Wealthier people are ditching the ACA exchanges

The universe of people covered by the Affordable Care Act keeps narrowing.

Between the lines: People who make too much money to qualify for help paying their premiums are fleeing the ACA’s insurance exchanges. But the exchanges are still pretty stable for people who receive premium subsidies, according to new federal data.

You can see two clear trends in these data.

• First, unsubsidized enrollment has fallen as premiums continue to rise. That makes sense: If you’re on the hook for your entire premium, you’re more likely to bail when those premiums rise.
• Overall enrollment tapered off under the Trump administration, which also makes sense: Trump’s policy decisions contributed to big premium spikes in 2018, and he has also expanded access to non-ACA options that may be more attractive to healthier, unsubsidized people.

My thought bubble: This is the continuation of a somewhat ironic trend. As the ACA’s coverage expansion has shrunk, the law has evolved to look more like a traditionally liberal health care program.

• Part of the initial goal was to create a competitive marketplace that would benefit even the middle-class households too wealthy for a premium subsidy.
• That’s the part that has fallen by the wayside as the ACA’s coverage expansion has narrowed down. Now it’s mainly direct government assistance — through Medicaid and premium subsidies — that’s concentrated among the poorest households.

Go deeper: The ACA is smaller, weaker and more liberal than Obama intended