OFFICE OF ISSUE BRIEF HEALTH POLICY April 29, 2022 ASSISTANT SECRETARY FOR PLANNING AND EVALUATION gg ASPE Health Coverage Changes Under the Affordable Care Act: End of 2021 Update The U.S. uninsured rate was 8.8% in the fourth quarter of 2021, approaching an all-time low. Enrollment in ACA-related coverage hit a record high by early 2022, topping 35 million Americans. Aiden Lee, Rose C. Chu, Christie Peters, and Benjamin D. Sommers KEY POINTS e Newly-released data from the National Health Interview Survey shows that the uninsured rate for the U.S. population was 8.8 percent in Q4 2021 (October - December 2021), down 1.5 percentage points from 10.3 percent in Q4 2020. This reflects approximately 4.9 million people gaining health coverage since the end of 2020. e Individuals withincomes below 200 percent of the Federal Poverty Level experienced larger decreasesin the uninsured rate than higher income households. e Coverage gains for adults ages 18-64 from the second half of 2020 to the second half of 2021 occurred across all racial and ethnic groups reported in the new data, with the uninsured rate declining by 3.5 percentage points among Latino adults, 1.8 percentage points among Black adults, and 0.5 percentage points among White adults. e Meanwhile, administrative data from late 2021 and early 2022 show a record-high number of people with coverage related to the Affordable Care Act (ACA)- with more than 35 million people estimated to be enrolled in the Medicaid expansion, Basic Health Program, or Marketplace coverage. e These data suggest that policies including the American Rescue Plan, new state Medicaid expansions, and the 2021 Marketplace Special Enrollment Period, in addition to the economic recovery, have helped Americans gain insurance coverage during the COVID-19 public health crisis. BACKGROUND Health insurance coverage expansion has been a key priority of the Biden-Harris Administration. Administrative and legislative efforts including an extended 2021 Marketplace Special Enrollment Period, robust Marketplace consumer outreach and enrollment efforts, the passage of the American Rescue Plan (ARP), two states adopting the ACA Medicaid expansions (Oklahoma and Missouri), and the Medicaid continuous coverage provision under the Families First Coronavirus Response Act have helped Americans gain and maintain health coverage during the COVID-19 pandemic. Previous estimates from the Centers for April 2022 ISSUE BRIEF 1 Disease Control and Prevention's (CDC) National Health Interview Survey (NHIS) showed a declining uninsured rate between the end of 2020 and the fall of 2021, and survey results for all quarters of 2021 are now available.+ This Issue Brief examines health coverage trends over time using newly-released NHIS data to assess changes during the pandemic and how they compare to pre-pandemic years, both for the population as a whole, as well as by age, income, and race and ethnicity. The report also presents administrative enrollment totals for coverage relatedto the ACA. These results update previously published ASPE reports with more recent data. METHODS We analyzed national survey data from NHISthrough the end of 2021, Marketplace enrollment data from the Centers for Medicare & Medicaid Services' (CMS) Center for Consumer Information and Insurance Oversight (CCIIO), and Medicaid enrollment data from CMS's Center for Medicaid and CHIP Services (CMCS). Quarterly uninsured estimates, as wellas estimates byincome and age, were obtained from the NHIS Early Release Program,' and coverage by race and ethnicity were obtained from biannual estimates available from the NHIS Data Query Tool.> NHISresults during the pandemic may not be as reliable for comparisons to survey results before the pandemic. The CDC suspended in-person visits to conduct the NHIS survey on March 19, 2020, so all NHISsurveys for Q2 2020 were conducted by telephone. Beginning in July 2020 through April 2021, data collection in select areas were opened for in-person visit interviewing. However, NHISdata collection remained predominantly by telephone during this period. Beginning in May 2021, NHIS data collection returned to in-person visits with Interviewers given discretion based on their own health riskand conditions to complete interviews by phone. Household response rates decreased from 60.0 percent for Q1 2020 to 42.7 percent for Q2 2020. Telephone numbers could not be matched for a number of addresses, especially for renters and those with lower housing tenure (years living at an address). Response rates were lower for groups including those who are younger, have low incomes, Black and Latino individuals, non- citizens, and those with lower education attainment. The NHIS weights its data to match U.S. Census Bureau population estimates for age and educational attainment, among other characteristics, and added housing tenure for Q2 2020." The CDC statesthat despite these efforts, there is likely to be some non-response bias in the Q2 2020 estimates; for this reason, our quarterly and biannual estimates below focus on estimates subsequent to that period. NHISresponse rates rebounded for the rest of 2020 and 2021. Marketplace enrollment totals from 2014-2021 reflected point-in-time effectuated enrollment counts; effectuated enrollment totals are not yet available for 2022. Instead, we estimated February 2022 Marketplace enrollment based on total plan selections at the end of the 2022 Open Enrollment Period (OEP), including from both states with Marketplaces using the HealthCare.gov platform and those with State-based Marketplaces, adjusted for the February 2021 effectuation rate of 94 percent (see Appendix Table 1 notes for further details). Medicaid enrollment statistics were state-reported counts of unduplicated individuals enrolled in the state's Medicaid program through the Medicaid Budget and Expenditure System (MBES). For states that have expanded Medicaid, the enrollment data provide specific counts for the number of individuals enrolled in the new expansion adult eligibility group, referred to as the "adult group," with separate totals for those who became newly eligible under the ACA expansion, as well as those who would have been eligible for coverage prior to the ACA but are now part of the adult group. * Family income could not be adjusted for because of the high rate of missing responses. April 2022 ISSUE BRIEF 2 Minnesota and New York also have implemented the Basic Health Program (BHP) option under the ACAto cover individuals with incomes between 138-200 percent of the Federal Poverty Level (FPL). We report annual average BHP enrollment for these two states, as reported toCMS by the states. FINDINGS Overall Uninsured Rate Figure 1 shows the uninsured rates by quarter for the U.S. population (all ages). The uninsured rate for the total civilian noninstitutionalized U.S. population was 8.8 percent for Q4 2021 (October - December 2021), approaching the lowest uninsured rates ever recorded in the NHIS - and similar to results from 2016 and early 2017.749.10 When consideredin context of the prior 12 months, the total uninsured rate decreased 1.5 percentage points from 10.3 percent in Q4 2020. This corresponds to 33.6 million uninsured individuals in Q4 2020 and 28.7 million in Q4 2021, indicating that approximately 4.9 million people gained healthcare coverage during this time period. Figure 1. Uninsured Rate by Quarter, AllAges (Q4 2020- Q4 2021) 10.5% 10.3% 10.0% 9.5% 9.0% 8.5% 8.0% Q4 2020 Q1 2021 Q2 2021 Q3 2021 Q4 2021 Source: Health Insurance Coverage: Early Release of Quarterly Estimates From the National Health Interview Survey, October 2020- December 2021. https://www.cdc.gov/nchs/data/nhis/earlyrelease/Quarterly Estimates 2021 April 2022 ISSUE BRIEF 3 Figure 2 shows that the population under age 65 experienceda 1.8 percentage point decrease inthe uninsured rate from Q4 2020 to Q4 2021. Figure 2. Uninsured Rate by Quarter, Ages 0-64 (Q4 2020 - Q42021) 12.5% 12.3% 12.0% 11.5% 11.0% 10.5% 10.0% 9.5% Q4 2020 Q1 2021 Q2 2021 Q3 2021 Q4 2021 Source: Health Insurance Coverage: Early Release of Quarterly Estimates From the National Health Interview Survey, October 2020-- December 2021. https://Awww.cdc.gov/nchs/data/nhis/earlyrelease/Quarterly Estimates 2021 Q14.pdf Figure 3 shows quarterly changes in the uninsured rate for the under-65 population for the past 4 years. The solid black line shows the quarterly trends for 2021, in which the uninsured rate declined from the first half of 2021 and then was stable from Q3 to Q4. This is in contrast tothe trends in 2018-2020, where the uninsured rate generallyrose over the course of the year from Q1 to Q4. Manyplan years begin in January, and individuals who stop paying premiums during the year may contribute to the rising uninsured rate by quarter; but in 2021, this trend has reversed. April 2022 ISSUE BRIEF 4 Figure 3. Uninsured Rate by Quarter, Ages 0-64 (2018 -- 2021) 16% 14% 11.4% a ee 12.5% toy 13% weer oowwncccse 12.3% 11.1% ===. = -oseeer"" 11.9% 10% 10.3% 10.5% 2018 8% e@eee 2019 6% @e2oee 2020 4% 2% 0% Quarter 1 Quarter 2 Quarter 3 Quarter 4 Source: National Health Interview Survey's Supplemental Quarterly Tables on Health Insurance Coverage, 2018-2021. https://www.cdc.gov/nchs/nhis/healthinsurancecoverage.htm Uninsured Rates by Income, Race, and Ethnicity Figure 4 shows that uninsured rates among lower income populations decreased the most during 2021. Individuals with incomes below 100 percent FPL experienced a 4.4 percentage point decrease in uninsurance from Q4 2020 to Q4 2021. Individuals with incomes between 100-200 percent FPL experienced a 3.6 percentage point decrease in uninsurance since Q4 2020 (though with a slightly uptick since Q1 2021). Those with incomes above 200 percent FPL have the lowest uninsured rate, but this too declined during 2021 (from 7.6 to6.4 percent). Figure 4. Uninsured Rate by Quarter, Ages 0-64, by Income (Q4 2020-- Q4 2021) 25% 21.3% 10, 20% 50.2% 17.7% 15% 15.8% '0 «100% FPL > 100% to < 200% FPL 10% -- > 200% FPL 7.6% = 6.4% 5% 0% Q4 2020 Q1 2021 Q2 2021 Q3 2021 Q4 2021 Source: Health Insurance Coverage: Early Release of Quarterly Estimates From the National Health Inter view Survey, October 2020- December 2021. https://Awww.cdc.gov/nchs/data/nhis/earlyrelease/Quarterly Estimates 2021 Q14.pdf April 2022 ISSUE BRIEF 5 Figure 5 shows uninsured rates byrace and ethnicity for adults ages 18-64 from the second half of 2020 through the end of 2021. Unlike the other NHIS estimates inthis report, which are quarterly, these estimates from NHIS are compiled in 6-month intervals. Uninsured rates across all groups declined from the second half of 2020 throughthe end of 2021. The largest decline (3.5 percentage points) was among Latino adults, with the second largest decline (1.8 percentage points) among Black adults. White, non-Latino adults experienced a 0.5 percentage point decline, and adults in other races (which are not disaggregated inthe current NHIS data release) experienced a 1.4 percentage point decline. Figure 5. Biannual Uninsured Rate, Ages 18-64, by Race and Ethnicity (July 2020 - December 2021) 35.0% 32.3% 30.0% 28.8% 25.0% 20.0% 15.0% 15.2% 13.4% le '0 10.9% 9.5% 10.0% --$_ 5.0% 8.9% 8.4% . '0 0.0% Jul-Dec 2020 Jan-Jun 2021 Jul-Dec 2021 ox! atino «= Black, non-Latino eeWhite,non-Latino Other, non-Latino Source: Interactive Biannual Early Release Estimates. National Center for Health Statistics. Accessed at: https://Awwwn.cdc.gov/NHISDataQueryTool/ER_ Biannual/index biannual. html Longer-Term Trends Figure 6 places these recent trends in the broader context of the changes in coverage since the implementation of the ACA, when many key coverage provisions took effect beginning in 2014. The uninsured rate declined dramatically between 2013 and 2016, but rose gradually until 2019, before declining againin 2020-2021. April 2022 ISSUE BRIEF 6 Figure 6. Annual Uninsured Rate, Population Under Age 65 (2013 - 2021) 13% 16.6% (44.3 m) 16% 14% 11.0%* 12% _- --__' m) 10% 8% 6% 4% 2% 0% 2013 2014 2015 2016 2017 2018 2019 2020 2021 Source: National Health Interview Survey's Health Insurance Coverage Reports, 2013-2020. https://www.cdc.gov/nchs/nhis/healthinsurancecoverage.htm Health Insurance Coverage: Early Release of Quarterly Estimates From the National Health Interview Survey, October 2020-December 2021. https://www.cdc.gov/nchs/data/nhis/earlyrelease/Quarterly Estimates 2021 4.pdf Note: Respondents are those who reported being uninsured at the time of interview. *2021 full year data point isan estimate based on the average for Q1-Q4 2021 early release estimates. Figure 7 shows that ACA-related enrollment increased in every ACA-related coverage type over the past year, with more than 35 million individuals estimated to be enrolled in the Marketplace, Medicaid expansion coverage, and BHP, based on the most current data for each program. A record-breaking 14.5 million people signed up for coverage in the Marketplace during the 2022 OEP; while final numbers on plan effectuation are not yet available, if recent effectuation rates remain stable from 2021, this will reflect an estimated 13.6 million consumers with coverage as of early 2022.11' See Appendix Table 1 for program specific data. + Using prior years' data on the percentage of individuals who effectuated their Marketplace plan selections, 13.6 million is an estimate of effectuated enrollment for February 2022 that reflects an average effectuation rate of 94 percent (similar to the February 2021 effectuation rate). April 2022 ISSUE BRIEF 7 Figure 7. ACA-Related Enrollment: Marketplace, Medicaid Expansion, and the Basic Health Program (2014-2022) 40,000,000 35,000,000 30,000,000 25,000,000 20,000,000 15,000,000 10,000,000 5,000,000 2014 2015 2016 2017 2018 2019 2020 2021 2022 @ Marketplace Enrollment ™ Medicaid Expansion Group, Newly-Eligible @ Medicaid Expansion Group, Previously Eligible M Basic Health Plan Note: See Appendix Table 1 for information on data sources. DISCUSSION The U.S. uninsured rate declined significantly during 2021, corresponding to approximately 4.9 million Americans gaining coverage since the end of 2020. At the same time, administrative data shows that enrollment in ACA-related coverage (Medicaid expansion and Marketplace enrollment) is at an all-time high of more than 35 million individuals. Legislative and administrative actions since 2021 likely have contributed to these trends. Legislative Actions: The American Rescue Plan and Families First Coronavirus Response Act The American Rescue Plan (ARP) provides expanded subsidies to Marketplace consumers by removing the income cap on eligibility for premium tax credits (PTC) and lowering the required premium contribution for all consumers who were already eligible for PTC prior to the ARP. These expanded subsidies beganin 2021 and continue through the end of 2022. The ARP substantially increased availability of zero- and low-premium health plans for both current enrollees and uninsured adults.12 Another ARP provision treats anyone in a household receiving unemployment compensation during 2020 as having incomes of 133 percent of FPL, which gives them access tozero- or near zero-premium health plans with minimal cost sharing. 13 The ARP also provided for 100 percent reimbursement of COBRA premiums to employers or health plans from April 1, 2021, through September 2021 for employees who lost employer coverage due to job loss or work hours. 14 The Families First Coronavirus Response Act (FFCRA) of 2020 required states, starting in March 2020, to suspend Medicaid eligibility terminations and maintain coverage for nearly all existing enrollees, in order to receive a 6.2 percentage point increase in their Federal Medical Assistance Percentage (FMAP). This Medicaid continuous coverage requirement was a primary driver behind Medicaid enrollment growth during the pandemic.15 CMSand states also developed numerous strategies and flexibilities to support Medicaid and CHIP operations during this time, often resulting in expedited enrollment and retention (e.g., presumptive eligibility, continuous eligibility, waiving premiums and cost sharing, and regulatory authority to apply exceptions to the timeliness standards for application and renewal processing). Medicaid expansion under the ACAhas also made Medicaid available to more families during the pandemic than during previous recessions. © Finally, two states --Oklahoma and Missouri- expanded Medicaid to adults withincome up to 138 percent FPL April 2022 ISSUE BRIEF 8 in 2021, while several other states had expanded in 2019-2020, and prior research suggests that expansions can take several years to reach full enrollment. 7" Administrative Actions: Outreach and Special Enrollment Period In response to the pandemic, CMS implemented a Special Enrollment Period (SEP) from February 15 to August 15, 2021, 1819 which allowed consumers in the 36 states that used the HealthCare. gov platform in 2021 to enroll without a life change, and later extended the SEP toAugust 15, 2021.2° All 15 State-Based Marketplaces (SBMs) also implemented broad SEPs in 2021 with varying start and end dates. The Department of Health and Human Services (HHS) first announced a $50 million marketing campaign for the 2021 SEP2! and then another $50 million.22, HHS also added $2.3 million for Navigator grants to assist consumers during the SEP (a 20 percent increase from the 2021 OEP).23 The marketing campaigns and Navigator grants helpedto inform and encourage enrollment. Almost half of HealthCare.gov consumers selected a new plan with a monthly premium of $10 or less (after subsidies) from February 15 - August 15, 2021, compared to 25 percent during the same period in 2020.24A total of 2.8 million consumers enrolled in coverage during the 2021 SEPs through HealthCare.gov and SBMs. 2° Nearly 209,000 consumers in the 36 HealthCare.govstates, including 84,000 new consumers, benefitted from the unemployment compensation provisions that qualified them for additional subsidies, from July 1 - August 15, 2021.26 These policy efforts likely accounted for a substantial portion of the coverage gains in 2021. Since the NHIS data currently only extend through December of 2021, they do not yet reflect the record-breaking enrollment in Marketplace coverage during the 2022 OEP, which likely reduced the uninsured rate further, with 14.5 million individuals signing up for or automatically re-enrolling in health insurance coverage through the Marketplaces.278 The large uptickin Marketplace enrollment during the 2022 OEP resultedin anestimated 2.3 million more consumers enrolling and effectuating their health insurance coverage as compared to 2021. CONCLUSION National survey data as well as Marketplace and Medicaid enrollment numbers show that health coverage stabilized and in fact increased in 2021, despite the COVID-19 pandemic. These findings suggest that the efforts to extend affordable coverage through the ARP, state Medicaid expansions, and Marketplace SEP have had a positive impact on providing coverage to individuals, and the results will help inform policy decisions in 2022. Additional analysis on changes in coverage by categories suchas education and state of residence will become possible as more data become available. Data from early 2022 will be criticalin order to assess the full effects of the recent Marketplace OEP, which was the first open enrollment in which the expanded ARP Marketplace subsidies were fully in effect. Future analyses of 2022 survey data will capture the effect of these changes on the national uninsured rate. April 2022 ISSUE BRIEF 9 APPENDIX Appendix Table 1. ACA-Related Enrollment: Marketplace, Medicaid, and the Basic Health Program (BHP), 2014-2022 2014 6,337,860 4,214,218 2,047,055 0 12,599,133 2015 10,187,197 9,103,944 3,002,271 358,000 22,651,412 2016 11,115,044 11,135,415 3,473,065 654,000 26,377,524 2017 10,330,759 12,229,576 3,524,856 772,000 26,857,191 2018 10,643,786 12,338,135 3,305,210 798,000 27,085,131 2019 10,579,744 12,201,118 3,247,188 833,000 26,861,050 2020 10,673,516 12,300,921 3,241,535 866,000 27,081,972 2021 11,290,546 14,849,998 3,890,934 961,000 30,992,478 2022 13,640,4124 16,781,800 4,261,277 1,135,190 35,818,679 Notes: * Marketplace effectuated enrollment figures for 2014 and 2015 are as of 12/31/2014 and 3/31/2015 respectively, versus February coverage as of 3/15 for 2016-2021. Marketplace enrollment data for 2014-2015 are lower quality due to the manual payment processing system in place for those years. 2014 and 2015 Marketplace enrollment figures are published here: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace- Products/Effectuated Quarterly Snapshots. February 2016-2021 data are from the CCIIO Enrollment Payment System and beginningin 2017 have been published in the Effectuated Enrollment Snapshot for the respective year. + Effectuated enrollment for 2022 was estimated applying the February 2021 average effectuated rate of 94% (as of 3/15/2021)to the 14.5 million people who signed-up for coverage during the 2022 Open Enrollment Period, health-insurance-exchanges-2022-open- enrollment-report-final.pdf (cms.gov) # Medicaid enrollment data, 2014-2021, are from the February monthly enrollment (ever enrolled during the month) for the expansion adult eligibility group, as reported by states through the Medicaid Budget and Expenditure System (MBES). 2022 Medicaid enrollment data are from September 2021 monthly enrollment, as this isthe most recent available monthly enrollment count from MBES. Published reports and detailed data information for Medicaid enrollment data, including caveats, can be found at: https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/medicaid-chip-enrollment-data/medicaid- enrollment-data-collected-through-mbes/index.html + BHP programs did not start until 2015. BHP enrollment data are based on average monthly (for Minnesota) or quarterly (for New York) projected enrollment submitted by the states to CMS in advance of the applicable quarter and are rounded to the nearest thousand. BHP enrollment data for 2021 is through May 2021. BHP enrollment data for 2022 is through March 2022. April 2022 ISSUE BRIEF 10 REFERENCES 1 Terlizzi Eand Cohen R. Health Insurance Coverage: Early Release of Quarterly Estimates From the National Health Interview Survey, October 2020-December 2021. Centers for Disease Control and Prevention. National Health Interview Survey. Accessed at: https://www.cdc.gov/nchs/data/nhis/earlyrelease/Quarterly Estimates 2021 Q14.pdf ? Health Coverage Under the Affordable Care Act: Enrollment Trends and State Estimates. (Issue Brief No. HP-2021-13). Washington, DC: Office of the Assistant Secretaryfor Planning and Evaluation, U.S. Department of Health and Human Services. June 2021. Accessed at: https: //aspe.hhs.gov/reports/health-coverage-under-affor dable-care -act-enrollment- trends-state-estimates 3 Chu RC, Lee A, Peters C, and Sommers BD. Health Coverage Changes From 2020-2021. (Data Point No. HP-2022-05). Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. January 2022. Accessed at: https: //www.aspe.hhs.gov/reports/health-coverage-changes-2020-2021 4 Terlizzi Eand Cohen R. Health Insurance Coverage: Early Release of Quarterly Estimates From the National Health Interview Survey, October 2020-December 2021. Centers for Disease Control and Prevention. National Health Interview Survey. Accessed at: https://www.cdc.gov/nchs/data/nhis/earlyrelease/Quarterly Estimates 2021 Q14.pdf 5 Interactive Biannual Early Release Estimates. National Center for Health Statistics. Accessed at: httos://wwwn.cdc.gov/NHISDataQueryTool/ER_ Biannual/index_biannual.html § Dahlhamer JM, Bramlett MD, Maitland A, and Blumberg SJ. Preliminary Evaluation of Nonresponse Bias Due to the COVID-19 Pandemic on National Health InterviewSurvey Estimates, April-June 2020. Centers for Disease Control and Prevention. National Health Interview Survey, February 2021. Accessed at: https: //www.cdc.gov/nchs/data/nhis/earlyrelease/nonresponse202 102-508. pdf. 7 Terlizzi Eand Cohen R. Health Insurance Coverage: Early Release of Quarterly Estimates From the National Health Interview Survey, October 2020-December 2021. Centers for Disease Control and Prevention. National Health Interview Survey. Accessed at: https://www.cdc.gov/nchs/data/nhis/earlyrelease/Quarterly Estimates 2021 Q14.pdf ® Cohen R, Zammitti E, and Martinez M. Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, 2016. Centers for Disease Controland Prevention. National Health Interview Survey. Accessed at: https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201705.pdf 3 Cohen R, Martinez M, and Zammitti E. Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January-March 2016. Centers for Disease Control and Prevention. National Health Interview Survey. Accessed at: https://www.cde.gov/nchs/data/nhis/earlyrelease/insur201609. pdf 10 Cohen R, Martinez M, and Zammitti E. Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January-March 2017. Centers for Disease Control and Prevention. National Health Interview Survey. Accessed at: https://www.cdc.gov/nchs/data/nhis/earlyrelease /insur201708.pdf 11 Biden-Harris Administration Annouces 14.5 Million Americans Signed Up for Affordable Health Care During Historic Open Enrollment Period. Centers for Medicare & Medicaid Services. January 27,2022. Accessed at: affordable- health- -care-during ?2 Branham DK, Conmy AB, DeLeire T, Musen J, Xiao X, Chu RC, Peters C, and Sommers BD. Accessto Marketplace Plans with Low Premiums on the Federal Platform, Part Ill: Availability Among Current HealthCare.gov Enrollees Under the American Rescue Plan (Issue Brief No. HP-2021-09). Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. April13, 2021. Accessed at: https://aspe.hhs.gov/reports/access-marketplace-plans-low-premiums-current-enrollees-american-rescue-plan. 13 Chu RC, Branham DK, Finegold K, Conmy AB, Peters C, De Lew N, and Sommers BD. The American Rescue Planand the Unemployed: Making Health Coverage More Affordable After Job Loss (Issue Brief No. HP -2021-15). Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. July 2021. Accessedat: 14 COBRA Premium Subsidies for Employers and Advisers. Department of Labor. Accessed at: https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/cobra/premium-subsidy-for-employers-and-advisers April 2022 ISSUE BRIEF 11 15 Ruhter J, Conmy AB, Chu RC, Peters C, De Lew, N, and Sommers, BD. Tracking Health Insurance Coverage in 2020-2021 (Issue Brief No. HP-2021-24). Office of the Assistant Secretary for Planningand Evaluation, U.S. Department of Health and Human Services. October 2021. Accessedat: https://aspe.hhs.gov/reports/tracking-health-insurance-coverage. 16 Agarwal SD, Sommers BD. Insurance Coverage after Job Loss - The Importance of the ACA during the Covid-Associated Recession. N Engl J Med. 2020 Oct 22;383(17):1603-1606. doi: 10.1056/NEJMp2023312. Epub 2020 Aug 19. PMID: 32813967. 17 Sommers BD, Kenney GM, Epstein AM. New evidence on the Affordable Care Act: coverage impacts of early medicaid expansions. Health Aff (Millwood). 2014 Jan;33(1):78-87. doi: 10.1377/hithaff.2013.1087. PMID: 24395938. 18 HHS Announces Marketplace Special Enrollment Period for COVID-19 Public Health Emergency. Health and Human Services. January 28, 2021. Accessed at: https://www.hhs.gov/about/news/2021/01/28 /hhs-announces-marketplace- special-enrollment-period-for-covid-19-public-health-emergency.html. 19 2021 Special Enrollment Period Access Extended to August 15 on HealthCare.gov for Marketplace Coverage. Health and Human Services. March 23, 2021. Accessedat: https://www.hhs.gov/about/news/2021/03/23/2021 -special-enrollment- period-access-extended-to-august-15-on-healthcare-gov-for-marketplace-cove rage.html 20 Special Enrollment Period Access Extended to August 15. U.S. Department of Healthand Human Services. March23, 2021. Accessed at: https: /Avww.bhs.gov/about/news/202 1/03 /23/2021-special-enrollment-period-access-extended-to- august-15-on-healthcare-gov-for-marketplace-coverage.html. 212021 Special Enrollment Period in Response to the COVID-19 emergency. Centers for Medicare & Medicaid Services. January 28, 2021. Accessed at: https://www.cms.gov/newsroom/fact-sheets/2021-special-enrollment-period-response- covid-19-emergency. 22 HHS Secretary Becerra Announces Reduced Costs and Expanded Access Available for Marketplace Health Coverage under the American Rescue Plan. U.S. Department of Health and Human Services. April 1, 2021. Accessed at: https://www.hhs.gov/about/news/202 1/04/01/hhs-secretary-becerra-announces-reduced-costs-and-expanded-access- available-marketplace-health-coverage-under-american-rescue-plan.html. 23 CMS announces additional Navigator Funding to Support Marketplace Special Enrollment Period. Centers for Medicare & Medicaid Services. March1, 2021. Accessedat: https://www.cms.gov/newsroom/press-releases/cms-announces- additional-navigator-funding-support-marketplace-special-enrollment-period. 242021 Final Marketplace Special Enrollment Period Report. U.S. Department of Healthand Human Services. September 8,2021.Accessedat: https://www.hhs.gov/sites/default/files/2021-sep-final-enrollment-re port.pdf. 25 2021 Final Marketplace Special Enrollment Period Report. U.S. Department of Health and Human Services. September 8,2021. Accessedat: https://www.hhs.gov/sites/default/files/2021-sep-final-enrollment-report.pdf. 26 2021 Final Marketplace Special Enrollment Period Report. U.S. Department of Health and Human Services. September 8,2021. Accessedat: https://www.hhs.gov/sites/default/files/2021-sep-final-enrollment-re port.pdf. 27 Ahead of January 15th Open Enrollment Deadline, New Numbers Show 14.2 Million Americans Have Quality, Affordable Coverage - Many With Even Lower Deductibles Under the American Rescue Plan. U.S. Department of Health and Human Services. January 13, 2022. Accessed at: https://www.hhs.gov/about/news/2022/01/13/ahead-january-15th-open- enrollment-deadline-new-numbers-show-14-2-million-americans-have-quality-affordable-coverage-lower- deductibles.html 28 Marketplace 2022 Open Enrollment Period Report: Final National Snaphot. Centers for Medicare & Medicaid Services. January 27, 2022. Accessedat: https://www.cms.gov/newsroom/fact-sheets/marketplace-2022-open-enrollment-period- report-final-national-snapshot April 2022 ISSUE BRIEF 12 HP-2022-17 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of the Assistant Secretaryfor Planning and Evaluation 200 Independence Avenue SW, Mailstop447D Washington, D.C. 20201 For more ASPE briefs and other publications, visit: aspe.hhs.gov/re ports ase] =] ABOUT THE AUTHORS Aiden Lee isa Public Health Analyst in the Office of Health Policy in ASPE. Rose C. Chu is an Analystin the Office of Health Policyin ASPE. Christie Peters is the Director of the Division of Health Care Access and Coverage for the Office of Health Policy in ASPE. Benjamin D. Sommers is the Deputy Assistant Secretary forthe Office of Health Policy in ASPE. SUGGESTED CITATION Lee A, Chu RC, Peters C, and Sommers BD. Health Coverage Changes Underthe Affordable Care Act: End of 2021 Update. (Issue Brief No. HP-2022-17). Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Healthand Human Services. April 2022. COPYRIGHT INFORMATION All material appearing in this reportis in the publicdomainand may be reproducedor copied without permission; citation as to source, however, is appreciated. DISCLOSURE This communication was printed, published, or produced and disseminated at U.S. taxpayer expense. Subscribe to ASPE mailing list to receive email updates onnew 'publications: For general questions or general information about ASPE: aspe.hhs.gov/about April 2022 ISSUE BRIEF 13