That’s in honor of the 7 million enrollees in the exchanges — or whatever the number really was.
1. Leading up to the end of open enrollment at midnight, there certainly was a surge: HealthCare.gov alone (there are 14 other exchanges, including New York’s and California’s) apparently saw 3 million visitors yesterday, and 1 million sign-ups occurred between last Thursday and midnight tonight, and 200,000 on the day of. SEIU of the Bay Area made 20,000 robocalls in Vietnamese, for goodness’ sake — so thanks Big Labor, though the surge almost surely had a lot more to do with people’s procrastination than it did any ultra-effective PR campaign at the last minute.
The AP reported this evening that the number of sign-ups was on track to hit 7 million — which Secretary Sebelius had set out as a reasonable goal last fall for the open-enrollment period. This was all despite the fact that the website was down for maintenance at various times, was still spitting out errors, and couldn’t create new accounts at one point on Monday. All of which means that there will be some surely non-negligible number of people who will be completing their enrollments after the fact, as HHS said a while ago they’d allow them to do. By HHS’s definition of enrollments, it should be over 7 million.
2. This 7 million is definitely not the same thing as the 7 million insured individuals the CBO had projected the exchanges would cover this year, though it’s a convenient coincidence. Whatever Secretary Sebelius’s exactly meant when she mentioned the same number as a metric for success last fall, the actual plan purchases the CBO was projecting seem likely to short of the 7 million number: If 85 percent of sign-ups pay their premiums, to take one estimate, that’s about 6 million people who actually get plans.
Moreover, the CBO’s 7 million projection was for covered individuals over the course of the year — since it’s a budgetary projection, this is an average over the course of the year, and not a specific number of individuals (e.g., it could be 7 million people covered for the whole year, or 6 million covered for the whole year plus 2 million for six months each, etc.). Surely as many people will drop off the exchanges as will join them because they lose a job or other insurance later this year, so we shouldn’t expect too many net new signups. Paid enrollment could even shrink noticeably.
But if HHS continues to count anyone who picks a plan on the exchange as an enrollment — and someone who’s gained insurance thanks to the ACA – we could be seeing a substantially larger enrollment number by the end of the year, a good bit over 7 million. Which will be a meaningless number, since the question should be how many people the program is covering, not how many have ever enrolled, but it’s possible they trot it out. (They’ve certainly been shameless about the Medicaid numbers.)
3. Now that you’ve taken the time to digest that: The CBO’s number is meaningless, it’s just a projection they did with their models. If the law had missed it hugely, it would show that HHS clearly didn’t execute the law as expected — but they did, somehow. We learned last fall that the federal government is incredibly bad at executing IT projects. But we learned this spring that by sheer dint of investment and effort, the feds plus Lebron can indeed get several million people signed up for health insurance. But that isn’t saying a lot, so how should we actually assess the law at this deadline?
4. Perhaps this is obvious, but there’s no one metric or threshold for whether the law “succeeds” or “fails.” For months, the media — and Republicans salivating over slow enrollments — focused on whether the exchanges would see near the number of enrollments the CBO and HHS projected and Sebelius targeted, while Joe Biden scrambled to redefine what a “helluva start” would look like. That wasn’t meaningless: Meeting the projection meant the law had been executed as designed, and it looks like HHS may still fall a bit short of that when and if they ever translate sign-ups into paid enrollments.
But there are plenty of more important questions: Will the law do what it set out to accomplish? Now Democrats are trumpeting having met the arbitrary metric, while Republicans are ignoring it and drawing attention to the number of plans bought by the previously uninsured — we don’t have a good idea of how that’s gone, though survey estimates suggest less than half of enrollees were uninsured last year, maybe something like a third or a quarter. (A note: The exchanges can be increasing insurance coverage otherwise, too — someone could be insured last year while only insured this year because of the ACA. The simpler way to describe this is that insurance is a continuous-time Markov chain — get it?)
If these estimates are correct and the Medicaid expansion turns out as skeptics expect, the number of uninsured will not drop all that substantially. It’s very hard to see it dropping by the 13 million people the CBO projected earlier this year. That would be a substantial miss this year, though, of course, reducing the number of uninsured is a long-term project for the law. Even longer-term, we will see if the ACA’s expansion of insurance makes Americans healthier and help them get health care more efficiently.
There’s also the question of whether the law is doing this at a reasonable cost and in a sustainable economic manner. Expect more focus on those two questions over the next year: Cost estimates will come in, premiums will get set for next year, insurers will have to decide whether to stay in the exchanges or not, etc. The raw number of enrollees and even their ages are only weak proxies for how costly the risk pools will be for insurers — it all depends on how sick enrollees are. Moreover, each state is its own risk pool, so the overall federal metrics don’t determine actuarial success or failure.
5. Enrollees from the surge may bring good news and bad news: On the one hand, one assumes that the people signing up for health insurance toward the end of the open-enrollment period — the 1 million signups over the last week — were more likely to be uninsured before the law, since they almost surely went a few months without insurance at the beginning of this year. That tallies in the law’s favor — as does the fact that marginal and reluctant enrollees are likely to be healthier than the eager enrollees from earlier in the process. But on the other hand, these people, though they’re more likely to qualify for generous subsides, are going to be among the most likely to stop paying their premiums at some point or never pay at all.
To get maximally cynical, many of them may have been pressured into signing up at the last minute along with assurances that their “enrollment” didn’t involve any financial obligation at all — since it didn’t. That could further depress the number of actual enrollments from the 7 million headline and make the surge more of a PR stunt than a real accomplishment, though when we’ll get an answer on that is unclear.
6. This wasn’t the deadline in a few states. People in states that have especially problematic exchanges have been given extensions by the federal government for the open-enrollment period: Oregon has a full month for all enrollees, Nevada is giving enrollees two months if they attempted during the open-enrollment period to use the state’s entirely broken exchange, etc. In most states, though, the grace period is more limited — just for people with open applications, and for just two weeks. It’s unclear when users of HealthCare.gov with pending applications will have to complete theirs.
This may boost enrollment from current levels, but it’s a big headache for insurers in those states: Every extra day when significant numbers of enrollees are still singing up is another day that they have to accept new customers that they don’t know much about — when the deadline for setting 2015 rates is just a month or two away. This could make them skittish about staying in the exchanges, more likely to raise premiums next year, or simply more likely to lean on various federal subsidy and reinsurance programs (risk corridors, etc.) this year and the next.
7. Enrollments will continue. “Open enrollment” has closed and won’t re-open until October 1 of this year, when people can buy coverage to begin January 1. But if you lose a job, have a child, or lose insurance for some other reason, you’re eligible for a “special enrollment period” for 60 days after the fact, at any point in the year. This will presumably be available, for instance, to enrollees in Obamacare’s “high-risk pool” insurance program for people with preexisting conditions, which was supposed to end December 31 but the Obama administration repeatedly extended. It now ends April 30, at which point enrollees will need insurance. Just how many of those people are still in the program, and how many will sign up for the exchanges over the course of the year, we don’t know.