Olav Grinde's blog

There are many ways of getting a society to “do the right thing”. Many years ago, as I was driving into San Francisco across the Bay Bridge, traffic was at a crawl – except for two lanes labeled Car Pool. Those cars whizzed by and their drivers didn’t even have to stop to pay the road toll. Life can be so unfair to a lonely guy in a BMW or Porsche.

Above the highway was a billboard advertising, in large letters, the Car Pool Switchboard; its sole function was to hook up people regularly commuting from one place to another at roughly the same time. Saving a few dimes by sharing gas expenses, or even being forgiven a couple of bucks in road toll, may not have seemed like much of an incentive – but getting to work (and home) 20–30 minutes faster each day, most certainly was!

City of Angels

Larry Levitt of Kaiser makes an interesting observation in a couple of Tweets yesterday:

States with big increases in ACA enrollment since December:

  • Mississippi ↑ 116% 
  • Florida ↑ 88% 
  • Louisiana ↑ 87% 
  • Texas ↑ 75% 
  • Georgia ↑ 73%

This list is all fed marketplace states. Growth generally lower in state exchanges because enrollment was higher to begin with.

Let me point out a few things that are worth noting here:

As we recall, HealthCare.gov and most state insurance exchanges moved their enrollment deadline for January 2014 coverage, first from 12/15 to 12/23, then to 12/28 or as close to the New Year as possible.

That, however, will not be the case for February coverage. That deadline is firm – and it is today.

Thus the number of enrollment days in January will be roughly half that of December. Or to put it in an amusing way: January is almost half a month shorter than December. We must bear this in mind when examining any statistics of how many people have ACA-compliant insurance on February 1st, not drawing overly hasty conclusions about the declining enrollment rate.

Yesterday, HHS extended its coverage of people in the Federal High-Risk Pool. The new deadline is March 15th, coinciding with the deadline for the ACA’s open enrollment. This adjustment will help ensure a smoother transition for patients with pre-existing conditions.

Already, more than 55,000 of the 85,000 people that were in the PCIP programs per October 1st have enrolled in other healthcare plans. This is a reduction of at least 65 %. According to HHS, less than 30,000 people now remain in the federal high-risk pool.

Since it was launched in late 2010, the PCIP program, has provided coverage for a total of 135,000 people with serious pre-existing conditions who would otherwise have unable to obtain insurance.

Kaiser Health News has an in-depth article on this topic by Mary Agnes Carey.

Yesterday, Charles Gaba examined the big numbers in the most recent HHS report, an unanswered question in the Medicaid numbers and sorted states according to how they’re doing relative to their (admittedly debatable) enrollment targets. Here I would like to briefly mention some rather interesting outliers and other data points, and share a few observations.

There is an 8 % difference between the genders: 54 % of those who have selected a Marketplace plan are women, while men account for only 46 %. Men are in the majority in only two states: Connecticut (54 %) and Hawaii (51 %), whereas the District of Columbia was evenly split per 12/28.

It’s also worth noting that in the District of Columbia, so-called “young invincibles” (enrollees between 18–34 years of age) account for 44 %, while in Massachusetts HHS pegs the portion to be 31 %. Nationally, people 34 years of age or younger account for 30 % of the enrollment, and 18–34 year olds account for just over 24 %.

For Massachusetts Health Connector’s Board of Directors, which is meeting today, the key question is: How bad do things have to be – and for how long – before the consequence is a brutal decision?

We know that MITRE, a private contractor, was hired to do a technical review of the flawed website of the Massachusetts state insurance exchange. MITRE is the same company that pointed out certain vulnerabilities in HealthCare.gov that have later been fixed.

CGI, which has been responsible for development, failed to deliver a working website. Worse than that: after three months, there is still no indication that CGI has the competency required to fix the website.

We’re seeing many types of outreach efforts to reach the uninsured. Navigators are doing their utmost (at least in states where their work is not being obstructed), and many church groups are addressing their congregations. Nevada has mounted a concerted door-to-door effort. Here are the results, as reported by Allison Bell.

Exchange managers want the canvassers to reach 450,800 people who seem likely to need individual or family health insurance. Mi Familia Vota says it made 53,052 total attempts from Nov. 1 through Dec. 31. The organization’s workers talked to people in 7,935 homes, or 18 percent of the homes in the target area, and generated 661 enrollment appointment leads. The canvassers found 8,377 households were inaccessible, and no one was home in 33,875. In 5,596, the residents already had health coverage. In 806 of the homes, residents refused to talk to the canvassers.

We’ve already dealt with Oregon’s recently updated enrollment numbers, but this bit of news from Nick Budnick’s article in The Oregonian the other day really caught my attention:

About half of those who applied for coverage effective Jan 1 were turned away because their applications were not fully filled out, state officials have said. Instead, they'll be processed for insurance effective Feb. 1.

If Oracle had delivered a working website to Cover Oregon, then online applicants would immediately have received feedback that they needed to fill in more information. Clearly this is an added source of frustration for Oregonians who had every reason to think that their paper application was complete and in order.

On the other hand, this speaks to a huge potential. If Cover Oregon can assist those 20,000 applicants quickly, that alone should double the state’s enrollment numbers! Who knows – with dedication and luck, Cover Oregon might well achieve that before the end of January.

The problems with the Obama Administration’s rollout of HealthCare.gov are reminiscent of the troubled rollout of the Medicare Part D expansion under President George W. Bush. In a candid interview with Kaiser Health News, former Health and Human Services Secretary Michael O. Leavitt offers telling details of their technical problems – and the Bush Administration’s solution.

…people were walking up to the pharmacy counter to get their drugs and their name wasn’t in the computer. Ultimately, we had to say, ‘give them their drugs, and we’ll work it out later.’ Then we spent 15 or 18 months working it out later. It was an expensive proposition and less than ideal.  But it allowed the limited number of people who were having problems with the system to have their human needs met.”

By contrast, the Obama Administration has spent just over three months working out glitches of HealthCare.gov, which was launched on October 1st, 2013. Perhaps after 15–18 months have passed, we can do a more complete comparison with President George W. Bush’s rollout of Medicare Part D?

It is well known, and highly embarrassing, that Oregon has yet to enroll a single person in a new insurance plan online. Since the 1st of October, Cover Oregon has had to do it all by hand, based on paper applications.

But did you know that in 2008 Oregon had an impressive success, enrolling 61,000 teachers and educators in a single month?

That, of course stands in stark contrast to today’s situation. In the course of three months, Cover Oregon has managed to enroll just 18,000 people in private insurance plans – and towering piles of applications are still awaiting the attention of their stressed case workers.

For California, we presently have data through the December 23rd. However, at the last minute, California extended its deadline to 12/27. This means that we are still waiting for four days of enrollment data! Keep in mind that just prior to the deadline, California was seeing 20,000 private plan enrollments daily.

It that rate continued unabated, we could be looking at as much as 80,000 signups beyond the 428,000 already registered. During the three days December 20–22nd more than 77,000 Californians enrolled in private plans. Granted, this is speculation – we won’t know until Covered California releases its figures.

An important develepmont is that Covered California extended its deadline for paying health insurance premiums to January 15th. Payment was originally due Monday the 6th. The extension also relieves pressure on insurers who were inundated with hundreds of thousands of new customers in December.

As part of its effort to reach minority uninsured, California has made paper applications available in Spanish, Chinese, Vietnamese and Korean.

One key question that I ask myself is this: For which states are we still waiting for data that may change the number of insured as of January 1st 2014? And how much of a change is possible? The various states offered different extensions. From the spreadsheet, we see that the California data is current only through 12/23. Likewise Washington, Connecticut and Nevada. We can also expect to see a significant movement in Vermont (current data is only through 12/11 plus one additional day).

Given this, I will be very surprised if we don’t add at least another 100,000 enrollments to the total, surpassing 2.25 million private plan signups.

Fourteen states and the District of Columbia have been operating their own exchanges, with varying degrees of success. At the end of 2013, the best 12 of these account for more than 950,000 enrollments in private insurance plans. In the table, the states are rated by performance, as measured by fulfillment of their enrollment targets.

In 2012, more than 50 million Americans lacked any form of health insurance. The Affordable Care Act was enacted into law in order to reduce that number. This website aims to give an accurate picture of how much.

In April this year, after the six-month open enrollment period has ended, it will be interesting to examine the statistics. Foremost among those numbers, in the minds of political pundits, will be how many Americans enrolled in private health plans? We will then know whether we reached, surpassed or fell short of the 7,066,000 enrollments projected by the Congressional Budget Office – long since elevated to a “target” rather than the projection it was.

How many more people are insured?
As we start this new year, at least 2.1 million people will be covered by new private plans, roughly 30 % of CBO’s first-year projection. However, this is by no means the only key figure. More than 4 million people are embraced by the Medicaid expansion. In addition, an estimated 3.1 young adults are now insured though their parents’ health plans. That adds up to 9.2 million people, which is a respectable start and should significantly reduce the number of uninsured. However, it must be underscored that many complex factors make it impossible to quantify that reduction, at least for the time being.

On top of that are an unknown number of people who have purchased ACA-compliant insurance plan off-exchange, i.e. directly from the insurance company. There are strong indications that total is significant – and we’ll return to that issue.