The enrollment period for new, ACA-compliant plans began on Oct. 1st, 2013. For most states, this means visiting Healthcare.gov, creating a profile, submitting information about your household and income, and selecting a health plan. 14 states, plus Washington, D.C., created their own state websites, or exchanges, in which residents sign up for plans via their respective state portal instead. The enrollment period officially ended on Mar. 31st, but one could still sign up for a plan on Healthcare.gov until Apr. 15th, assuming a profile was already created, and the customer indicated they previously tried to sign up for coverage but were unable to do so because of technical difficulties. Most states with their own exchanges are also briefly extending enrollment periods.
Initially, Healthcare.gov was extremely error prone and virtually non-functional for the majority of users, while most state websites, such as those in California, Connecticut, and Kentucky worked quite well from the very beginning. Most of the technical glitches weren’t straightened out until December, meaning the first 2 months of enrollment were all but lost, including here in Michigan, which opted not to create its own exchange. Nevertheless, a surge in signups after the site became functional, especially in the month of March, led to total signups meeting and surpassing the original Congressional Budget Office (CBO) projection of 7 million people. Indeed, an additional 500,000 people have signed up since March 31st, and it’s entirely conceivable that the total could reach 8 million by the time the enrollment period ends for good.
Furthermore, the 7 million figure only refers to signups for private, for-profit health insurance on the exchanges. The ACA created a number of other ways to acquire health care insurance, notably via the expansion of Medicaid, and through a provision that allows younger Americans to stay on their parent’s plans until the age of 26. Initially, the law required that all states expand Medicaid eligibility to residents earning up to 138% of the federal poverty level (currently, between $15k and $16k a year for an individual, and $32k and $33k for a family of 4), but a Supreme Court ruling in the summer of 2012 deferred that decision to the states. Since then, 26 states and Washington, D.C. have opted to expand Medicaid within these parameters, which means that the costs of their additional share of enrollees will be covered 100% by the federal government until 2016, then phase down to 90% in 2020 and beyond.
So, how many people have acquired health care insurance since the implementation of this law? This is the most important question, and also the most difficult one to answer. For one, there’s a lot of moving parts to this law, and tracking specifically who signed up for health care insurance as a result of those moving parts is a difficult task. For example, there has been a significant uptick in Medicaid enrollees in states that expanded Medicaid, but there has also been a noticeable uptick in states that decided not to expand Medicaid. The CBO attributed this to federal outreach efforts to inform people that they might now be eligible for coverage, which had a bleed over effect in encouraging people who already may have been eligible to apply themselves. So in a sense, this subset of the population acquired insurance as an indirect result of the law as well.
To clarify things, it helps to try and track how many people have obtained insurance by categories. All of the following numbers come from these sources:
1) ACAsignups.net - The best website, by far, for tracking enrollment numbers.
2) The RAND Corporation - A survey conducted by the RAND corporation, in which American households were polled between Sept. 2013 and Mar. 2014 to determine how many people acquired health care insurance, and what type of coverage they acquired.
3) The Urban Institute - Another survey tracking the change in the rate of the uninsured between the first quarter of 2013 and the beginning of Mar. 2014.
4) Gallup - A polling firm that tracks the rate of the uninsured every quarter.
Here are the relevant categories:
1) Sub26er’s – This category refers to young Americans under the age of 26 who have acquired health insurance under their parent’s plans. ACAsignups.net puts the number of people who have gained coverage through this provision between 1.6 and 3.1 million. It isn’t easy to pin down a number for this category, due to the constant churn of people aging out, or leaving their parent’s plans to acquire different types of insurance, losing that insurance for various reasons, and then winding up back on their parent’s plans.
2) Qualified Healthcare Plans (QHP) via the exchanges – We know that 7.5 million people have signed up for coverage via the federal exchange, Healthcare.gov, and the state exchanges. The number could reach 8 million by the end of the first enrollment period. But there’s an important caveat here: this is only the number of people who have signed up for plans. In order to be officially enrolled, customers must pay at least the first month’s premium. Still, we know that an average of about 80 - 85% of QHP enrollees to date are paid up (thanks to the states and insurers that actually report such data), and that an additional 10% or so will pay in the following months, as there’s some lag time between signing up for a policy and receiving the first month’s bill. So, if 8 million people eventually sign up, we can assume that the actual number of enrollees will be about 7.4 million.
3) Medicaid - As I wrote, 26 states, plus Washington, D.C., have chosen to expand Medicaid. Here again, though, it’s difficult to tell how many have signed up for Medicaid as a direct result of the expansion provided by the ACA, or how many of the previously eligible signed up due to the “woodwork” effect (or, people who signed up due to massive outreach efforts and increased awareness that this program exists). The RAND survey suggests that 5.9 million people signed up for Medicaid between September and March, and that many of them were previously uninsured. ACAsignups.net suggests that 5.2 million people signed up as a direct result of the expansion, and that just over 2 million signed up due to the “woodwork” effect.
It’s clear that the Medicaid expansion is helping to reduce the number of uninsured in a big way. The Urban Institute, for example, found a sharper decline in the uninsured rate amongst states that opted to expand Medicaid vs. those that did not:
The Kaiser Family Foundation found that about 4.8 million more people would have potentially been eligible for Medicaid had their respective states chosen to expand the program. This is especially true in larger states such as Texas and Florida, where a significant number of residents are uninsured:
4) Other – One of the more interesting aspects of the RAND survey was the observed 8.2 million increase in enrollments in employer-sponsored insurance (ESI).But it’s very difficult to determine how much of this is due to the ACA. Per the authors:
“Some of these newly insured individuals may have taken up an employer plan as a result of the incentive created by the individual mandate; others may have newly found a job. The U.S. unemployment rate fell slightly between September 2013 and March 2014, so part of the increase in ESI enrollment could have been due to economic recovery rather than the ACA.”
Finally, an undetermined number of people signed up for QHP’s directly through the insurers, or a broker, or via other websites, like eHealthInsurance.com. It is estimated that the vast majority of these people already had insurance before moving over into ACA-compliant plans.
What do these numbers mean? Everything, if you have a preexisting condition and/or very little income and were locked out of purchasing or acquiring coverage as a result. It means you now have access to affordable health care insurance. But for many of us, it means surprisingly little for now. The RAND survey found that 80% of American adults had the same form of coverage in Mar. 2014 as in Sept. 2013. This is because most insured Americans get coverage through their employers, which are essentially left untouched by the ACA. There are some anecdotal stories about ESI premiums going up as a result of the law, but they are largely unfounded. In fact, “U.S. employers and their employees saw the lowest health care premium rate increases in 2013 in more than a decade," according to the Insurance Journal. Meaning, premiums aren’t rising as fast as they were before the law passed.
Did some Americans lose coverage as a result of the ACA? Yes. It is estimated that 4.8 million people received cancellation notices at the end of 2013, the bulk of which being those covered in the individual market (or, private plans not sponsored by an employer).
But it’s very important to put this number in perspective. The RAND survey found that fewer than 1 million people who previously had insurance in the individual market actually wound up uninsured in the period they polled. In other words, the majority of those who received cancellation notices simply transitioned into other types of coverage, such as ACA-compliant plans on and off the exchanges, ESI, or Medicaid.
This point can’t be emphasized enough, as the bulk of the political opposition to the ACA (as evidenced by the TV ads funded by the conservative Americans For Prosperity) is centered on these families who received such cancellation notices. Yet, the empirical evidence leads to one undeniable conclusion: far more Americans have gained insurance as a result of the ACA. 3 separate independent firms confirm it:
- The RAND survey, which observed a net gain of 9.3 million more people with health coverage (including ESI), and a drop in the rate of the uninsured amongst 18 to 64 year olds from 20.5% (in the 3rd quarter of 2013) to 15.8%.
- The Urban Institute survey, which observed a net gain of 5.4 million more people with health coverage, and a drop in the rate of the uninsured amongst 18 to 64 year olds from 18.5% (in the 2nd quarter of 2013) to 15.2%.
- The Gallup survey, which observed a drop in the rate of the uninsured amongst adults 18 and older from 18% (in the 3rd quarter of 2013) to 12.9%.
The Gallup survey is the most recent out of the 3. Here's what the authors have to say about the impact of the law:
"There has been a statistically significant and meaningfully large decline in the percentage of uninsured U.S. adults. The uninsured rate peaked at 18.0% in the third quarter of 2013, the highest rate measured since Gallup and Healthways began tracking in 2008. The uninsured rate has been consistently trending downward since then, falling to 15.0% in March and further to 12.9% for April 1-14 polling. If the rate for the first half of April holds throughout the month, it will be the lowest monthly uninsured rate in 76 months of tracking."
While the first enrollment period is soon coming to a close, people will be able to sign up for Medicaid year-round. Given this, what was once obvious is now even more so: the ACA is here to stay. Millions upon millions of Americans have acquired health insurance as a direct result of it. Repealing the law would mean that those very millions would lose their coverage, and, whatever else they may say, even Republicans don’t want that albatross hanging around their necks.
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