Charles Gaba's blog

Thanks to Charles Ornstein for giving me a heads' up about an article in Yahoo Finance (reposted from Investors Business Daily) today, which has a rather loaded headline and lede:

ObamaCare Enrollment Falling Significantly, Insurers Reveal

ObamaCare exchange statistics should clear up any doubt as to why the Obama Administration has been tight-lipped about enrollment since celebrating 8 million sign-ups in mid-April.

Reality, evidence suggests, could require quite a come-down from those lofty claims.

The nation's third-largest health insurer had 720,000 people sign up for exchange coverage as of May 20, a spokesman confirmed to IBD. At the end of June, it had fewer than 600,000 paying customers. Aetna expects that to fall to "just over 500,000" by the end of the year.

Yup, on the surface that does look pretty bad. Or, at least, it would, if a) that was representative of the trend as a whole and b) if I hadn't already addressed the "attrition" factor several times in the past.

OK, I still have to plug the numbers into the spreadsheet, but here's the major takeaways:

  • Across the 49 states (including the District of Columbia) that provided enrollment data for June 2014, states reported that approximately 66 million individuals were enrolled in Medicaid and CHIP. [actual: 66,112,314]
  • 602,210 additional people were enrolled in June 2014 as compared to May 2014 in the 49 states that reported both June and May data.
  • ...approximately 7.2 million additional individuals are enrolled in Medicaid and CHIP, a 12.4 percent increase over the average monthly enrollment for July through September of 2013.
  • Among states that adopted the Medicaid expansion and whose expansions were in effect in June 2014, Medicaid and CHIP enrollment rose by over 18.5 percent compared to the July- September 2013 baseline period, while states that have not, to date, expanded Medicaid reported an increase of approximately 4 percent over the same period.
  • These enrollment counts are in addition to the enrollment increases from the nearly 950,000 individuals who gained coverage as a result of the Affordable Care Act before open enrollment began. Seven states implemented an “early option” to expand Medicaid coverage to adults with incomes up to 133 percent of the FPL between April 1, 2010 and January 1, 2014, using new state plan authority provided by the Affordable Care Act or a Section 1115 demonstration building upon that authority.

When we last checked in on Arkansas, they had enrolled 185,000 people in their unusual "Private" Medicaid option program via the ACA. That number has since grown to over 192K:

According to the latest information released by the Department of Human Services today, 192,210 Arkansans have gained coverage via the private option, the state's unique version of Medicaid expansion which uses Medicaid funds to purchase private insurance for low-income Arkansans. This includes both beneficiaries enrolling in a private plan and those deemed medically needy and routed to the traditional Medicaid program (around 11 percent of the total). 

In this case it's important to note that these folks have actually gained coverage already. That is, this doesn't include people still "in process" etc. With appx. 225,000 Arkansans eligible for the program, that means AR has reached over 85% of the total possible.

Mitch McConnell just had 71,000 more headaches dumped on him.

OK, I can't embed the video and even the link above just goes to the general Hardball video archive page, but on MSNBC's Hardball this evening, Kentucky Governor Steve Beshear gave an updated total for ACA enrollments via the Kynect exchange: 521,000 Kentuckians. The exact quote, about 2 minutes into the segment:

“The numbers speak for themselves...from the time we opened up our healthcare exchange on October 1 at 12:01am, Kentuckians started swarming all over that website, and today, 9 months later, 521,000 Kentuckians, almost 1 in 10 Kentuckians have signed up for affordable healthcare coverage.”

He repeated the 521K number not once more but twice; obviously this was the key talking point he wanted to emphasize. Unfortunately, as has been typical for Kentucky since the end of open enrollment, he didn't break out QHPs from Medicaid/CHIP enrollments.

Chris Conover and I have developed a sort of grudging respect for each other. This evening he asked me why I use a blanket "90% Paid" estimate for the states for which I don't have any hard data, instead of running a weighted average of the data I do have and using that. This is a fair question.

I partially answered it in an entry from about a week ago, in which I noted that if you average the numbers for the 18 states which have provided at least 1 payment rate update since the end of open enrollment:

...Add all of these up and you get a total of out of 2.542 million out of 2.932 million, or 87%...and again, take a look at how out of date most of those numbers are (especially California, which makes up almost half of the total, yet hasn't been updated since April 21st...a solid 9 days before hundreds of thosuands of their policies even started coverage!).

Once again, I'm quite confident that the true eventual number is around 90%.

Yes, I'm quoted extensively in this CNBC piece by Dan Mangan, and yes, I rip on the HHS Dept. quite a bit in it (towards the end) for their continuing failure to issue monthly ACA enrollment reports during the off season. However, in terms of actual new enrollment data, there's a bit earlier in the story which caught my eye: least 10 of those [state-run] exchanges have disclosed, at some point, how many people have paid their first month's premiums.

For example, a spokeswoman for Colorado's exchange, in a statement to CNBC, said: "As of June, we received data from the health insurance carriers that show 89.9 percent of Coloradans who purchased private health insurance through Connect for Health Colorado paid their first-month premium. There is some lag in data, so we anticipate that percentage may actually be higher ... we obtain this data from each of our 17 carriers and anticipate more complete information as we move forward."

A few days ago, AccessHealthCT (Connecticut's state-run ACA exchange) gave me their exact total enrollments as of 8/02: 250,633. Unfortunately, they were unable to provide a breakout between QHPs and Medicaid/CHIP enrollments. Yesterday the Hartford Courant reported a higher combined total:

Access Health CT, the state-run onlinehealth insurance marketplace created under the federal Affordable Care Act, has enrolled more than 256,000 state residents in private health plans or Medicaid since the website launched last fall.

The open enrollment period total of 218,100 (including everything through 4/19) broke out roughly 36:64. Assuming "more than 256K" is roughly 256,100, that means about 38,000 more people since then. If that ratio has stayed consistent, it should be around 13,700 QHPs and 24,300 Medicaid. However, as I noted the other day, with off season enrollment being limited for QHPs but open-ended for Medicaid/CHIP, the ratio has almost certainly shifted substantially in Medicaid's favor.

Hmmm...another unusual slowdown for Oregon; total QHPs are only up 873 since 7/28, and net QHPs are actually down 63, presumably due to purging of unpaid enrollments and cancellations of existing policies. Medicaid enrollments, meanwhile, are up another 499.

August 6, 2014
Update: Private coverage and Oregon Health Plan enrollment through Cover Oregon

Medical enrollments through Cover Oregon: 337,518
Total private medical insurance enrollments through Cover Oregon: 96,910      

Oregon Health Plan enrollments through Cover Oregon: 240,608

Dental enrollments 
Total private dental insurance enrollments through CoverOregon: 19,489

Net enrollments 
Net private medical: 82,305
Net private dental: 15,605

Me, June 26, 2014:

As an aside, I also question the wisdom of not requiring everyone to re-enroll each year. Obviously HHS is trying to minimize the inconvenience/hassle factor, but it seems to me that this is just going to cause even greater confusion than it would if they simply issued a blanket statement: If you enrolled via an ACA exchange, you have to renew once a year even if nothing else has changed.

I don't see doing this as a big deal; people have to renew their license plates every year even if it's for the same car, for example. They don't have to make it that complicated...just have big Yes/No radio buttons once you log in that says "Have you had any significant changes in (income, dependents, etc...provide a list) since (date of existing policy enrollment)?" If no, then you click "Save" and you're done. If yes, then you go ahead and make whatever changes are necessary.

OK, they can't make it quite that simple on...

Yesterday, the Big News on the ACA front was a new state-by-state survey from Gallup which showed the overall impact to date on total uninsured rates across the country.

Not surprisingly, the main takeaway, as noted by Jeffrey Young over at the Huffington Post, is that states which have embraced the law (Medicaid expansion, their own exchanges) have done a much better job overall of reducing their uninsured numbers than those which shunned it.

It's an interesting survey and an interesting piece, complete with a color-coded map which shows how the different states have fared (although I really wish they'd used higher-contrast colors; it's hard for me to distinguish some of the ranges from others).

However, there's one state which really stands out to me, and it's smack in the center: Kansas.

Yesterday I put out an open call for off-season QHP data from California, New York and Rhode Island, none of whom have released this info since 4/19 (Connecticut hasn't either...they gave me their combined total for QHPs + Medicaid, but I can't use that for a proper projection until I know the actual breakout between the two).

Today, thanks to Dara Chadwick of HealthSourceRI, I can cross Rhode Island off the list:

We had 25,767 total paid QHP enrollments during the open enrollment period, including all individuals who enrolled by March 31 and paid by April 23. 

As of August 2, 2014, 26,686 Rhode Islanders are enrolled in QHPs. Of those, 25,892 have paid.

OK, I'll have to reverse engineer things slightly here, since the paid number is given for both August 2nd and March 31st, but the total number is only given for August 2nd. Looking back at my last entry for Rhode Island, the 3/31 total was 27,968.

NOTE: I originally posted this as an update to my Florida rate increase entry this morning, but it's important enough that I figured I should repost it as a separate entry.

Thanks to Caitlin Sweany of PricewaterhouseCoopers for explaining an interesting discrepancy I noted in at least one state (my own state of Michigan). This is another example of how difficult it is to nail down the actual impact of these rate changes (and remember, in many cases these are still just requests, not approved rates, subject to change). Case in point:

According to the Detroit Free Press's original story on the subject, Michigan's "average" premium rates are only going up 0.8%. Yayyyy!!!

A couple of caveats: This report from private online insurance broker eHealth Insurance a) only reflects off-exchange enrollments, b) only includes people who enrolled through their brokerage, not directly via the companies themselves, and c) is, frankly, kind of difficult to actually read as presented, but contributor Esther F. noted an important section:

Outside of open enrollment, health insurance shoppers may only be able to purchase individual and family major medical coverage when they experience a qualifying life event such as marriage, divorce, the birth of a child, the loss of employer-based health insurance, etc. A June 2014 analysis of eHealth shoppers has shown that nearly half (49%) of those who reported a qualifying life event selected "loss of coverage" as the qualifying life event which they had experienced. More than one-in-ten (11%) indicated that they had moved to another city or state, while six percent (6%) indicated that they were recently married or divorced and three percent (3%) reported the birth or adoption of a child.

Most of the states which have released their proposed (or final) 2015 rates have looked pretty good so far, with Rhode Island (4.3%), Connecticut (appx. 4.5%), California (4.2%) and Oregon (6.8%) only going up between 4-7% on weighted average, and Mississippi actually seeing an overall weighted average decrease of around 2%.

The exceptions to date include Michigan (9.4%), New York (13.4%)...and now, it appears, Florida:

Floridians who buy health insurance on the individual market for next year will face an average increase of 13.2 percent in their monthly premiums, according to rate proposals unveiled Monday by the state’s Office of Insurance Regulation.

Of the 11 returning plans, eight filed average rate increases ranging from 11 to 23 percent, and three filed rate decreases ranging from 5 to 12 percent, the state’s insurance regulator reported.

Minnesota keeps cranking along, up another 310 QHPs and 4,888 Medicaid/CHIP enrollments in the past week.

latest enrollment numbers

August 3, 2014

Health Coverage Type Total Enrollments 
Medical Assistance 165,740
MinnesotaCare 60,435
Qualified Health Plan (QHP) 53,169
TOTAL 279,344