Dive Brief:

• The Affordable Care Act online marketplaces reported a drop of 2.5 million unsubsidized shoppers between 2016 and 2018. Unsubsidized shoppers are those who don't qualify for subsidies to help them purchase affordable coverage.
• While unsubsidized enrollment declined 24% over that two-year span, enrollment among those receiving subsidies increased 4%, CMS said in a report Monday.
• The decline in enrollment comes as average monthly premiums went up, particularly for those in the unsubsidized market who are not shielded from steep increases.

Dive Insight:

The gap between those on the exchanges with subsidized coverage and those without it continues to grow. Last year, the subsidized market was 122% larger than the unsubsidized.

What's staggering is the number of states that lost at least 50% or more of their unsubsidized shoppers. Iowa lost nearly all of its unsubsidized enrollment by 2018. From 2017 to 2018, the state experienced an 85% drop among its shoppers who didn't receive subsidies. Five other states lost 50% or more of its unsubsidized market over the same period, including Georgia, Nebraska, Tennessee, Virginia and Kentucky. 

But Cynthia Cox, vice president at the Kaiser Family Foundation, attempted to put Monday's numbers into context, noting there are still more people buying coverage now than there were prior to the ACA.

Still, the average monthly premiums are out of reach for some — at nearly $600 as of February. About 87% of those on the exchange in February received a subsidy, which drove their average premium down to $514.

"I think the report does raise concerns about affordability of coverage for people without a subsidy. Even though premiums dropped a bit on average going into 2019, coverage is still too expensive for people who make just too much money to qualify for a subsidy," Cox told Healthcare Dive.

A recent KFF analysis found that affordability depends largely on where shoppers live, based on 2019 premiums. For example, a 60-year-old earning $50,000, or slightly above 400% of the federal poverty level, would spend 32% of his or her income on the lowest-cost plan in Thomas County, Nebraska, or $1,314 in average monthly premiums.

But that same 60-year-old would spend only $384 in monthly premiums, or 9% of income, in Albany County, New York.

As those with middle incomes struggle to afford coverage, some states such as California are attempting to craft policy fixes for them that would expand subsidies to middle-income earners. It would also reinstate the individual mandate, forcing many Californians to have coverage or face a fine.

The drop in unsubsidized enrollment comes as the Trump administration has also ushered in an expansion of lower-cost plans that do not comply with ACA protections. And Congress has zeroed out the individual mandate financial penalty. It's unclear from CMS' report how these actions affected enrollment.