With the first annual open enrollment period for the Affordable Care Act down to its final few weeks, you are going to hear a lot of spin about the numbers. The end of March will be the first real test of ACA enrollment, because as of April 1, most people will have had to enroll in a health plan that meets the law’s requirements or pay a fine (equal to 1 percent of their taxable income, or $95, whichever is greater).
By the end of March, will the administration be able to say that it met its latest marketplace enrollment target of 6 million (which was lowered from its original 7 million)? As of February 25, the administration reported that 4 million had signed up.
How many who selected a plan will have paid their premium, and if they haven’t, how many will end up being dropped from the enrollment totals? How many will receive tax credits to help them afford the marketplace plans? How many will choose a plan in each tier? Will there be enough younger and healthier people enrolled to offset the costs of covering older and sicker people? If that number falls short, will it lead to a “death cycle” in premiums because insurers will have to raise rates to everyone else?
How many people will sign up for Medicaid? How many of them are newly eligible because of the ACA, and how many would have signed up anyway? And how many people who get covered by the ACA were previously uninsured, compared to those who switch from a plan that didn’t measure up?
It’s going to be dizzying, and for good reason. As the Washington Post’s Sarah Kliff notes, drawing conclusions from the ACA enrollment numbers will be exceedingly hard “Mostly because there's no national database of who is uninsured, who has coverage, and, if they do have coverage, where they get it.”
People will be even more confused by the inevitable spinning of the numbers. The anti-Obamacare crowd will selectively seize on the most negative numbers possible to try to further discredit an already unpopular law; the pro-ACA crowd will selectively seize on the most positive numbers possible to show that the law is beginning to achieve its lofty goals.
The reality likely will fall somewhere in between. Based on what we know now or can reasonably expect:
- Enrollment may fall modestly short of meeting the administration’s revised enrollment goals although still "large enough for the market to function."
- The initial reported end of March enrollment numbers will probably be reduced a few weeks later when the government figures out how many people actually ended up paying the premium. Currently, about one out of five have not paid according to the New York Times and will be dropped from the initial enrollment totals.
- Enrollment of younger people may also fall short although not by enough to create a premium death cycle.
- The number of Americans without health insurance will decrease by several million in 2014 although millions more will remain uninsured—no big surprise, since all along it was expected to take as much as a decade to cover the bulk of the uninsured. Sarah Kliff notes that in its most recent report, the non-partisan Congressional Budget Office determined that "Over time, more people are expected to respond to the new coverage options, so enrollment is projected to increase sharply in 2015 and 2016 . . . Starting in 2017, between 24 million and 25 million people are expected to obtain coverage each year through exchanges, and roughly 80 percent of those enrollees are expected to receive subsidies for purchasing that insurance."
- The enrollment numbers will be a complicated mix of people who previously didn’t have coverage (the uninsured), people who had to switch plans because their old plans didn’t meet ACA standards (some of whom will like their new plans, others who won’t), people newly eligible for Medicaid, people who already were eligible for Medicaid but didn’t know it, and people who left employer-coverage to buy a marketplace plan, either on their own volition or because they had no choice.
- Enrollment will vary greatly by state. Reports of “success” stories in some states with better than expected enrollment are likely to be counterbalanced by reports of “failures” in other states with lower than expected enrollment. For example, as of February 1, Pennsylvania was way ahead of many other states in ACA marketplace penetration: out of 286,926 eligible to enroll in a marketplace plan, 123,680—just over 43%--had signed up. In Delaware, fewer than 24% of eligible persons had enrolled; in New Jersey, it was just over 27%.
You probably won’t hear a lot about the actual people behind the enrollment numbers who have gained the most from the ACA. They include 1.8 million who could not get coverage because of a cancer diagnosis and more than 2.8 million who faced the same hurdle because of a diagnosis of diabetes. “Altogether, more than 5.7 million have been diagnosed with these . . . and similarly serious conditions,” reported health policy scholar Harold Pollack in a recent blog post. For the first time, many of them will have access to affordable health insurance coverage that can’t be denied because of their pre-existing conditions.
Finally, the enrollment numbers from the ACA’s first year need to be taken in perspective. They will represent what happened in the first six months (October through March) of the first year of the ACA’s first-ever open enrollment period. We really won’t know how well the law is doing for another two, three, or four, enrollment periods. Be skeptical of anyone who declares the law to be a resounding success or failure based on the initial numbers, because like any baseball fan knows, you can’t predict how your team will do for the season based on the score in the first inning of Opening Day.