Key takeaways
- During the 2024 open enrollment season, a record number of individuals and families enrolled in marketplace coverage.
- Record enrollment was driven by more affordable monthly premiums.
- Marketplaces provided private insurance for many no longer eligible for Medicaid.
- Marketplaces attracted new enrollees across key target populations — including children, young adults, older adults, and across rural communities.
Marketplaces strengthen role as a bridge to coverage with record 2024 enrollment.
Over 21 million individuals enrolled in coverage through the health insurance marketplaces during 2024 open enrollment — the highest marketplace enrollment to date.
This continues an enrollment growth trend fueled by increased affordability and coverage transitions during "Medicaid unwind."
SBMs report growth trends after the institution of an enhanced advanced premium tax credit program (APTC) in 2021.
Growth was further accelerated last year as SBMs coordinated with Medicaid agencies during “Medicaid unwind.” SBMs are a critical landing space for individuals and families transitioning from Medicaid.
Enhanced advanced premium tax credits lowered costs and expanded access to health insurance for millions.
The enhanced APTC structure, originally enacted under the American Rescue Plan Act (ARPA), makes private health insurance more affordable by:
- Increasing the amount of tax credits available to enrollees, which lowers monthly premiums
- Eliminating the income cap to recognize that middle-class families and moderate-wage earners alike struggle to afford premiums
- Enabling those with incomes of approximately $22,500 or less to purchase coverage for $1 or less a month
More individuals have enrolled in comprehensive coverage at a low cost.
The enhanced APTC structure makes comprehensive health plans widely available for ≤$10 per month for lower-income households.
Other factors, including increased enrollment among young adults and state affordability initiatives, also contribute to lower monthly premiums across marketplaces.
SBMs report significant growth in enrollment in low-cost coverage.
Low-cost options eased transitions for those on the cusp between coverage programs.
SBM data indicate growth in enrollment from low-income families, many of whom sit at the cusp of eligibility between Medicaid, CHIP, and marketplaces.
Availability of no- or lower-cost premiums, enabled by enhanced APTCs, eased transitions for many transitioning from Medicaid.
Enhanced tax credits benefited middle-income families who newly qualified for benefits.
The new tax credit structure ensures that all individuals have access to coverage that costs no more than 8.5% of income, which previously only applied to individuals and households at or below 400% of the federal poverty level (FPL).
This has contributed to growth in enrollment across these mostly middle-class individuals and families. Enrollment in this group has more than doubled since 2021 in CA, CO, ID, MN, NJ, NV, PA, and VT.
Enrollments are up among children, young adults, and “pre-retirees.”
While trends vary by SBM, many report significant enrollment increases across key age groups, especially:
- Young adults, who often forgo coverage, are essential to a healthy risk pool, helping to reduce overall premium costs
- Children, a top target for states whose goals are to ensure access to early intervention services
- Older adults or pre-retirees, who often fall into coverage gaps due to moves to self employment, loss of employer-sponsored insurance, and high-priced, age-rated coverage
SBMs report success in reaching target groups during the 2024 season.
Supporting Small Businesses and Employees
DC’s HealthCare4ChildCare (HC4CC) reduces health insurance premiums paid by child development facilities for their eligible employees. More than half of small businesses enrolled in the program did not previously offer health coverage. In the program’s first year, DC doubled the number of HC4CC businesses in its small business marketplace.
Other SBMs report similar stories of supporting small business owners and families to access coverage. From Washington:
“I had been working for a local school district for 13 years when I decided to venture out and follow my dream come true — opening a flower shop!… Once [our broker] was able to get a clearer picture of our financial situation, she was able to access the subsidies available through Cascade Public Option plan. Our payments are now going to be approximately $108/month and the most we will pay for my husband’s cancer treatment is $2,500!!!
Anonymous, Washington
Enrolled in coverage through Washington HealthPlanFinder
Supporting Rural Communities
Enrollment across rural counties grew significantly across many SBMs. From 2021-24, enrollment in Jackson and Letcher Counties in Kentucky grew by 65% and 44% respectively. Enrollment in Franklin and Yakima counties in Washington both increased by 55%. In Charles, Washington, and Wicomo counties in Maryland, enrollment grew by over 30%, and Vermont saw enrollment grow by approximately 20% or more in Essex, Lamoille, and Windham counties. In some cases, rural enrollees have also experienced cost savings since 2021. For example, Idaho reports that net premiums lowered by at least 16% in Cassia, Lemhi, and Madison counties since 2021.
Supporting Communities of Color
In Maryland, Black and Hispanic enrollment was up 33% and 30%, respectively, after focused marketing and outreach to these groups this year. Kentucky also reported a 62% increase in Black/African-American enrollment and a 78% enrollment increase for Hispanic populations. California reported similar increases, including a 31% increase for Latinos, an 18% uptick for Asian-American and Pacific Islanders, and an 11% jump for African Americans. New Mexico doubled enrollment for Native American populations. From 2021–24, Washington reports significant leaps with 124% growth for Hispanics, 107% for Black/African Americans, 85% for American Indians and Alaska Natives, 707% for Ukrainian speakers, and 130% for Russian speakers.
Notes
- Information based on data reported by state-based marketplaces in CA, CO, DC, ID, KY, MA, MD, MN, NJ, NM, NV, NY, PA, VT, and WA.
- Where necessary, data was supplemented by Marketplace Public Use Files available through the Centers for Medicare & Medicaid Services: https://www.cms.gov/data-research/statistics-trends-and-reports/marketplace-products
