Subsidzied ACA enrollment chart The number of unsubsidized enrollees on the Affordable Care Act health care exchanges dropped by 1.2 million last year, according to a report from the Centers for Medicare and Medicaid.

While the drop in the number of enrollees footing the whole bill for their coverage is no surprise, given the pricey premiums involved, it’s not good news, and it doesn’t fit with the CMS claim. From 2016 to 2018, the report says, unsubsidized enrollment on the exchanges fell 40 percent, with declining numbers in nearly all states. Meanwhile, from 2016 to 2018, 2.5 million people altogether—who were paying the whole premium bill for ACA coverage themselves—have dropped out of the individual market.

CMS administrator Seema Verma took advantage of the news to claim that this was yet another sign that the ACA isn’t working. “As President Trump predicted, people are fleeing the individual market,” she said. “Obamacare is failing the American people, and the ongoing exodus of the unsubsidized population from the market proves that Obamacare’s sky-high premiums are unaffordable.”

ACA supporters point out that contrary to Verma’s claims, the number of enrollees actually highlights the number of people still buying ACA coverage on the exchanges, despite “sabotage” by the Trump administration and Congressional Republicans’ efforts to hamstring the program.

“It clearly shows that the American people still want the quality coverage that the Affordable Care Act provides,” Leslie Dach, chair of the liberal advocacy group Protect Our Care, told Modern Healthcare.

Christen Linke Young, a fellow with the USC-Brookings Schaeffer Initiative for Health Policy, shares Dach’s belief that increasing declines reflect the effects of the elimination of the individual mandate, expansion of short-term plans and cuts to enrollment marketing.

There have been steady increases in the cost of premiums since the exchanges launched in 2014, but those increases spiked after Trump canceled the cost-sharing reduction payments that helped to offset copays for lower-income people. Premiums actually declined a bit last year when individual market insurers engaged in “silver-loading” cost-sharing reduction payments into the ACA’s benchmark plans.

While unsubsidized enrollment is falling off, CMS numbers show that subsidies have increased 114 percent since 2014, with average federal spending per person on the exchanges topping spending for Medicaid expansion where people have fuller coverage.

The political picture around the ACA has changed as the race for president in 2020 heats up, with Republicans having backed off—at least for the time being—on ACA repeal, lawsuits challenging the law’s constitutionality are in the courts and Democratic candidates are divided on whether to stick with the ACA or go bold and embrace some version of Medicare for All that would cover a much broader swath of the population than even the ACA has managed.

In addition, the entrée of serious talk about Medicare for All has spurred defensive action on the part of the health insurance industry and hospital groups attempting to defend the ACA against any potential new legislation that could threaten their profits—and that includes any moves toward a Medicare for All policy, which even so-called moderate Democrats are now willing to consider in some form.

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Unsubsidized ACA enrollment down by more than a million

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