Why neither Romneycare, Medicare Part D nor even the December Surge may be a good parallel (UPDATED)

Now that we're hitting crunch time and I'm getting some national TV buzz (well, The Graph is, anyway), people have started asking me what the best comparison to use for The Surge should be. There are three examples which come to mind for obvious reasons...and while all three are indeed very similar to the current situation in many ways, they're also very different.

Massachusetts/Romneycare, 2006: The irony of having the very guy who ran against President Obama on his signature healthcare law happening to be the same guy who implemented essentially the same law in his own state as Governor in the first place aside, there were a lot of similarities between the 2006 Massachusetts healthcare law and the Affordable Care Act. This article from last fall does a good job of going over the main ways that the two are similar...and how they're different. In short:

Similarities: Both use website-based insurance exchanges; both offer subsidies for lower-income citizens, and both have a legal requirement to be insured or face a financial penalty.

Differences: Size/scope are vastly different (6.5 million people in a single state vs. 300 million+ across all 50 states + DC); cost sharing for preventive services, and Medicaid expansion (although obviously that's been lopped in half by a bunch of states after the SCOTUS ruling on the ACA). Also, I believe Romneycare had an 11 month enrollment period when it launched, vs. the ACA's 6 months.

The first difference is the one that's most relevant to the next two weeks: The experience of a single exchange on a single website for a single state with 6.5 million people is simply too different a situation. In addition, while I'm sure it was highly controversial at the time, I'm guessing that Mitt Romney didn't have billionaires pouring hundreds of millions of dollars into attack ads falsely claiming that his signature law was destroying the state of Massachusetts and lying about its financial impact on cancer patients. Then again, I've never been to Massachusetts; perhaps it was uglier than I think. Anyway, I'm not saying that the March Surge won't parallel the final days of the Romneycare experience, I'm just saying that it doesn't necessarily follow that it's going to.

UPDATE: I've just been informed by contributor Esther Ferington that the 2006 Romneycare bill actually wasn't particularly controversial, even at the time:

One of the foremost brands in New England, the Boston Red Sox baseball team, supported the state’s “Connect-to-Health” campaign and continue to participate actively in public education efforts. Dozens of corporate sponsors joined labor unions, community health centers, hospitals, and advocacy and religious groups in promoting coverage. ...

The continuous campaign has produced an unprecedented level of public support in Massachusetts. Initially, some 61 percent of likely voters supported Chapter 58. For legislation that garnered virtually unanimous, bipartisan support, this was high but not astonishing. What is truly unprecedented is the steady climb in public support since then, for reform and the individual mandate. In 2007, 67 percent of likely voters supported Chapter 58; this number climbed to 69 percent in 2008. Support for an individual mandate increased from 52 percent to 58 percent during those years.

This makes my point even stronger.

Medicare Part D, 2006: President Bush's prescription drug benefit was highly controversial at the time, and again, had some other similarites to the ACA: Unlike Romneycare, this one was national in scope and it did involve a Federal HHS website enrollment program. In addition, unlike Romneycare's 11 month enrollment period, the Medicare Part D period was 6 months (like the ACA) and even overlapped the Holiday Season and 2 calendar years, like the ACA enrollment period is (November - April instead of October - March). There was even a financial penalty for not hitting the deadline (although this was more along the lines of paying higher rates for drugs than an actual IRS fine, I believe).

There are so many seeming parallels that both Avalere Health and the Committee on Energy and Commerce Democratic Staff have both relied on the Medicare Part D experience as the basis of their projections for final ACA QHP enrollment this month (Avalere) or to make a point about how far behind the CBO's initial estimates Pres. Bush's law was at the time (the Dem. Staff of the Energy/Commerce Committee).

However, there are at least three major differences I can think of that make this a false comparison: For one thing, while Med D was national in scope, it was also extremely limited in scope...because it only applied to those over 65, about 14% of the population at the moment. While there are a similar 16% uninsured people being "targeted" by the ACA today, these are completely different groups demographically. The current push is primarily for young and healthy people, not the elderly (I hope that didn't sound rude).

Secondly, while I don't know much about how Medicare works, I presume that if you missed the boat on the prescription drug benefit, you were still covered by the other parts of Medicare; you weren't going without any coverage, just the prescription portion (although I know that a single pricey prescription can wipe you out almost as easily as a medical procedure).

Finally, again, unlike the ACA, while I remember there being a lot of Democratic opposition to how Medicare Part D was funded and managed, I don't remember there being anywhere near the level of political opposition or hatred of the law that we're seeing these days by the Republican Party. Perhaps a vote to repeal it squeaked by (I don't think so, I'm sure someone will correct me on this), but there sure as hell weren't fifty of them.

Finally, we come to the most recent comparison model: The December 2013 ACA Surge (I don't think I need to provide links for this one). The exact same law. Only 3 months ago. The same websites (albeit working better now, for the most part, a few states notwithstanding). There were days in December where California alone managed to break 30,000 enrollees in a single day, so we know that hitting 100K - 150K per day is possible (and I made this very point myself just the other day).

However, there's also one major difference, similar to the Medicare Part D point: In December, I gotta figure that the vast majority of last-minute enrollees fell into one of two categories:

  • The "OMG!! 5M POLICIES CANCELLED!!!" Crowd--that is, those who (like my own family) had their existing, non-compliant policies cancelled who didn't want to have a gap in their coverage. These folks were already familiar with the procedure involved in applying for health insurance, were used to the concept of paying substantial amounts of money each month to have it, and mainly just wanted to make sure they continued to be covered. (NOTE: And before anyone starts thinking that I'm "admitting" that all or even most of the 5.2M+ QHP enrollees to date were previously covered, that's not what I'm saying at all; I'm saying some of them likely were, but we have no idea how many yet).
  • The Pre-Existing Condition / Always Wanted It But Couldn't Afford It Crowd--that is, people who have been wanting (desperately, in many cases) health insurance coverage for months or even years, but who couldn't get it before due to having a pre-existing condition or simply not being able to afford it. I suspect this makes up a good half or more of those who have enrolled to date.

In both of these cases, it didn't take a whole lot of prodding or encouragement to get them to enroll, as long as the websites were working properly.

In March, the "low-hanging fruit" has mostly been picked already. They're targeting a completely different, and presumably more difficult-to-convince crowd:

  • The so-called "Young Invincibles", healthy/mostly young folks who have never bothered getting insurance before. This is made doubly difficult when you consider that the ACA also includes a provision that allows young adults to stay on their parents' plans until they're 26. How the hell the administration hopes to get 19-26 year olds to pay for their own policy when the very same law also allows them to stay on their parents' policy, I have no idea. I'm not saying that's a bad provision, mind you; I think it's a great part of the law. I'm just saying that it's hard to enroll a huge number of 19-34 year olds when you've also just told half that age bracket that they're already squared away for the next few years.
  • People who are, quite simply, procrastinators and tend to wait until the last second to do anything.
  • People who flat-out hate the law and are willing to pay the fee out of pure ideology or spite. After all, Massachusetts' law has been on the books for years now and there's still about 57,000 uninsured people there who don't qualify for Medicaid even with expansion. I assume some number of these people have been refusing to get insurance for years, choosing to pay whatever MA's fee is year in and year out rather than get a policy.
  • UPDATED: Believe it or not, there's still a lot of people who don't know about either the 3/31 deadline or the financial penalty. This blows my mind, since even those opposed to the law have been screaming about being "forced to buy insurance", "tyrrany", "oppression", etc etc...even if they're furious about it, they know about it...but whatever...

In summary, I expect the enrollment numbers over the final two weeks to spike dramatically, as they did in Massachusetts in 2006 and nationwide this past December...and I'm already seeing a surge even as I type this...but none of the three examples above are quite close enough to conclude that it will continue to do so. Maybe it'll be a smaller spike. Maybe it'll spike dramatically and then drop back down in the final week. Maybe, maybe, maybe...

Of course, it's also possible that March will exceed everyone's expectations and end up blowing the lid off of even the CBO's original 7M projection. Highly unlikely...but no one knows anything; we're in uncharted waters at the moment, which is kind of my whole point.