Some quick thoughts on enrollment to date

I’ve mostly abstained from the turbulent month-to-month commentary about enrollment on the insurance exchanges, largely because I don’t think those reports are very useful. The administration reportedly hit their target enrollment target late last week—six million enrolled through the exchanges, though not everyone has paid their first month premium yet—but that’s a fairly empty metric, since it provides little information about the characteristics of that population and risk pooling happens at the insurer/state level.

But I wanted to highlight a story from Noam Levey that pushes back on the notion that Obamacare is failing to reach the uninsured. Levey got his hands on as-of-yet-unpublished survey results from the Rand Corporation. Among other things, Rand reportedly found:

  • Uninsurance among adults has fallen from 20.9% last fall to 16.6% this month.

This is a statistic that needs to be interpreted with caution. Similar Gallup polls have generally shown an encouraging trend in insurance over the last few months, but we need more data to determine how much of the improvement can be attributed to the ACA (versus, say, the recovering economy).

  • 4.5 million people who were previously uninsured have received coverage under the Medicaid expansion.

It’s unclear how many of these people are truly “new eligibles” vs. the “woodwork” population of people who previously could’ve received coverage under the program. It’s my understanding that HHS wasn’t receiving enrollment data from states in a way that allowed them to reconcile this difference, but that information will eventually be forthcoming (sometime in the next few months).

  • 9 million people—most of whom were previously insured—have skipped the exchange, enrolling in plans directly from insurers.

This is less important from a “how much is Obamacare reducing the number of uninsured” perspective, since most people buying direct apparently had coverage. But it does matter quite a lot for risk pooling. Insurers actually pool their on-exchange and off-exchange populations together—however sick the exchange population is, insurers’ risk pools will be tempered by this large off-exchange population. (It’s true that some insurers aren’t offering plans on the exchanges, so that slice of the 9 million doesn’t offer anything to the risk pooling story, but my understanding is that most big players in the insurance markets are offering exchange plans.)

A final point: ACA enrollment was always going to be weakest in year one. CBO set the expectation that 6 million would enroll in the exchanges by the end of 2014—that’s the end of the calendar year (including people who enroll during special enrollment periods), not by March 31. But projections get much bigger over the next few years: Medicaid enrollment is expected to jump 50% between 2014 and 2015.CBO expects enrollment in exchanges to double in 2015, then reach 24- 25 million by 2017.

For those of you looking for a frame of reference, CBO projected that the number of uninsured would fall by 13 million in 2014. It’s unclear whether the ACA will achieve this. But health reform has never happened overnight, and it’ll take us months to fully understand the ACA’s impact in 2014 (to say nothing of future years). Media—and the politics it covers—generally operate on the wrong time scale for nuanced policy analysis, and Obamacare is no exception.

Adrianna (@onceuponA)

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