Graphic Credit: AP
For the record and as we crawl chaotically towards repeal & replace or repair, the final numbers on ACA enrollment for 2017 are in. They reflect coverage in the 39 states that operate through healthcare.gov plus the 11 states and DC that run their own insurance exchanges.
A total 12.2 million people signed up. That’s 3% to 4% fewer than last year. HHS and the Associated Press (AP) put enrollment through healthcare.gov at 9.2 million; AP puts the number of enrollees in the 11 states plus DC at 3 million.
Of the 9.2 million who signed up through healthcare.gov, 6.2 million were returning customers and 3 million were new.
According to an analysis by Charles Gaba, who runs the website acasignups.net, enrollment through healthcare.gov was down about 5% while enrollment in the 11 states and DC was up 2%.
Gaba and other analysts attribute the healthcare.gov decline to consumer confusion about the fate of the ACA and the Trump administration’s pull back on consumer outreach and ads in the final weeks of sign-up in January. So the last minute rush this year was much reduced.
AP analyzed where the sign-ups occurred, state by state, and found that 7.8 million enrollees live in states that went for Trump in 2016 while 4.4 million live in states that went for Hillary. Here’s a map of this analysis.
The total number of enrollees fell short of the 13.8 million the Obama administration projected early last fall.
But I think the fact that enrollment was not 10% to 20% below last year’s is a minor miracle for three reasons: (1) premium increases exceeding 10% to 15% in many states; (2) widespread media attention to those premium increases, and (3) tremendous and hyperbolic negativity surrounding Obamacare during the 2016 campaign and from President-Elect Trump and Republicans starting on November 9. (“It’s a Disaster.” “We will kill Obamacare as soon as possible.”)
What does this tell us? Quite simply, that the need and desire for coverage is as strong as ever, and is independent of political winds and ideology because it involves people’s medical and financial security, and choices for their families.
That is increasingly clear to Republicans at the moment, as they ponder repeal & replace and the fix they got themselves into with all that loose talk.
Of course, sign ups are just that. People who enrolled must now pay their premiums. There will be attrition as in the past. The average dropout is 15% to 20% per year, occurring throughout the year. Some don’t even pay the first month’s premium. New enrollees also enter the program during the year, due to qualifying events. That’s a part of the program that Republicans have alleged allows for too much “gaming”—and they are almost certain to make mid-year entry stricter this year.
The big question, though, is whether the dropout rate this year will be even higher because premiums are higher. That will be closely watched and very likely have an impact on the repeal & replace debate.
HHS is due to release a full analysis of 2017 enrollment in March. We’ll see if that analysis, which under Obama was more or less apolitical, is tainted.
We’ll be getting some fresh analysis of the Medicaid expansion soon, too, from various sources. As a reminder, 32 states and DC chose to expand Medicaid under the ACA; 19 chose not to. In 2015 and 2016, an estimated 12 to 13 million people were covered through the expansion.
Notably, a study by Jonathan Gruber at MIT published last November found that about two-thirds of people who gained coverage through the Medicaid expansion would have been eligible under previous (pre-ACA) state eligibility criteria. That’s a positive testament to the outreach and public education that occurred in 2013 and 2014, especially in the larger states.
In another analysis, the Urban Institute last year projected that an additional 5 million people would gain coverage if all 19 states that have not yet expanded Medicaid did so. At least three Republican governors in those states are newly interested, but they and everyone else are caught up in the uncertainty over repeal & replace and whether it will undermine the Medicaid expansion.
An estimated 30 million people in the U.S. in 2016 were uninsured for the entire year.
Steven Findlay is an independent journalist, policy analyst, researcher and consumer advocate.
Categories: Uncategorized
Thanks for the article, Steve, and thanks to Barry for his thoughtful suggestions. But Steve, you spoke too soon to say that Barry’s ideas were in the Republican playbook.
Barry’s third idea about large risk adjustments subsidies was fought bitterly by Republicans almost from the moment that the ACA began. Now, maybe this Republican sabotage was solely intended to harm Obama and his plan — and as such it worked rather well. Maybe they really believe in risk adjustment, as opposed to a frankly stupid and extremely insular free market approach that they have been talking up for the last 6 years. We will see.
Barry’s third idea that no one should have to pay more than ten per cent of their income for health insurance is one that I have championed also. Linda Blumberg and John Holohan have mentioned it also in their fine articles. The concept snuck onto page 40 or so of a Hillary Clinton proposal.
But this will cost at least $10-$15 billion a year, and that is OK with me, but no Republican has ever come near it to my knowledge. This idea of Barry’s would remove the hideous “cliff” that occurs in the ACA at 400% of the poverty line. But like any provision that removes the cliff in a means-tested program, it costs a fair amount of tax money to pull it off.
I could envision the following ACA fix that would be admittedly expensive.
First, keep the ban on denial of coverage related to pre-existing conditions for ACA exchange plans along with allowing adult children to stay on their parent’s plan until age 26. Tighten up the special enrollment period rules to make it harder to game the system.
Second, eliminate the individual mandate and allow healthy people to buy low cost underwritten plans that accurately reflect their actuarial risk.
Third, provide reasonable protection for insurers against large losses by using risk adjustment, reinsurance and risk corridors.
Fourth provide age-based tax credits to help people who don’t get their health insurance coverage through an employer to buy it in the individual insurance market.
Fifth, allow the ACA exchanges to evolve into explicit high risk pools and provide additional subsidies on top of the age-based tax credits to ensure that nobody, regardless of income, pays more than 10% of modified adjusted gross income for health insurance.
Sixth, allow states to choose between the ACA Medicaid expansion and block grants to finance their own approach to covering their lowest income citizens through Medicaid.
Seventh and last, address the large adverse impact on the federal budget as part of comprehensive corporate and individual tax reform. Design a system that significantly broadens the base and lowers the rates but produces sufficient revenue.
Thanks for these thoughts, Barry. Your suggestions, as you know, are very much out of the Republican playbook. I’m a strong supporter of social insurance on the European model, with the young and healthy cross subsidizing the older and less healthy. That is also, of course, the model of large self-insured employer pools. And Medicare, where through flat Part B non-age pegged premiums the 65 to 73 years olds subsidize older folk as their health inevitably declines, stuff happens and disability occurs. The ACA moved us towards the social insurance model in the individual market, though not all the way. I believe the coming R&R debate is all about whether we go backwards with the uniquely American “self-interest-me-first” model the Rs present or forward by recognizing the inherent wisdom, social solidarity, and long-term economic wisdom of the social insurance model. My one area of agreement with the Rs and apparently you in to give states the right and flexibility to experiment, with some national requirements such as the pre-ex ban.
Steven
Are you aware of how Part D is funded?
It is funded with government debt
There are people of your persuasion that believe Part D is fully funded for the government can always issue more debt
There apparently is enough people of this ilk that it even has a name: the trust fund perspective