Massachusetts is, in many ways, the birthplace of the Affordable Care Act (Obamacare), which was largely based on "RomneyCare"...the healthcare reform system established by GOP Governor Mitt Romney back in 2006. It is therefore either completely fitting or highly ironic that Massachusetts is also the last state that I've analyzed to figure out just how many people would likely lose healthcare coverage if and when the ACA is indeed fully repealed without a reasonable replacement policy immediately in place.
In Nevada, , 89,000 people enrolled in exchange policies as of the end of January. Of these, I estimate around 62,000 of them would be forced off of their private policy upon an immediate-effect full ACA repeal, plus the additional 320,000 enrolled in Medicaid expansion, for a total of 382,000 Nevadans kicked to the curb.
The last official ACA Medicaid expansion enrollment number I have recorded for Indiana (via their modified "Healthy Indiana 2.0" program) was 290,000 people way back in July 2015. At the time, the maximum potential HIP 2.0 enrollment total was 680,000 Hoosiers, made up of 350,000 newly covered plus another 330,000 being transferred over from the HIP 1.0 program.
This NPR article from a couple of weeks ago states that as of January, "the Healthy Indiana Plan that he established in 2015 as the state's governor has brought Medicaid coverage to more than 350,000 people." However, that number is a bit confusing given that they were also supposedly transferring the other 330K over from the other program as well. I'm not sure if 350K refers to total HIP 2.0 enrollment or only those who were previously uninsured.
UPDATED 2/19/17 with more recent data (final OE4 exchange enrollment data & February 2017 Medicaid expansion data):
Louisiana just expanded Medicaid via the Affordable Care Act last July, and as of Februay 16th had over 400,000 residents enrolled in the expansion program. All of those people would be kicked right back off of that coverage again if the ACA is repealed. In just 7 1/2 months...
58,713 Adults have received preventive healthcare or new patient services
In Connecticut, 111,541 people selected Qualified Health Plans during the 2017 Open Enrollment Period. Of these, 76% are receiving financial assistance; of those, I estimate around 69,000 will actually pay their premiums and receive significant tax credits. In addition, the CT Dept. of Social Services just confirmed 213,000 CT residents enrolled in Medicaid via ACA expansion. That's a total of 282,000 CT residents who would likely lose coverage if the ACA is fully repealed without a reasonable replacement on hand.
For the individual market, my standard methodology applies:
Yesterday was supposed to be a Big Day for Congressional Republicans, as they were set to finally reveal their Master Plan to replace the Affordable Care Act. Speaker of the House Paul Ryan held a press conference about it, and they even released a 19-page "Policy Brief" which purported to explain it to everyone. Hooray! They were hoping that the entire news universe would be singing their praises all day long.
That didn't happen, however, for two reasons. FIrst, because Donald Trump's bizarre, surreal press conference, complete with racist and anti-semetic incidents, pretty much sucked all the oxygen out of the news cycle. The other reason is that their "policy brief" didn't really include much that we hadn't seen before. As Jeffrey Young of the Huffington Post put it:
It was basically the same as what Ryan and the leadership outlined over the summer with “A Better Way” proposal.
IMPORTANT: This is my county-level estimate for California. The congressional district breakout will be following soon.
Update 2/17/17: (SEE BELOW: CONGRESSIONAL DISTRICT BREAKOUT ADDED!!)
Regular readers know that I started out the "How Many Could Lose Coverage..." project at the state level, then moved into analyzing the county-level data, before finally tackling the hardest challenge: Breaking them out by Congressional District.
The state level table includes all 50 states (+DC), while I managed to break out the county level data for 34 states so far before moving into the Congressional District analysis by popular demand. There, I've managed to crunch the numbers for 43 states so far.
So, All Around Awesome Dude @LOLGOP tweeted out a link to my "How many could lose coverage in YOUR Congressional District?" project, created as a resource for progressives, Democrats and others who support saving and improving the Affordable Care Act to use to provide quick, easy and reasonably accurate estimates to utilize for Congressional town hall meetings, social media and so forth.
Countless hours of painstaking research and analysis have gone into this project (and is still ongoing...I have about a dozen states left to go). In order to avoid even the slightest claims of exaggeration, I've bent over backwards to error on the conservative side with my estimates as follows:
Over at Politico, Paul Demko has an extensive article (with an assist from Adam Cancryn, Jennifer Haberkorn and Rachana Pradhan) which confirms many of the things I've been saying for awhile now...although it also weakens one of my arguments as well. In an odd way, that's entirely in keeping with the overall theme of the article itself. That is, every one of the following statements appears to be true simultaneously:
The Trump administration is deliberately sabotaging the ACA exchanges.
The Trump administration is sort of trying to shore up the ACA exchanges.
Congressional Republicans are full-speed ahead on repealing the ACA.
Congressional Republicans are putting the brakes on repealing the ACA.
The Individual Market isn'tin a Death Sprial yet, but could be next year.
The Individual Market is already in a Death Spiral in some states but doing just fine in others.
A full replacement plan is ready to go at any moment.
A full replacement plan hasn't even made it past the first stages yet.
In a classic case of trying to have it both ways, the Trump Administration is simultaneously taking every action it can to damage/kill the ACA while also taking actions which are supposedly attempting to stabilize it. This is leading to some very...interesting...results, such as this press release sent out an hour or so ago:
CMS Issues Proposed Rule to Increase Patients’ Health Insurance Choices for 2018
The Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule for 2018, which proposes new reforms that are critical to stabilizing the individual and small group health insurance markets to help protect patients. This proposed rule would make changes to special enrollment periods, the annual open enrollment period, guaranteed availability, network adequacy rules, essential community providers, and actuarial value requirements; and announces upcoming changes to the qualified health plan certification timeline.
Regarding the company’s individual commercial medical coverage (Individual Commercial), substantially all of which is offered on-exchange through the federal Marketplaces, Humana has worked over the past several years to address market and programmatic challenges in order to keep coverage options available wherever it could offer a viable product. This has included pursuing business changes, such as modifying networks, restructuring product offerings, reducing the company’s geographic footprint and increasing premiums.
Republicans' Struggles to Replace Obamacare Feel Like Deja Vu All Over Again
Republicans in Congress are hitting roadblocks as they try to devise a plan to replace Obamacare, stuck over issues like how to structure tax breaks they want to give people to buy insurance.
...Republicans, who have spent more than six years vowing to smash the Affordable Care Act, swept into control of the White House and Congress pledging a swift repeal. But they’ve made little progress in deciding how to do that, or what should come next.
...Republicans agreed on vague concepts such as tax breaks, letting insurers sell across state lines and letting states run Medicaid.
...In fairness, as Adam Cancryn noted in his epic Risk Corridor Autopsy piece, there were a lot of other factors which caused half of the Co-Ops to fail in the first two years. It's possible that some of them would have gone under even with the RC money, and there's no guarantee that all of the remaining ones will thrive or even survive. But there's no denying that the RC payments they were counting on were a major factor, and at least a few of them would almost certainly have survived if not for having the rug yanked out from under them.
So, to review, the end result of Marco Rubio's shenanigans are:
up to 800,000 people nationally lost their insurance coverage, on very short notice, and were forced to scramble to find alternate coverage
the new coverage these people ended up with is generally more expensive, and in many cases has worse networks
the federal government has to therefore pay out more in premium subsidies to cover the increased costs as benchmark plans were increased
over a dozen insurance carriers went out of business, meaning hundreds of people lost their jobs
the loss of over a dozen carriers means less competition in those markets, therefore less competition, therefore higher premiums, therefore even more cost to the federal government in subsidies to make up the difference
since all of the carriers which went out of business were little guys, this also means the big kahunas suck up even more market share
the original $2.5 billion which Rubio was supposedly trying to "save" taxpayers ends up being paid out anyway; and
it's possible that, in addition to all of this, assuming the government decides to just concede the point (which, by all rights, they should), it's conceivable that Marco Rubio's "genius" stunt from December 2014 could also very well end up costing taxpayers $2.5 billion MORE than it would have to just let the government make the payments they were supposed to in the first place.
...all so that Marco Rubio could earn a couple of political brownie points to help him win the GOP nomination for President...which he appears to be failing at anyway.
Here in Idaho, Gov. C.L. “Butch” Otter, a Republican, vowed to come up with a replacement after declining to fully embrace the Medicaid expansion that was offered as part of the Affordable Care Act. He’s tried to persuade his heavily Republican legislature to set aside their hands-off views about the government on this issue. Studies have been conducted. Proposals have been put forward. But after four years, lawmakers have come up with no alternative.
“While it is clear there is broad agreement on the fact there is a problem, agreement on what to do about it is another story,” Otter wrote in a statement to The Washington Post.
Over the past week or so, there've been several eyebrow-raising videos posted from Republican Congressional Town Hall meetings across the country. They show huge crowds of protesters demanding that the ACA be saved, ironically remnisicent of the Tea Party protests which showed up at Democratic Town Hall meetings just 7 years earlier.
There were two in particular from last night which caused Twitter to explode, however. The first is of Jason Chaffetz of Utah:
I've written a lot about the negative impact on enrollment this year due to deliberate sabotage efforts on the part of Donald Trump and the Congressional GOP, and I stand by it. I've run the numbers and honestly believe that I've proven pretty conclusively that these efforts--in particular, the last-minute yanking of millions of dollars' worth of HC.gov "Final Deadline!" advertising--had a significant negative impact, to the tune of several hundred thousand "lost" enrollments.
However, I've also repeatedly stressed that there were most definitely other factors as well which can't be pinned on Trump's efforts. Some of these are quantifiable and pretty obvious:
NOTE: I have to attend a field trip with my kid this morning so won't be able to post about the Minnesota results until around noon, but here's an overview:
There are only 2 states which still haven't announced their final 2017 Open Enrollment Period totals: Vermont and Minnesota. Vermont isn't likely to have anything too noteworthy to say (I've confirmed ~29K QHPs...they'll probably top out at ~30K), but Minnesota has a very special situation.
Minnesota confirmed ~106,000 QHP selections as of January 10th, so they probably tacked on another 5K - 10K during the last 3 weeks of open enrollment, for a total of perhaps 115,000. This would be impressive already, since they only enrolled 83.5K people last year.
However, they're also wrapping up (even as I type this) an 8-day Special Enrollment Period piggybacked onto the end of January, and those who enroll during this SEP could receive a 25% discount on their premiums depending on their income. Here's the backstory.
The table below is a slightly-modified version of the one I've been using for my "Trump Sabotage Effect" post. This version ignores all of that and simply presents all 50 states (+DC) together.
A few days ago I assumed the grand total would come in between 12.3 - 12.4 million, but I was misreading California's total based on their previous report which had made it look like they would break 1.6 million. Instead, they came in 44K below that mark, so the national total now stands at exactly 12,227,442 QHP selections, or 3.6% below 2016's final total. There's only 2 states missing data now: Minnesota and Vermont.
A record number of Idahoans signed up for health insurance coverage through the statebased health insurance exchange during the latest open enrollment period, which ended on January 31.
“Over the last three months, more than 105,000 people selected a health insurance plan through the exchange,” said Pat Kelly, executive director of Your Health Idaho. “We have never seen more interest in Your Health Idaho. We know changes are coming to the health insurance marketplace but we want our customers to know our entire team remains committed to serving them and providing them with access to affordable health insurance options.”
In total, 105,977 Idahoans signed up for coverage through Your Health Idaho during the 2017 open enrollment period.
For the past three years, Idaho has been the leader in per-capita enrollments for state-based exchanges. YHI is currently waiting on nationwide enrollment numbers to determine how it ranks for the 2017 open enrollment period.
Oof. Regular readers know that I've compiled plenty of evidence showing that while the 39 states run through the federal exchange (HC.gov) showed a ~5% enrollment drop this year, the state exchanges have been showing an overall net increase of roughly 2% over 2016. Rhode Island, however, is the odd man out on this front, as shown in this email I just received (not up on their website yet):
Despite facing a unique set of challenges this open enrollment, 29,420 individuals selected 2017 coverage through HealthSource RI during open enrollment period (November 1, 2016 – January 31, 2017). As of January 31, 27,395 of those individuals paid, and are therefore confirmed, in 2017 coverage. We do anticipate these number will change as payments are made through the February 23 payment deadline and also as HealthSource RI remedies account issues incurred during the open enrollment period. It is difficult to point to one clear cause for this year-over-year drop in enrollment, but we believe several factors might have played a role:
Over the past few weeks I've compiled increasingly solid evidence (supported by a separate analysis by David Anderson of Balloon Juice) showing that yes, a significant portion of the reduced 2017 ACA exchange enrollment was due specifically to sabotage efforts on the part of Donald Trump and the GOP.
The reason this is so significant is that the state exchanges have their own marketing budgets, ad campaigns, outreach efforts and most significantly, branding. Ads promoting "Covered California" are gonna have a far bigger impact on enrollment for the residents of CA than ads for "HealthCare.Gov". There's some residual effect, because some people visit HC.gov first and are then redirected to CoveredCA from there, but for the most part, the state exchange branding is completely separate. (As an aside, this can sometimes have negative consequences, as in the case of "kynect" in Kentucky, which did such a bang-up job of isolating their brand from "Obamacare" that most of the state hasn't the foggiest idea that the two were the exact same law, but that's a separate discussion).
Last night, CNN held a full, 90-minute debate between Bernie Sanders and Ted Cruz which was billed as "The Future of Obamacare". It was a clever idea for a couple of reasons: Not only was each of them the "runner up" for the 2016 Presidential nomination of their party, but each of them made healthcare a core part of their campaign (Bernie, of course, is a die-hard Single Payer guy, while Cruz literally shut down the federal government to stop the bulk of the ACA from being implemented).
A sizable minority of Americans don’t understand that Obamacare is just another name for the Affordable Care Act.
This finding, from a poll by Morning Consult, illustrates the extent of public confusion over a health law that President Trump and Republicans in Congress hope to repeal.
In the survey, 35 percent of respondents said either they thought Obamacare and the Affordable Care Act were different policies (17 percent) or didn’t know if they were the same or different (18 percent). This confusion was more pronounced among people 18 to 29 and those who earn less than $50,000 — two groups that could be significantly affected by repeal.
...When respondents were asked what would happen if Obamacare were repealed, even more people were stumped. Approximately 45 percent did not know that the A.C.A. would be repealed. Twelve percent of Americans said the A.C.A. would not be repealed, and 32 percent said they didn’t know.
I've been cautioned that these numbers are preliminary, but that's true of all of the "final" enrollment numbers to date; there are often minor clerical corrections and the like before the final numbers are baked in.
Anyway, here's the OE4 QHP enrollment numbers for the DC exchange, which is up about 3.1% over last year.
However, according to the official ASPE report for 2016 Open Enrollment, DC's QHP tally was slightly lower (22,693); since that's the official total used by HHS, that's what I'm going with, which means they've enrolled about 4.1% more this year.
LT. GOVERNOR WYMAN, ACCESS HEALTH CT ANNOUNCE 2017 OPEN ENROLLMENT NUMBERS
111,524 Residents Enrolled Through Access Health CT; 13,791 are New to the Exchange
(HARTFORD, Conn.) – Lieutenant Governor Nancy Wyman, Chair of the Board of Access Health CT (AHCT), and AHCT CEO Jim Wadleigh today announced that the state’s health insurance exchange enrolled 111,524 residents during the 2017 Open Enrollment Period, which ended at midnight on January 31, 2017. Of those enrollees, 13,791 consumers are brand new to the exchange. In addition, 5,000 people came through AHCT seeking dental coverage and 1,467 enrolled in health coverage through the Small Business Program.
Covered California Finishes Fourth Open Enrollment With More Than 412,000 New Consumers and Strong Participation From Young Enrollees
New plan selections met enrollment projections for the fourth open-enrollment period.
Nearly 50,000 consumers signed up for health care coverage in the final two days before the Jan. 31 deadline.
Strong finish and overall enrollment are credited to effective work by Certified Insurance Agents and enrollers and robust television, digital, print and outdoor advertising that ran throughout the open-enrollment period.
The crucial demographic of young adults ages 18–34 accounted for 37 percent of enrollment, contributing to a healthy risk mix for 2017.
SACRAMENTO, Calif. — Covered California announced Monday that it finished the open-enrollment period with 412,105 new consumers signing up for health coverage.
Today marks the end of our fourth and by far most successful Open Enrollment period. The number of plan selections ran 12% ahead of last year’s pace and the volume of last-minute customers Monday and Tuesday led us to extend sign-ups for three days for those who started the process before Tuesday’s deadline.
I share this information with extreme gratitude to our dedicated staff, our Assistance Network, our Broker partners, our health insurance company partners and the many other supportive stakeholders who helped us move forward with our shared mission no matter the headwinds we encountered along the way.
In 1897, the Indiana state House passed a bill which would have attempted to legally defined the value of π (Pi) as 3.2. Yes, I'm quite serious:
Any high school geometry student worth his or her protractor knows that pi is an irrational number, but if you’ve got to approximate the famed ratio, 3.14 will work in a pinch. That wasn’t so much the case in late-19th-century Indiana, though. That’s when the state’s legislators tried to pass a bill that legally defined the value of pi as 3.2.
The very notion of legislatively changing a mathematical constant sounds so crazy that it just has to be an urban legend, right? Nope. As unbelievable as it sounds, a bill that would have effectively redefined pi as 3.2 came up before the Indiana legislature in 1897.
As I noted last Friday, there's pretty good evidence that the Trump administration killing off most of the final HealthCare.Gov open enrollment deadline TV ads was directly responsible for a significant portion of the OE4 enrollment reduction on the federal exchange. The most obvious evidence of this is that in the final, critical 5 days of the period (when there's always been a significant spike in last-minute enrollees), the state-based exchanges (which run their own marketing campaigns) saw a 1.5% enrollment increase (at least 44,000 people) at the same time that HC.gov enrollment fell by 5% (450,000 people) short. This discrepancy between the state exchanges and the federal one will become a bit larger once the final enrollment numbers from CT, DC, ID, MA, MN, RI & VT come in.
Republicans begin to grumble: Why haven't we repealed Obamacare yet?
...The sentiment is beginning to simmer within the influential conservative wing of the Republican Party and hints at what could be the opening of an intra-party rift as the GOP's mission to overhaul the country's health care system appears to be losing steam.
...That shift in tone has irked other Republicans who are eager to take a swift vote to roll back as much of Obamacare as possible. Their fear: their conservative constituents back home won't settle for anything else.
"For goodness sake, we should be able to put something on President Trump's desk that's at least as good as what we put on President Obama's desk. Not something watered down," Rep. Jim Jordan, R-Ohio, told CNN in an interview. "Let's repeal it. Let's do what the voters sent us here to do."
2017 using my known flawed data was running .96% behind 2016 on the January 14th inclusive update. 2017 ended up running 5.25% behind 2016 on Healthcare.gov states. The increment (using favorable to the null hypothesis data) slowdown in pace that can be attributed to Trump Administration actions is 5.25-.96 or 4.29% of enrollment was lost due to the executive order and other Trump administration actions such as shutting down some outreach and advertising in the last eleven days of enrollment.
Before the election, I was assuming the 2017 Open Enrollment Period would rack up between 13.5 - 14.0 million QHP selections...between 6% - 10% more than last year. The HHS Dept. agreed with me, projecting around 13.8 million (an 8.6% increase).
Last year the federal exchange included around 76% of the total enrollments (around 9.6 million). This year, HC.gov added Kentucky, which should have bumped the ratio up to around 77% this year. Assuming 13.8 million total, that would mean roughly 10.6 million enrolling via the federal exchange.
After Trump won and the GOP immediately started the actual legislative process to repeal the Affordable Care Act with preliminary votes in both the House and Senate, I downgraded my projections to around 13.3 million nationally (10.2 million via HC.gov).
Over 700,000 Additional Pennsylvanians Enrolled in Governor Wolf’s Medicaid Expansion Plan
February 02, 2017
Harrisburg, PA – In February of 2015, Governor Wolf expanded Medicaid to ensure that Pennsylvanians can receive affordable, straightforward, accessible healthcare without unnecessary delays and confusion. Today, Governor Wolf announced that over 700,000 Pennsylvanians have enrolled in HealthChoices, Pennsylvania’s mandatory managed care Medicaid program, since expansion occurred two years ago. U.S. Census data shows that the commonwealth’s uninsured rate has dropped from 10.2 percent in 2010 to 6.4 percent in 2015.
NEARLY 158,000 MARYLANDERS ENROLLED IN HEALTH COVERAGE FOR 2017 THROUGH THE STATE MARKETPLACE
INCLUDING MEDICAID, 501,000 HAVE ENROLLED SINCE NOV. 1
BALTIMORE (Feb. 1, 2017) – A total of 157,637 Marylanders enrolled in private health coverage plans for 2017 by yesterday’s deadline for open enrollment, capped by the largest single-day call volume ever for Maryland Health Connection, the state’s health insurance marketplace.
Including Medicaid enrollments, more than a half-million Marylanders have newly enrolled or renewed in health coverage for 2017 through the state marketplace since Nov. 1 when open enrollment began. Maryland Health Connection now covers 1.1 million in all — one of every six people in Maryland.
Hmmm...I'm honestly not sure what this last number (1.1 million covered by the exchange) refers to...they just said it was 158K QHPs + 343K in Medicaid = 501K total.
More than 225,000 people used Washington Healthplanfinder to select Qualified Health Plans – a 13% increase over last year’s total.
The ASPE report for OE3 showed WA's official 2016 tally at 200,691, so 225K would actually only be 12.1% higher, but the press release says it's 13%, so either they're basing it on a slightly lower unofficial 2016 tally, or "over 225K" actually means closer to 226,000.
GOP Rebrands Obamacare Strategy From 'Repeal' to 'Repair'
Some Republicans in Congress are starting to talk more about trying to “repair” Obamacare, rather than simply calling for "repeal and replace.”
There's good reason for that.
The repair language was discussed by Republicans during their closed-door policy retreat in Philadelphia last week as a better way to brand their strategy. Some of that discussion flowed from views that Republicans may not be headed toward a total replacement, said one conservative House lawmaker who didn't want to be identified.
Using the word repair “captures exactly what the large majority of the American people want,” said Frank Luntz, a prominent Republican consultant and pollster who addressed GOP lawmakers at their retreat.
I'm actually a bit surprised that NY State of Health is the first state exchange out of the gate with final enrollment numbers, but good for them:
Press Release: NY State of Health Announces Enrollment Surges: More Than 3.6 Million New Yorkers Secure Health Coverage
Feb 1, 2017
Nearly 50,000 sign up during final two days of Open Enrollment
An additional 800,000 New Yorkers enroll through the Marketplace since January 2016
ALBANY, N.Y. (February 1, 2017) -- NY State of Health, the state’s official health plan Marketplace, today announced that more than 3.6 million New Yorkers enrolled in comprehensive health coverage through NY State of Health, a 28 percent increase from 2016.
“New York continues its commitment to bring affordable, comprehensive health coverage to New Yorkers” said NY State of Health Executive Director, Donna Frescatore. “New Yorkers now have access to affordable health insurance coverage, giving hundreds of thousands of previously uninsured individuals economic and healthcare security.”
Politically, the big unknown is whether or not Paul Ryan and Mitch McConnell will get away with trying to pin the blame for this on the Democrats/the law itself. That's why they've been pushing the "Obamacare is already in a death spiral!" claim hard for the past few weeks, even though it quite simply isn't.
...So, if this does end up in a worst-case scenario, Trump's "stop enforcing the mandate altogether!" order here could end up causing that death spiral even if the GOP doesn't technically end up repealing anything legislatively. The carriers would start announcing that they're bailing next year as soon as this spring (remember, the first paperwork for 2018 exchange participation has to be filed in April or May), and McConnell/Ryan would simply say, "See?? We told you it was collapsing all by itself! We didn't touch nuthin'!!"
I've stated many times over the past few weeks that between the GOP actively starting the legislative repeal process with preliminary votes, Trump actually taking office, his executive order within hours of doing so instructing the HHS Dept. to actively sabotage implementation of the ACA, and the last-minute yanking of TV advertising for the final few days of Open Enrollment that there's simply no way of making a solid prediction about what the final enrollment tally will end up being.
However, based on previous yearly patterns and spot-checks of HealthCare.Gov and the buzz from some of the state exchanges earlier today, I'm still gonna take a shot: I expect the final QHP selection tally to come in...pretty damned close to last year's 12.7 million, actually.
Officially, I'm giving it a range of anywhere between 12.4 - 13.0 million, with around 9.5 - 10.0 million of that coming via the federal exchange (which covers 39 states this year, including Kentucky) and the remaining 3 million or so being courtesy of the 12 remaining state-based exchanges.