How the District’s Obamacare exchange is unlike any other

Every Obamacare health insurance exchange is different in its own way, but Washington, D.C., is undoubtedly home to the country's most unique.

The exchange, known as D.C. Health Link, is signing up young adults at the highest rate of any exchange. Meanwhile, D.C. enrollees are far less likely to get help from the federal government to purchase insurance.

Just before the start of October open enrollment, the Obama administration had projected 8,600 would enroll through D.C. Health Link. Through the end of March, the exchange reported 9,838 people signed up for individual coverage, and enrollment is open for another week.

About 46 percent of those signing up for private coverage are between 18 and 34 years old – by far, the highest rate of youth enrollment among the country's 51 public exchanges. The Obama administration and Obamacare allies have emphasized youth enrollment to help fund the costs of insuring older and sicker patients in the insurance marketplaces.

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“We knew that about 60 percent of the uninsured are under age 40,” said D.C. Health Link Executive Director Mila Kofman. “We always planned to be very targeted to younger people, but I have to say I was pleasantly surprised with how well we did.”

Meanwhile, just about 15 percent of those signing up for coverage qualify for federal assistance, which include premium tax credits or subsidies helping with out-of-pocket costs. However, the national rate through February was 83 percent, according to the enrollment report issued by the Department of Health and Human Services last month.

The District’s exchange estimates about 8,800 people are eligible for premium tax credits, available to individuals and families earning up to 400 percent of the federal poverty level. About 1,500 D.C. residents have have signed up for plans with federal aid.

Why such a low rate? Kofman offers several possible explanations. The District’s Medicaid program covers adults earning twice the federal poverty level, who otherwise would have received the most generous subsidies available under the Affordable Care Act. Above 200 FPL, or $23,340, the premium subsidy gets pretty small for young people in particular. A single 27-year-old earning $25,000 per year would qualify for a $37 tax credit for coverage costing as low as $163 per month, according to a subsidy calculator on D.C. Health Link's Web site.

“The tax credit is very small that you would only get a few dollars,” Kofman said.

The exchange has been reaching out out to people who were determined eligible for a subsidy but hadn’t signed up for a plan. Kofman said the Health Link found those people either moved away, started a job with coverage, were determined eligible for Medicaid or believed coverage would still be unaffordable with the tax credit.

There’s also a major difference in what plans people are picking through D.C. Health Link. Nationally, about two-thirds have selected silver-level plans, in which insurers cover 70 percent of the costs. The distribution is much more even in the District, with about 42 percent purchasing more comprehensive gold and platinum plans.

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D.C. Health Link has also run one of the most successful small business exchanges in terms of enrollment, but that’s largely because congressional staffers and lawmakers are required to shop there. Capitol Hill accounts for all but about 500 of the 12,907 people who have signed up through the Health Link’s small business exchange, Kofman said. The rest of small business enrollment comes from 174 companies.

While individual enrollment in the District ends April 15, small businesses can sign up year-round.

“Most of the focus has been on the individual side," Kofman said. "Now we’re switching gears to focus on small business enrollment."

Jason Millman covers all things health policy, with a focus on Obamacare implementation. He previously covered health policy for Politico.
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