Defying Odds, 2018 Was Pretty Good for Health Insurance Signups

Updated: 4/17/2018
Hard-working Texans need access to health coverage, even if they are not fortunate enough to have jobs that offer affordable health insurance to employees and their families. Health coverage improves access to health care and protects against financial calamity in the face of significant illness or injury. People who do not have access to job-based insurance and do not qualify for Medicare or Medicaid can access comprehensive coverage with premiums tailored to their income through the Health Insurance Marketplace. 
On April 3, 2018, the Centers for Medicare and Medicaid Services (CMS) released their annual report on the Affordable Care Act (ACA) Marketplace open enrollment period for 2018. The report explains how many people signed up for health insurance through the federal Marketplace. As we learned from the snapshot provided by CMS back in December, 1.1 million Texans selected a 2018 Marketplace plan. This is down by about 100,000 people, or eight percent, from 2017. * Texas the highest uninsured rate of any state in the country, but since the Affordable Care Act was passed we have seen steady increases in the number of Texans with insurance. Due to the drop in Marketplace enrollment this year, Texas may see this progress stalled. 
In light of the efforts by both Congress and the Trump administration to undermine the Affordable Care Act, it’s surprising news that enrollment only went down a relatively modest amount. However, Texas could have avoided this drop if Congress and the administration had made real efforts to improve access to, and the affordability of health care instead of focusing on undermining the Affordable Care Act. 
The final report also provides new county-level enrollment data. The chart below shows Marketplace enrollment numbers for the 10 most populous counties in Texas (sorted by overall enrollment change). 

  2017 Enrollment  2018 Enrollment  Overall Enrollment Change  Change in # of New Consumers  Change in # of  
Fort Bend County  51,916  50,700  -2%  -23%  9% 
Harris County  240,064  229,493  -4%  -18%  5% 
Montgomery County  23,389  21,298  -9%  -31%  4% 
Bexar County  81,323  73,621  -9%  -34%  6% 
Dallas County  120,976  106,923  -12%  -25%  -3% 
Cameron County  18,290  16,098  -12%  -34%  2% 
Williamson County  23,893  20,660  -14%  -21%  -10% 
Travis County  68,199  58,557  -14%  -23%  -9% 
Tarrant County  83,029  68,649  -17%  -20%  -16% 
Denton County  32,703  26,997  -17%  -17%  -18% 

All of these counties had a reduction in Marketplace enrollment from 2017 to 2018, however the large variation in how much enrollment decreased county to county is noteworthy. For example, enrollment in Fort Bend County and Harris County only decreased two and four percent respectively, while enrollment in Tarrant County and Denton County decreased by 17 percent.
In several counties, more Texans chose to continue to purchase insurance from the Marketplace making up for some of the overall enrollment declines. The largest counties all had large decreases in new consumers in 2018 compared to 2017. However, the counties where (compared to last year) a higher number of people with existing coverage chose to continue purchasing Marketplace insurance are also the counties with the lowest overall enrollment declines. 
For example, Fort Bend County, where enrollment dropped only two percent, had a nine percent increase in the number of people who re-enrolled this year compared to 2017. In comparison, Denton County – which had the largest decrease in overall enrollment, down 17 percent – also had the largest decrease in the number of health insurance renewals (down 18 percent). 
After the Trump administration cut the open enrollment time in half and severely reduced its funding and support of outreach and enrollment efforts, one of the reasons that enrollment only decreased a modest amount was due to Herculean efforts that in-person enrollment assisters, community groups, and foundations put in to fill the void. Enrolling in health insurance is a complicated process, this is especially true for individuals purchasing coverage through the individual market who may have to compare as many as 30 plans depending on where they live. The Affordable Care Act addressed this concern by creating several programs to train individuals in local communities to provide free, in-person assistance. These enrollment assisters help individuals understand the application process to purchase Marketplace insurance and receive financial aid. They also assist them in understanding how insurance works and which plan best meets their needs. Investments in outreach and enrollment results in more people with coverage and the security it brings. Had the administration invested in these efforts at an appropriate level we may have been able to avoid the drop-in enrollment altogether.  
* The 2018 Open Enrollment Final Report only includes data on Marketplace enrollment through December 23, 2017. Many Texans were allowed to enroll after this point as a result of the special enrollment period for those affect by hurricane Harvey, which was available through December 31, 2017. 

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