As pandemic flexibilities unwind, here's how enrollment in different types of coverage could change

As flexibilities rolled out during the COVID-19 pandemic wind down, there will be plenty of factors at play that could impact uninsured rates in the coming years.

Analysts at the Congressional Budget Office (CBO) project that while the rate will increase from current levels, it will decline over the next decade from pre-pandemic levels. They estimate that 10.1% of people will be uninsured in 2033, down from 12% in 2019, according to a new study published in Health Affairs.

By comparison, the CBO estimated that 248 million people under 65 in the U.S. have coverage this year, and 23 million people in that age group, or about 8.3%, are uninsured.

"Importantly, those projections take into account many estimated components, including demographic, economic and behavioral variables, and are conditioned on the assumption that current laws stay in place," the researchers wrote.

The CBO analysts said that the current record lows in the number of uninsured people are tied to continuous coverage provisions in Medicaid and expanded subsidies for plans on the Affordable Care Act's (ACA's) exchanges. Those continuous coverage mandates have expired with the public health emergency, and states have begun the lengthy process of working through that backlog of eligibility determinations.

CBO projects that 9.3 million people under aged 65 will move from Medicaid to other forms over coverage over the next two years, and 6.2 million people will become insured.

The enhanced ACA subsidies led to record enrollment in exchange plans, and those were extended for several years. However, should they expire in 2025 as they're currently set to do, it will likely lead to 4.9 million people signing up for marketplace coverage, according to the report.

Some of this population will shift to unsubsidized group coverage or employer plans, and some will become uninsured, CBO projected.

Even as these coverage shifts occur, the CBO analysts said that employer-sponsored coverage will remain the largest source of insurance. They projected that average monthly enrollment will be between 155 million and 159 million over the next decade.

In addition to examining how people may move between types of coverage, the CBO report also estimates how premiums could change over the next several years. The researchers projected that premiums will go up by 6.5% in 2023 and then by an average of 5.9% between 2024 and 2025.

In the 2026 to 2027 time frame, premiums could increase by 5.7% on average and then by an average of 4.6% from 2028 to 2033.

"The higher short-term growth rates partly reflect a bouncing back of medical spending from the suppressed levels of utilization during the initial months of the COVID-19 pandemic in 2020," the analysts wrote.