Short Takes On News & Events

Parsing The President’s 9 Million Enrollees

By Julie Appleby

January 29th, 2014, 1:37 PM

Nine million. That’s the number President Barack Obama touted last night as having signed up for health insurance.

President Barack Obama delivers the State of the Union address in the House Chamber at the U.S. Capitol in Washington, D.C., Jan. 28, 2014. (White House Photo by Pete Souza)

That total is important to supporters as a sign that the law is working — and as an indication of the difficulties Republicans would face to rescind the law or roll back certain provisions. Critics have pointed out that 9 million isn’t a huge number — and that some of those people, perhaps even many of them, were previously insured.

Here’s the breakdown supplied by the administration: 3 million have signed up for private plans through the federal and state health exchanges since they opened for enrollment in October. Another 6.3 million have been deemed eligible for Medicaid in the past three months of 2013.  In addition, the administration had previously said that 3 million young adults under age 26 have been able to stay on their parents’ plans under the law.

Let’s parse those numbers a bit:

1) The 3 million enrolled in private coverage

A surge in late December and early January helped push enrollment totals to about 3 million despite the troubled rollout of the federal exchange and some state marketplaces. It puts sign-ups almost halfway to meeting the Congressional Budget Office projection that 7 million  would sign up the first year with another two months left to go in open enrollment.

What’s not known is how many of those 3 million have actually paid their first premiums, which is a requirement to become covered.  So the number could be less. On the flip side, it also isn’t known how many people bypassed the federal and state marketplaces and signed up directly with insurers, so the number could be higher.

And the administration has released only limited information on enrollees. Are they mainly the sick, who are clearly more motivated to enroll despite the difficulties with the websites? Or is it a good mix of the healthy and the sick?

Data released by the administration earlier this month showed that 33 percent of enrollees were ages 55 to 64, while 24 percent were 18 to 34.

While advancing age is generally associated with more health problems — and higher costs — there is no way to tell the health status of enrollees. The law bars insurers from denying applicants with health problems, so no questions about past issues are asked. As a result, whether insurers have correctly calculated the costs — and set their premiums accordingly — won’t be known until well into the year when actual claims costs can be analyzed.

Is the law reducing the number of uninsured, which was one of its main goals?

Some reports, including a McKinsey study cited by the Wall Street Journal, have said few of those enrolling were previously uninsured.

Using an online survey of 4,500 people who were uninsured, bought their own coverage or said they were losing job-based plans, McKinsey estimated that most people who have enrolled were renewing or replacing existing policies. This follows a spate of news stories about people who sought to buy coverage only after learning that their existing individual policies were not being renewed because they failed to meet some of the law’s requirements.  Only 11 percent in the McKinsey survey reported they were uninsured in 2013.

No one knows if the sample used by McKinsey accurately reflects those who have signed up.

Still, the McKinsey report offered some cause for optimism for the law’s backers, noting that of those who had not yet enrolled, 26 percent said they intended to do so. The majority of those respondents said they were uninsured. “This suggests a higher percent of prospective market growth from those previously uninsured” if issues such as cost and website problems can be addressed, the report said.

The most telling tabulation of whether the law reduced the number of uninsured won’t come until well into 2015 when the Census Bureau releases figures for 2014.

But remember those under-26-year-olds? The provision allowing them to stay on their parents’ plans went into effect in 2010. The census has reported a drop in the uninsured rate among 19-25-year-olds since then, even as the rate for 26-34-year olds remained stable.

2) The 6 million enrolled  in Medicaid

What’s not clear from the Medicaid sign-ups cited by the administration is how many of those were renewing coverage or were qualified under the old rules, compared with how many are new under the federal law’s expansion.  Under the law, states can expand coverage to all those under 138 percent of the federal poverty level, about $26,951 for a family of three, with the federal government picking up 100 percent of the cost for the first three years.

Half the states and the District of Columbia have expanded their Medicaid programs to cover more people. Many states are keeping the old rules for Medicaid, which often do not cover adults without dependent children, no matter what their income level.

So, 9 million Americans may well have signed up, but a lot remains unknown about who they are. Supporters and critics alike will use the figures anyway, but it will be a while before a full assessment of the law’s effect can be reliably made.

7 Responses to “Parsing The President’s 9 Million Enrollees”

  1. The husband of one of my friends, formerly uninsured, has signed up with Obamacare in Michigan. He is sick and, until now, could not afford to see a doctor. If he follows his doctor’s advice, he may live longer than the 5 years I project without medical care.

    I treated many medically indigent adults at our County Clinic, who will now be covered. They will not have to wait for a volunteer doctor/facility to repair a hernia, replace worn out hip joints, or excise basal cell cancer from the nose.

    Frankly, statistics are less important than individuals. Obamacare is the right program, but will need tweaking. One can only hope that Republicans will find their brains so they can make positive suggesting to improve outcomes and improve value.

    Obamacare requires 3 tiers instead of 5, raising costs to the young. Obama care requires patients to add additional benefits, like preventive care and OB, previously eschewed. So our government may have overreached with a paternalistic play. Preventive care is not cost-effective except for immunizations. Health Policy Guru’s may have overplayed their hand.

  2. Sharon Postel says:

    We know that Obama’s 9 million is specious (signed up is not enrolled – evidenced by paid premiums to private insurers or eligibility confirmed by state Medicaid agencies and enrolled in managed care organizations) …

    … because the media are not touting the number. They know the flaws and short-comings of the current counts by USDHHS. And you had better believe that USDHHS has ALL THE DEMOGRAPHICS, ENROLLMENT, ETC. statistics and they are really weak. The SOTU statement was parsed by Obama staffers and its words are OK. The truth? Who knows.

  3. George Fulmore says:

    One source says that the percentage of legal Americans without health insurance has dropped almost one percent already. That is the primary goal of obamacare: reduce that percentage. Most of the folks that will be added formerly have not been able to afford insurance.

  4. Barbara Elmore says:

    Parsing the numbers often means that people who enrolled don’t fit into narrow categories. How about a category for those of us who were previously under-insured and could have kept their policies but did not wish to? Also, although Kaiser reporting has been excellent, the errors have weighed heavy on the government’s side and pretty much let the insurance companies off the hook. One such company, whose workers I have talked to repeatedly in the last month because of a less-than-smooth transition from one of their policies to another, failed to staff its call lines appropriately because “we did not know what to expect.” I think all parties failed to anticipate the deep interest and broad need for this reform. Of course it will get better once we all learn how to do it.

  5. Many of the comments, pro and con, insinuate the notion that there are only two choices: “ObamaCare” (the more distorted status quo) and the previous original status quo. Neither position fixes anything because each fail to deal with the fundamental cost driver: Third-party financed, prepaid care that comes with an unhealthy dose of government defined benefit programs (as opposed to defined contributions). You thought I was going to say malpractice or defensive medicine, didn’t you. Nope. Defensive medicine and the legal costs associated with it only make up about 10% or less of the total cost of health care.

    ObamaCare is unsustainable for most of the same reasons that the old system was unsustainable: 1) A huge portion of the costs/expense are paid for by other poeple’s money in form of taxes, subsides, artificial price supports, price caps and insurance company stop-loss guarantees – 2) employer-favored tax incentives that don’t apply equally to individuals shopping for coverage in the individual market same as pre-Obamacare – 3) defined benefit programs that are financially unsustainable as opposed to defined contribution model – 4) Related to #3, the financial incentive are all screwed up in ObamaCare – government pays insurers to take excessive risks, levies reinsurance taxes on certain policies in the small business market, takes money away from lower risk pools with cheaper premiums, etc… 5) Mandated coverage without mandating savings for same (See Singapore)

    6) ObamaCare further distorts the financial checks & balances in the market by removing the ability to asses risk and allowing insurance to be purchased AFTER someone gets sick (like purchasing home insurance after your house catches on fire) – 7) mandates unnecessarily expensive “one-size fits everyone” coverage – 8) prices that coverage artificially low in some cases and unnecessarily high in others – 9) forces people into Medicaid even if the don’t want it – 10) treats small employer market differently than the large

    ObamaCare just piles more expense, cost shifting, and unnecessary mandates; all of which just doubles down on the dysfunctional characteristics of our current third-party dominated system. ObamaCare is a knee jerk, wrong-headed political reaction to something that needed an economic & fiscal policy fix and a tax reform fix. As an analogy, ObamaCare is like taking a water balloon filled to the point of breaking and then squeezing it in the middle and hoping the ends don’t break open.

  6. Bill Baar says:

    Re: They will not have to wait for a volunteer doctor/facility to repair a hernia, replace worn out hip joints, or excise basal cell cancer from the nose.

    Having insurance doesn’t take the “wait” out of healthcare. They may well wait longer than they would have for free care, and also find themselves with steep deductables they can’t pay.

  7. A fair overview of the situation, but you’re missing quite a bit.

    First, in addition to the 3 million “fully enrolled” Private QHP folks, there’s an additional 117,000 people (at least) who have enrolled but who hadn’t paid as of a few weeks ago; some or all of these should be paid in full by now.

    Second, there’s at least 51,000 employees who have enrolled via the ACA’s SHOP market for small businesses (the federal version isn’t online yet but many of the state ones are).

    Third, there’s a minimum of 96,000 people who have enrolled in private QHP’s *directly* via insurers (you mentioned this briefly, but the numbers appear to be huge…this 96K is from 2 insurance companies alone)

    Fourth, the above data mostly only runs through around January 22 (just before the “3M” announcement). We have over a week’s worth of additional enrollments which haven’t reported in.

    All told, the tally through the end of January looks like it will end up somewhere around 3.3 million or higher.

    On the Medicaid side, you state: “What’s not clear from the Medicaid sign-ups cited by the administration is how many of those were renewing coverage or were qualified under the old rules, compared with how many are new under the federal law’s expansion. ”

    Actually, I’ve done an extensive analysis using the HHS reports, CMS reports and more recent reports from individual exchanges whcih puts the grand total of NON-RENEWAL Medicaid/CHIP enrollments at just shy of 7.4 million people, when you include *direct* (off-exchange) enrollments.

    Now, this figure *does* include those who were previously eligible but weren’t enrolled earlier (the “out of the woodwork” crowd), but it does NOT include any renewals of existing Medicaid/CHIP enrollees.

    I should note that while the CMS refuses to officially confirm my final tally, they have agreed that my methodology is sound.