Charles Gaba's blog

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:

1. System and service issues

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.

I've mainly focused on the last-minute "ad kill" stunt pulled by the Trump administration, in which they yanked millions of dollars worth of TV ads reminding people fo the deadline during the critical last 5 days, and the evidence is pretty telling: Enrollment across the 39 states run through the federal exchange (HC.gov) dropped by about 5% from last year, while enrollment on the other 12 state exchanges increased by over 2% (there's still final enrollment data to be added from ID, MN, RI & VT).

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).

I didn't actually watch it live last night; I watched it on YouTube this morning (no idea whether this version will stay up or not).

I don't have time to get into a detailed analysis of the whole thing, but here's some general observations:

 

Presented without comment:

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.

Access Health CT, the Connecticut ACA exchange, just announced their final OE4 enrollment numbers; they're down about 3.9% year over 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.

OK, I'm a bit confused by Covered California's press release just now:

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.

The official enrollment report won't actually be released until a little later, but Connect for Health Colorado just posted the following: (it's dated 2/03 but just went live on their site today):

CEO Blog: End of Open Enrollment Update

Posted on Friday, February 3, 2017

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.

There's no specific number listed, but last year's official Open Enrollment Period QHP selection total for Colorado was 150,759 people.

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.

Over at CNN, MJ Lee reports that the Republican natives are getting restless:

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."

MAJOR UPDATE 3/22/17: As I've noted repeatedly, my estimates of how many people are at risk of losing their coverage has always been based on the assumption of full repeal with immediate effect and, most importantly, no replacement healthcare policy whatsoever. I had to do it this way at first because there was no Republican replacement plan available until a couple of weeks ago. Then, when the AHCA plan was released, I didn't have the time or expertise to properly overhaul my projections accordingly.

Fortunately, the Center for American Progress does have the time, manpower and expertise to do exactly this. They crunched the numbers and, based in part on the recent Congressional Budget Office scoring of the AHCA, put together their own fully-detailed analysis of what impact partially repealing the ACA by passing the AHCA would have on coverage losses.

In light of this, at this point you can pretty much ignore everything below, as it no longer applies; the question is no longer "what happens if the ACA is repealed without anything replacing it?" but rather "what happens if the ACA is partially gutted and replaced with the AHCA?"

The amazing thing is that the grand total number losing their coverage would be virtually identical in either scenario! The numbers vary widely from state to state and district to district, but when you add it all up, it still comes in at around 24 million people either way!

Anyway, I've put together SIDE BY SIDE COMPARISON TABLES for each state here.

Unfortunately, due to the sheer amount of time it would take to do so, and the fact that the House is voting on the AHCA tomorrow (Thursday, 3/23), I don't have time to completely update/overhaul the Google Docs version of this data.

UPDATE 2/07/17: Over at Balloon Juice, David Anderson (aka 'Richard Mayhew') tackled the "last-minute sabotage" issue from a completely different angle, using actual statistical analysis methodology (remember, I'm not a statistician regardless of what everyone thinks)...and came to the exact same conclusion I did:

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).

I haven't posted an update on Pennsylvania's implementation of the ACA's Medicaid Expansion provision since last May, when it stood at around 625,000 enrollees.

Just moments ago, PA Governor Tom Wolf announced that enrollment has now broken the 700,000 milestone:

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.

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