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Winners and Losers in 2018 ACA Exchange Enrollment

President, Freedman HealthCare, LLC

John, principal of Freedman HealthCare LLC, has 25 years of experience in performance measurement & improvement, health IT, care delivery, and health care reform. At FHC he has helped many states create all-payer claims databases, implement health insurance exchanges, and support health care transformation.

The numbers are in for 2018 health insurance exchange (HIX) enrollment. According to CMS, enrollment fell 3.7% to just under 11.8 million.  However, that total hides a big difference between the federal exchange and the state-operated exchanges.


HIX 2017 Enrollment 2018 Enrollment Change
Federal Exchange/Healthcare.gov (34 states) 8,751,102 8,289,073 -5.3%
State-run Exchanges (16 states plus DC) 3,464,901 3,471,447 +0.2%


This is not surprising. The Trump administration has pressed hard to eliminate the ACA. Legislative efforts, slashing the Healthcare.gov’s marketing budget, cutting support for Navigators, and shortening the enrollment period are just a few examples of the tactics. These efforts have clearly been successful. Had the federal exchange performed similarly to the state exchanges (which themselves were almost certainly held back by some of the efforts to repeal or suppress enrollment), nearly half a million more Americans would have coverage through the exchanges (478,562, to be precise).


Evidently, there remains considerable demand for ACA-exchange coverage, even in such an uncertain political atmosphere.


The two states with the greatest proportion of residents using the exchange to purchase coverage are Florida (1.7 million or 8.2%) and Utah (194,000 or 6.3%), both on Healthcare.gov.


Let me also point out one other success story in all this. The state of Rhode Island, which has had its share of publicized problems with its insurance exchange, was the biggest winner for 2018 enrollment: up 12.1% in a strong bounceback. And, yes, Rhode Island invested in marketing, Navigators, and they extended their enrollment period. Not rocket science after all.

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