions against pre-existing condition discrimination or with requirements to cover comprehensive “essential” health benefits.

Waivers issued by the Trump administration that allow states to impose Medicaid work requirements will also be under scrutiny, the official said. But what exactly to do about them is a “decision for the agency.”

The Trump administration approved 12 waivers that force Medicaid recipients in certain states to work as a condition of coverage, according to the Kaiser Family Foundation’s online tracker. The HHS secretary has the authority to rescind them, but the waivers give the states the right to notice and a hearing.

The U.S. Supreme Court is expected to hear oral argument in March on the legality of work-requirement waivers approved for Arkansas and New Hampshire.