The Kansas Health Insurance Marketplace Enrollment Growth from 2014-2024

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The Kansas Health Insurance Marketplace Enrollment Growth from 2014-2024

Key Points

• Marketplace enrollment in Kansas was 171,376 in 2024, having tripled from 57,013 in 2014 and nearly doubled from 85,837 in 2020.
• Key policies driving enrollment growth include enhanced financial assistance, increased navigation support and extended special enrollment periods.
• The federal American Rescue Plan Act (ARPA) of 2021 and the Inflation Reduction Act (IRA) of 2022 resulted in enhanced financial assistance by increasing the value of Advance Premium Tax Credits (APTC) and by extending eligibility for APTC to more enrollees starting in plan year 2021 and currently lasting through 2025.
• Enrollment growth has been greatest for enrollees with income between 100 and 250 percent of the federal poverty level, a group that benefits from Cost-Sharing Reduction subsidies as well as the enhanced APTC.

Introduction

The 11th annual open enrollment period for Kansans seeking health insurance coverage through the federally facilitated marketplace created by the federal Affordable Care Act (ACA) began on Nov. 1, 2023, and ended on Jan. 16, 2024. Enrollment has tripled from 57,013 in 2014 and nearly doubled from 85,837 in 2020 to 171,376 in 2024. However, participation in the marketplace has fluctuated and has been driven by policies that impact enrollment.

The record growth since 2020 can largely be attributed to the enhanced subsidies of the American Rescue Plan Act (ARPA), increased navigation support and extended special enrollment periods, among other key policies. The Kaiser Family Foundation reviewed recent growth in the marketplace to understand where the market is growing fastest and why, and reported that Kansas ranks 16th with 99.7 percent growth since 2020. Among the 16 states where enrollment has doubled since 2020, all use the federally facilitated marketplace and eight have not expanded Medicaid.

This issue brief looks back at the results of the first eleven open enrollment periods in Kansas for the plan years 2014 through 2024. It highlights key policies that impacted enrollment and how these policies have affected enrollees at different income levels.

Kansas Marketplace Enrollment

The first 11 years of the marketplace have changed what health insurance coverage looks like for many Kansans. More than 171,000 Kansans enrolled for plan year 2024, the third year of record enrollment, and the growth is expected to continue to increase for plan year 2025. Enrollment has tripled since the beginning of the marketplace in 2014 and doubled since 2020. From 2015 to 2018, enrollment remained relatively steady, reaching its lowest level in 2020 (Figure 1).

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Key Policies Impacting Enrollment

Since the ACA was enacted in 2010, several key policy changes have contributed to enrollment trends in Kansas, including enhanced financial assistance, increased funding for navigator programs that provide enrollment support and special enrollment periods (Figure 2).

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Financial Assistance

Under the ACA, individuals with annual income between 100 and 400 percent of the federal poverty level (FPL) may be eligible for Advance Premium Tax Credits (APTC) to help pay for premiums. Individuals with incomes between 100 and 250 percent FPL also may be eligible for Cost-Sharing Reduction (CSR) subsidies, which reduce out-of-pocket costs (deductibles, co-payments and coinsurance). The APTC can be used to subsidize the premiums of a bronze, silver or gold plan. CSR subsidies are only available for silver plans.

The American Rescue Plan Act (ARPA), enacted in March 2021, extended APTC eligibility to people over 400 percent FPL and increased premium assistance for people already eligible for APTC under the ACA for two years (2021 and 2022). The Inflation Reduction Act (IRA), signed into law in August 2022, extended the enhanced tax credits through 2025.

With enhanced tax credits, enrollees making between 100 and 150 percent FPL have no-cost premiums for a benchmark silver plan that pays 94 percent of health care costs on average. Enrollees making between 150 and 250 percent FPL are paying between 2.0 percent and 4.0 percent of their income in premiums. All income groups have a premium cap of 8.5 percent of income.

With the enhanced APTC, nearly all enrollees in the marketplace are subsidized. In 2024, 160,185 of the 171,376 (93.5 percent) enrollees received APTC and/or CSR in contrast to 73,579 of the 85,837 (85.7 percent) enrollees in 2020.

Consumer Assistance for the Kansas Marketplace

Under the ACA, the navigator program was designed to provide outreach, education and assistance for consumers enrolling in health insurance coverage through HealthCare.gov. Through grants awarded to nonprofit and provider organizations, navigators and assister programs help consumers to understand the coverage options available to them, find affordable coverage that meets their needs and provide the information, tools and resources to maintain their health coverage all year. Funded organizations operate as navigators year-round. Navigators are specifically required to provide assistance for underserved and historically marginalized populations.

Kansas received $3.7 million in navigator funding in 2024, a dramatic increase from $213,317 in 2020 and the initial funding in 2013 of $886,085. This most recent funding is significantly higher than the amount Kansas received during the Trump and Obama administrations. Kansas navigator programs have received a total of $15.9 million in funding since the first open enrollment period, which was for plan year 2014.

Open Enrollment and Special Enrollment Periods

Open enrollment is the time period for enrolling in, reviewing or changing health insurance plans through the marketplace for the coming year. Typically, the open enrollment period (OEP) is 45 days long and runs from Nov. 1 through Dec. 15 for plans starting Jan. 1. The first OEP for plan year 2014 was more than six months long.

The COVID-19 public health emergency - declared on Jan. 31, 2020, and ending on May 11, 2023 - was a federal designation that provided additional resources to address the health and economic impacts of the pandemic. The COVID-19 Special Enrollment Period (SEP) extended the OEP to Aug. 15, 2021, allowing individuals without a qualifying life event to enroll in health coverage or reevaluate their existing health plan needs to take advantage of the increased APTC. The OEP was extended to 75 days for plan years 2022 through 2025.

Additional SEPs, outside of qualifying life events, include a low-income special enrollment period and an unwinding special enrollment period. From March 18, 2022, through Dec. 31, 2025, people who are eligible for APTC with expected income at or below 150 percent FPL can enroll or update an existing application throughout the year. The unwinding SEP is for qualifying individuals and their families who are losing Medicaid or Children's Health Insurance Program (CHIP) coverage due to the end of the continuous enrollment associated with the COVID-19 public health emergency. The unwinding SEP from March 31, 2023, to Nov. 30, 2024, allowed enrollees to start coverage the first day of the month after they selected a plan.

Why It Matters

The enhanced Advance Premium Tax Credits (APTC) made available through the American Rescue Plan Act (ARPA) and the Inflation Reduction Act (IRA) are set to expire at the end of 2025. Sixteen states - including Kansas and seven other states that have not expanded Medicaid - have seen marketplace enrollment nearly double with the enhanced subsidies. Enrollment in states that have expanded Medicaid may be less impacted by the sunsetting of the enhanced subsidies, as many potential enrollees with income up to 138 percent of the federal poverty level qualify for Medicaid.

Fixing the Family Glitch

Under the ACA, low- and middle-income consumers are eligible to receive APTC to help pay their health insurance premiums for plans purchased on the ACA marketplace. However, the "family glitch" prevented eligible family members from receiving APTC for a marketplace plan if the employee's self-only coverage was deemed "affordable" - meaning the premium for self-only coverage did not exceed 9.12 percent of their household income - and "adequate" - meaning the health insurance covered at least 60 percent of average health care costs.

The family glitch was fixed before the 2023 open enrollment period, allowing family members whose premiums exceed 9.12 percent of their household income and who don't have affordable coverage from another employer to receive tax credits. An estimated 40,000 Kansans were impacted by the family glitch; however, it is unknown how many of the new enrollees in 2023 and 2024 were the result of fixing the family glitch.

Medicaid Redetermination

The Families First Coronavirus Response Act tied to the nationwide COVID-19 public health emergency (PHE) incentivized states to maintain eligibility for Medicaid enrollees during the COVID-19 pandemic by increasing federal funding for state Medicaid programs. In response, Kansas, and all other states, delayed action on annual reviews, ensuring continuous Medicaid coverage during the pandemic. Kansas was required to process all eligibility casework for KanCare (Kansas Medicaid and CHIP) that was not acted upon during the PHE starting in April 2023. This process of redetermination is also known as unwinding.

Kansas completed its unwinding process as of May 31, 2024, discontinuing 114,000 individuals from KanCare. Nationally, the Office of the Assistant Secretary for Planning and Evaluation within the U.S. Department of Health and Human Services estimated that 43.8 percent of those who lost Medicaid eligibility had an income level between 100 and 250 percent FPL and could have qualified for enhanced APTC and CSR.

Enrollment by Income Level

Enrollment trends have varied by income level, highlighting the impact of enhanced subsidies, increased navigation funding and changes in open enrollment periods. Figure 3 shows enrollment by income - shown as a percentage of the federal poverty level - from 2016 to 2024. Enrollment growth has been greatest for enrollees with income between 100 and 250 percent FPL, a group that benefits significantly from subsidies. In 2024, this income group represented 128,385 Kansans, or three-fourths (74.9 percent) of Kansas enrollees.

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ARPA and IRA expanded eligibility, allowing more enrollees to receive APTC and increasing the average value of APTC, starting in plan year 2021 and continuing through plan year 2025. For the first time, individuals with income above 400 percent FPL became eligible to receive subsidies. The enhanced subsidies also increased the availability of $0, or no-cost, premiums for those with income between 100 and 150 percent FPL - a group which also benefits from a year-round low-income special open enrollment period which began in 2022.

Conclusion

Enhanced financial assistance, increased outreach and extended open enrollment periods have contributed to the tripling of marketplace enrollment since 2014. The enhanced subsidies are currently set to expire at the end of 2025. If the enhanced subsidies expire, almost all marketplace enrollees will experience an increase in premium payments, and many may no longer consider marketplace premiums affordable. However, the subsidies come at a cost to taxpayers, with a projected cost nationally of $251 billion over the next 10 years.