THCB

Data Points: More Backroom Chaos and Low State Numbers

Shifting Millennial Attitudes on Obamacare December 2013.
Harvard Institute of Politics. Dec 4th, 2013. Poll

A few observations after 10 weeks of Obamacare implementation.

The Obama administration released the first two months enrollment figures this week. With HealthCare.gov still struggling in November, the enrollment of 137,000 people in the 36 states was expected. The main event for the federal exchanges will play out in December now that most people can navigate it

What I found notable in the report was the lack of robust enrollment in the states. In states where the exchange has been running at least adequately for many weeks now, the enrollment numbers are far from what I would have expected.

California enrolled 107,000 people in private plans in the first two months. But California has cancelled 800,000 current individual health plans effective January 1––all of whom have to buy a new plan by January 1 or become uninsured. The only place those who are subsidy eligible can get a subsidized plan is in the California exchange.

In addition, California has about 2.5 million people uninsured and exchange eligible. A Robert Wood Johnson (RWJ) report estimated that California has 1.4 million of those people eligible for subsidies in the exchange. Given the $250 million in outreach and marketing money the federal government has earmarked for California’s exchange, the dearth of sign-ups so far is concerning.

Similarly, New York enrolled only 45,000 in an exchange plan through November but has over 2 million uninsured. The RWJ report estimated that 563,000 people alone are exchange subsidy eligible. The rule of thumb is that about half of those eligible for the exchanges will be subsidy eligible and half will not. That means that something close to the 563,000 subsidy eligible are also able to buy on the New York exchange.

Washington, the state most believe has done the best job building and running an exchange, has 959,000 uninsured, with RWJ estimating 223,000 are eligible for a subsidy in the exchange, but has only enrolled a total of 17,000 for private insurance in the first two months.

Kentucky has 646,000 uninsured and an estimated 132,000 eligible for subsidies yet has enrolled only 13,000 people in their exchange––both subsidy and non-subsidy eligible.

The rest of the states are either doing no better or are doing much worse.

Health plans I have spoken to are also worried about the people who have enrolled so far paying for their coverage. If an enrollee does not pay their first month’s premium by December 31, their enrollment will be void. So far, the health plans I have spoken to have seen only about 20% of their enrollees pay their premium.

Clearly, December is going to be a big month both for enrollments and premium payments. It’s sort of like going to church on Sunday morning. No one is in the pews 15 minutes before but they all come in the last 5 minutes.

While the open enrollment will continue to March 31, I would have to believe those anxious to get their pre-existing conditions covered, those who look forward having a premium subsidy for the first time, those who are losing their coverage at year-end, and those who just simply value having health insurance, will get themselves signed up by January 1. I will suggest the March 31 deadline is more the deadline for the procrastinators.

Particularly in the states that haven’t had big computer problems, the only thing we can say so far is that the church is pretty empty.

In terms of backroom issues, the problems continue:

  • As of this week, the 834 transaction error rates (enrollments sent from the government to the health plans) are better than they were in October and early November but are still running in the 5% to 10% range––a place they have been for a number of weeks now.
  • The Obama administration has still not built the reconciliation computer system needed to clean up the remaining enrollment data issues between HealthCare.gov and the health plans. The health plans have been told to expect an electronic file in the next few days, containing what the feds think are the health plan’s enrollments through November. The plans will then have to figure out how to reconcile the two lists and then fix the problems. Many plans will have thousands of enrollments to reconcile. There will be another such file coming in January for the December enrollments with likely tens of thousands of more names to reconcile. That means that any December errors will have to be fixed before people can be covered, thereby creating additional customer service issues until the files can be cleaned up.
  • The feds can’t pay the insurers their premium subsidy payments because a payment system has not yet been built. The government is asking the health plans to prepare their own bill and send it to the government for a preliminary payment until this is resolved.
  • The feds haven’t been able to transmit the proper Medicaid enrollment to the state Medicaid plans in the 36 federally run exchange states. So, the feds will be sending an abbreviated “flat file” until that system is built. In the meantime, the states will have to deal with much less eligibility data then they currently require.
  • There have been reports of HealthCare.gov enrolling exchange eligible people in Medicaid instead of the private plan they want (Federal Exchange Sends Unqualified People to Medicaid). No one seems to know how big a problem this is.

How many people’s enrollments––Medicaid and private plans––have been jeopardized by these backroom issues? Until the federal government can do a timely and efficient reconciliation of those who have applied compared to those whose coverage has actually been established by the health plans and state Medicaid programs, there is no way to know.

Robert Laszewski has been a fixture in Washington health policy circles for the better part of three decades. He currently serves as the president of Health Policy and Strategy Associates of Alexandria, Virginia. You can read more of his thoughtful analysis of healthcare industry trends at The Health Policy and Marketplace Blog, where this post first appeared.

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EditorG-MomtlegacyflyerBobby Gladd Recent comment authors
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Editor
Guest

Approve! The site will be fully operational on the front and back-ends in the near future and people will sign up. In 3 years we’ll all be talking about how much this is helping the economy.

http://www.healthcaremarketplace.com

Bob Hertz
Guest
Bob Hertz

Note to T:

I do not know of any precise tax on small businesses by Obamacare.

But going beyond that, if we are going to have an emergency health system that serves everyone, then everyone has to pay for it.

Fire and police departments have worked that way since 1850 in most parts of the country.

I grant that the whole issue is muddled by insurance, but the basic fact remains:

If hospitals are funded largely by taxes, then they do not need to crush patients with user fees

Bob Hertz
Guest
Bob Hertz

Ok, G-Mom, I accept the challenge. What would my alternative solution look like? Here goes: 1. Medicare Part A as the payer of last resort for hospital care. EMTALA claims are paid by Medicare if the patient has no insurance or no financial assets. (their home and retirement funds and $50,000 of savings are exempt). 2. Anyone who does not have health insurance pays an extra 2-3% income tax, in order to help pay for the additional Medicare claims noted above. 3. Any bill by any provider that exceeds Medicare rates can be challenged in a special Health Court. If… Read more »

t
Guest
t

#2, so you believe a tax on the unemployed/under employed and small businesses is a good plan? That’s what we already have with Obamacare.

archon41
Guest

Just consider yourselves the broken shells for a most delectable egalitarian omelette.

G-Mom
Guest
G-Mom

OK, just some clarification questions on your plan, and yes, I’m playing devil’s advocate, but the devil is in the details: 1. What is your definition of “retirement savings?” Pension, 401-K, Roth IRA and other classified investment vehicle? 2. “Anyone who does not have insurance…” I am considered un-insurable, where am I getting this insurance in your world. Are you doing away with pre-existing condition exclusions? I am also self-employed, so where is my insurance coming from? Private insurers? 3. Who is on this “Healthcare Court?” Doctors? Politicians? Elected officials? Appointed officials? Who appears before it? Patients? Doctors? 4. Price… Read more »

G-Mom
Guest
G-Mom

What would a solution look like if it were crafted by those here? If complete single payer was NOT an option and hybrids were not off the table, and you were all actually willing to compromise to create the best option for the American public. Insurance, no insurance, what should healthcare look like?

G-Mom
Guest
G-Mom

How would that solution differ for the assumed “healthy” majority versus the “un-insurable” chronically ill?

Would it be progressive, based on income?

What are YOUR list of covered, necessary procedures?

Bob Hertz
Guest
Bob Hertz

Legacy Flyer is on target

Both Medicare and private insurance overpay hospitals for imaging tests.

The solution of course is something Germany or Japan would have done 20 years ago:

$150 per test, take it or leave it, and no balance billing.

Bob hertz, The Health Care Crusade

Peter1
Guest
Peter1

“$150 per test, take it or leave it, and no balance billing.” Bob, that’s essentially what Japan did – in a single-pay system. The result were much less expensive machines. If you look how corporations cut their budgets, they do across the board cuts and let individual managers and divisions decide what and where to cut. But corporations are essentially single-pay systems with accountability. Legacy and everyone, there’s nothing wrong with Medicare doing blanket reimbursement cuts, the failure is the providers, not looking at ways to make those cuts manageable because they have more than one income stream to keep… Read more »

Peter1
Guest
Peter1

I will also say that insurers are using car dealership tactics in the “low” monthly premiums quoted by ACA exchanges – but with looming high deductibles if care is needed. In the car business it’s, “sell the monthly payment, not the price”, this is particularly true for leases. The advertised monthly payments you see are lease payments because they can hide the buy-out price at the end of the lease. Health insurance premiums are no different, except that your body can’t be repossessed and you will be on the hook for that deductible. It’s a shell game any way you… Read more »

t
Guest
t

Nay-sayers? LOL, count me in. Because of the “Affordable” Care Act, I’m cancelling my plan. I will go without insurance at all next year. Insurance hasn’t been a good value for a long time. The “Affordable” Care Act simply accelerated the path to doom.

I assume that those who call us “naysayers” and other schoolyard names have employer sponsored plans. If you didn’t? you wouldn’t be happy about the policy either. Trust me.

legacyflyer
Guest
legacyflyer

archon41, As a Radiologist, I agree with your comment about “self referral” (or at least that is what I interpreted your comment to mean). What the government has done instead is to ratchet down the reimbursement for outpatient imaging – particularly on the “technical side” to a point where many imaging centers are folding. For the most part, this “cures” the problem of physicians referring to their own offices. It also penalizes those who own outpatient imaging facilities that are not based on self referral. However, as more physicians become employed by hospitals that own imaging equipment, I would not… Read more »

archon41
Guest

I defer to your expertise, but you see what I’m driving at. I don’t see a realistic attempt here to curb the monkeyshines so persuasively documented by Dr. Gawande. I don’t doubt that much “overtreatment” results from a prudent desire to “be on the safe side,” but some are obviously “gaming the system.”

Perry
Guest
Perry

You’re absolutely right legacy, it’s being done right now.

archon41
Guest

If the authors of the ACA had had any serious interest in controlling health care costs, as opposed to creating another “entitlement” for their partisan “base,” they would have, in light of the abuses disclosed by Dr. Gawande (and others), extinguished any financial interest physicians might have in diagnostics, particularly imaging. But they steered well away from that lion’s den, didn’t they? Still, they wear out creation with the claim that alternatives do not exist. It has not escaped the attention of the more cynical among us that some ACA cheerleaders stand to reap a financial benefit from it.

archon41
Guest

Massa sold us down the river.

Bobby Gladd
Guest
Bobby Gladd

Racist much?

archon41
Guest

I’ll tell you what’s “racist”: the crude racial preferences mandated by the provisions of Obamacare dealing with the recruitment and training of new providers.

Bobby Gladd
Guest

Verbatim citations, please?

archon41
Guest

I made reference to the relevant sections of the ACA in comments I made here shortly before it became law, an exercise I do not intend to repeat. Seek and ye shall find.

Bobby Gladd
Guest

“I made reference to the relevant sections of the ACA in comments I made here shortly before it became law”
__

Weak.

Joel Hassman, MD
Guest
Joel Hassman, MD

Just remember anyone reading here who is unbiased and objective, and interested in seeing the system work as best able, there are plenty of commenters here who either cluelessly believe the system is infinite in paying costs, providing services, and access to products, or, they just pathologically want people to cling to false hope and faith and just strip all who are inattentive or gullible for every buck until they are spent, or dead. Yeah, that is a harsh statement above, so is this legislation and how it is being implemented to just favor cronies. What is going on now… Read more »

Joel Hassman, MD
Guest
Joel Hassman, MD

In times of desperation, when legitimate and respectable defenses can no longer be utilized, turn to the Saul Alinsky playbook. After all, isn’t this legislation really just about winning, not about caring? What is sad and unchangeable is there is an entrenched 25-30% of the public who will defend this legislation even if it approached the potential to cause violence to see it stay in place. And, I honestly believe those in power would not hesitate to see things deteriorate to that level. It is what extremist zealot ideology entertains. Let’s have a moment of brutal candor here, the Left/Progressives/Democrats,… Read more »

archon41
Guest

We have met the One Percent, and he is us.

Kim S.
Guest

There are still a lot of misconceptions and misinformation about what the Affordable Care Act means. Like any new system, it’s met with ridicule, nay sayers and resistance. Is it perfect? Hell, no. Will it get better? It will as the problems get worked out just like with any system. Many believed the same about Social Security and Medicare. I was one of the first who enrolled once the website opened and I’m from Illinois. I’ve lived in an unfair system where if you don’t get insurance from your employer and you need good private insurance either you have to… Read more »

Peter1
Guest
Peter1

“More Americans getting insured will be better for our country in the long run.”

No, more Americans getting the appropriate medical care will be better in the long run. Insurance is not care, the “system” is not sustainable.

Kim S., can you describe your policy and do you get a subsidy? Do you have an opinion on those of moderate income not receiving a subsidy but now forced to “pay top dollar”?

archon41
Guest

What music more sweet, than the indignant squealing of our “moral elites”? Don’t miss With Affordable Care Act, Cancelled Policies for New York Professionals (Anemona Hartocollis, NYT, 12-13-13.)

Dr. Rick Lippin
Guest
Dr. Rick Lippin

Peter 1 –

Your comments above very interesting and helpful- Thanks

archon41
Guest

The proposals urged by my “progressive” friends share several conceptual flaws. They all assume that the costs of health care can be significantly reduced by eliminating “huge” insurer profits and “overhead.” When asked why, in that case, the savings of large, self-insured employers have been so modest, they have no credible response. These proposals also reflect a profound reluctance to take prompt and vigorous action against the abuses revealed by the studies of Dr. Atul Gawande. This situation has become intolerable. “…a quarter of all health care dollars are spent on defensive medicine–about $650 billion a year.” (How to Fix… Read more »