How many licks does it take to get to the center of an Obamacare Pop?
(title corrected...everyone knows it was "licks", not "bites"...d'oh!!)
Last night I got embroiled in a Twitter discussion with Ken Kelly and Seth Trueger about the various categories of policies available (on exchange, off exchange, grandfathered, etc). I got to thinking about it; believe it or not, there are over a dozen that I've tried to track over the past year and a half:
- 1. ACA Exchange-Based Qualified Health Plans (QHPs)
Current Paid Enrollment: Around 10.3 Million
- 2. OFF-Exchange (direct) Qualified Health Plans (no tax credits)
Current Paid Enrollment: Around 8.1 Million (including #3 below)
- 3. Off-Exchange ACA-Compliant (but not QHPs)...believe it or not, there are policies available directly via the insurance companies which are compliant with ACA requirements, but which aren't defined as "QHPs" (that is, they still couldn't be sold on the exchanges even if the insurance company wanted them to be).
Note that I've pretty much merged #2 & #3 together in an attempt to prevent an already complex tracking system from becoming even more confusing. The distinction between these two is important for some reasons, but not for my purposes, and I've been assured that all 3 of the above are part of the same "risk pool" anyway when it comes to setting premium rates/etc.
- #4 Off-Exchange Grandfathered policies: These are ones which were already in place before March 23, 2010 (when the ACA was signed into law). People on these policies can keep them for as long as they wish (or until they die or the insurer yanks them off the market).
Current Enrollment: Perhaps 3-4 Million? (including #5 below)
- #5 Off-Exchange Grandmothered (or "Transitional") policies: These are the infamous "If you like your plan you can keep it" plans--the ones which were created after the ACA was signed into law, but which aren't compliant with ACA standards. They were supposed to be cut off by 12/31/13, but after the huge backlash that November, President Obama and HHS announced that they'd leave it up to the individual state insurance commissioners to decide whether to allow up to a 1 year extension (later this was extended up to 3 years). Some states allowed it, some didn't; within the states which did, some insurance companies did, others didn't. As a result there's a hodge podge of policy cancellations spread out over a 3 year period instead of being cut off all at once.
Again, I've merged together these two in most cases (I don't include them on the spreadsheet or graph anyway) in the interest of simplicity.
- #6: SHOP Enrollments: Can't forget the Small Business Health Options Program, even if it only enrolled about 80,000 people last year and likely only about 330,000 (at most) so far this year.
OK, that's it for private policies. What else?
- #7. Medicaid, traditional, existing: People who were already on Medicaid and are simply renewing their enrollment in the program via pre-ACA eligibility rules.
Current Enrollment: Around 58 Million (including #8 below)
#8. Medicaid, traditional, new additions: People who fall into traditional Medicaid eligiblity status for the first time due to a bad turn in their lives.
I actually haven't really tried to "count" #7 & 8...instead, I've tried my best not to count them, or at least to weed them out of the Medicaid spreadsheet, which is an exercise in futility in some states which tend to lump renewals in with new enrollees.
- #9. Medicaid, traditional, "woodworkers": People who were eligible for "traditional" Medicaid before ACA expansion but who never actually enrolled due to not being aware of their eligiblility, not knowing how to apply, being too embarrassed to do so, etc, but who have since gone ahead and signed up.
Current Enrollment: Around 3.5 Million
- #10. Medicaid, ACA expansion specific: People who are only eligible to enroll in Medicaid due to ACA eligibility expansion itself.
Current Enrollment: Around 9.5 Million
- #11. Medicaid, "Bulk Transfers" due to ACA expansion: People who weren't enrolled in traditional Medicaid itself, but were enrolled in some other state-based low income health program. These people qualify for ACA expansion and were transferred en masse over to "official" Medicaid over the past few years. The main shift here isn't that anyone is newly "covered" but who's paying for that coverage (federal instead of state funds).
Current Enrollment: Around 950 Thousand
- #12. CHIP program: I haven't really counted these kids separately, generally lumping them in with the various Medicaid categories due to the nature of the program and, again, in an attempt to keep things from becoming even more confusing.
OK, that's it, right? Well, sort of...there's some other "special cases"...
- #13. Arkansas' "Private Medicaid Option": Instead of simply expanding Medicaid coverage to a higher income level, which would be too simple and make far too much sense, Arkansas Republicans couldn't stomach the idea, so they did something more complicated for no particularly good reason: They took the Medicaid funding and used it to pay for QHPs (off exchange, I think...or at least they aren't counted as part of the official HC.gov QHP data, anyway) for those who would otherwise qualify for Medicaid expansion. Ironically, this effectively amounts to buying a QHP via the exchange and getting a 100% tax subsidy, as far as I can tell. Whatever works, I guess...a few other states either have or are planning on moving to a "hybrid" version along these lines...I had a hard time deciding which category to place this in on the spreadsheet/graph, but went with Medicaid since it's not gonna be counted on the QHP side by HHS.
- #14: Minnesota's "MinnesotaCare": Minnesota is the only state (so far) to implement one of the more obscure ACA provisions: A "Basic Health Program" for people who make too much for Medicaid (even expanded Medicaid) but can't really afford exchange QHPs, even with heavy tax credits. Here's an explanation of it. Again, I couldn't figure out where to place it but ultimately went with the Medicaid side, for the same reason: It's not gonna be listed on any HHS report as a QHP, so I'd just be asking for a headache trying to explain why my data showed QHPs higher than the official reports.
- #15: New York's "Child Health Plus" or "CHP" Program: Another neither-fish-nor-fowl program (made even more confusing since it sounds so close to CHIP, even though it's a completely separate program). Basically, this is a privately-funded (via grants and the like) program unique to New York State. It's not a minor one either--there's 157,000 children covered through CHP. I have them categorized as "Off-Exchange QHPs" simply because I didn't know where the hell else to put them.
- #16: "Sub26ers" (discontinued): These are the "19 to 25 year old young adults on their parents plans" which got a lot of acclaim last year. HHS claimed there were about 3.1 million people in this category last year, but the true number was really, really hard to pin down for a variety of reasons. This year I decided to just scrap the category completely, figuring that most of those in it had already been "absorbed" into other categories (QHPs, Medicaid expansion, etc.) by now.
Believe it or not, I've probably missed a few. Note that none of the above includes Employer Sponsored Insurance (ESI), Medicare (of course) or other programs such as the Indian Health Service.
In fact, this year, I've actually had to split category #1 (exchange QHPs) into at least 3 additonal sub-categories:
- Automatic Renewals from 2014
- Active Renewals from 2014
- New Additions for 2015
Needless to say, I'm getting a bit burnt out these days.