VINDICATION: KFF Study: 57% of EXCHANGE QHPs were Previously Uninsured

Hat Tip To: 
Brian W.

Well slap my ass and call me Susan. Remember that pissing match between Avik Roy and I back in late March over the now-infamous "McKinsey Study" which claimed that only 27% of individual market enrollees since the start of Open Enrollment were "previously uninsured"?

McKinsey itself stated no less than seven times throughout that it included both ON- and OFF-exchange enrollees, and therefore was pretty much useless for trying to figure out how many of the exchange-based QHP enrollees were "previously uninsured", since there was no separation between the two in the data. For all anyone knew at the time, there could have been twice as many off-exchange QHPs as exchange-based ones, and even if it was a 50/50 split, for all anyone knew, it could have been 0% prev. uninsured OFF exchange and 54% prev. uninsured ON the exchange. Basically, it was meaningless for that purpose.

This didn't stop Roy from insisting that...

.@charles_gaba @UriManor Read your blog post. You overstate impact of off-exchange #Obamacare enrollment. See update:

— Avik Roy (@Avik) March 25, 2014

...I was "overstating the impact" of off-exchange enrollment.

He was certain that they accounted for only 20% of the total, based purely on the opinion of a single, unnamed "Wall Street analyst":

Fortunately, we don’t have to rely on personal suspicions. As my colleague Scott Gottlieb notes, we have actual data from insurers on this topic; most analyses estimate that approximately 20 percent of sign-ups to date have been off the Obamacare exchanges.

I tore this logic to shreds. As for my own estimate of the "previously uninsured" question, as I had stated 3 weeks earlier (on March 8th), in response to Megan McArdle's similarly flawed interpretation of the McKinsey study:

my personal suspicion is that the true "previously insured / uninsured" breakout nationally is closer to 50/50 overall.

There was also a lot of fuss and bother about the definition of "previously uninsured", since some respondants might have been confused; what if their prior policy had just been cancelled the day before? What if they were insured up until a few weeks earlier? Etc, etc. 

Well, first of all, the whole "overstated off-exchange enrollment" claim has already been debunked; the actual number of off-exchange QHPs has been shown to be close to 8 million...roughly the same as the exchange-based QHP figure. So yes, we're looking at roughly an even split between on- and off-exchange enrollments, which is kind of handy.

As for the original question: The Kaiser Family Foundation has just issued the results of their own new, comprehensive, properly broken-out survey:

January 1, 2014 marked the beginning of several provisions of the Affordable Care Act (ACA) making significant changes to the non-group insurance market, including new rules for insurers regarding who they must cover and what they can charge, along with the opening of new Health Insurance Marketplaces (also known as “Exchanges”) and the availability of premium and cost-sharing subsidies for individuals with low to moderate incomes. Data from the Department of Health and Human Services and others provide some insight into how many people purchased insurance using the new Marketplaces and the types of plans they picked, but much remains unknown about changes to the non-group market as a whole. The Kaiser Family FoundationSurvey of Non-Group Health Insurance Enrollees is the first in a series of surveys taking a closer look at the entire non-group market. This first survey was conducted from early April to early May 2014, after the close of the first ACA open enrollment period. It reports the views and experience of all non-group enrollees, including those with coverage obtained both inside and outside the Exchanges, and those who were uninsured prior to the ACA as well as those who had a previous source of coverage (non-group or otherwise).

Their methodology is thoroughly explained and seems to cover all the bases:

The survey was conducted by telephone from April 3 through May 11, 2014 among a nationally representative random sample of 742 adults who purchase their own insurance. Computer-assisted telephone interviews conducted by landline (333) and cell phone (409, including 219 who had no landline telephone) were carried out in English and Spanish by SSRS. Respondents were considered eligible for the survey if they met the following criteria: 

  • Between the ages of 18-64 
  • Currently covered by health insurance that they purchase themselves
  • Not covered by health insurance through an employer, COBRA, Medicare, Medicaid, or the U.S. military or VA 
  • If purchase insurance from a college or university, the insurance covers health services received both within and outside the university setting 
  • If a small business owner, the health insurance they purchase is only for themselves and/or their family, and does not cover non-related employees of their business 
  • If purchase from a trade association, respondent pays the entire premium themselves 
  • Respondent was able to answer a question about whether insurance was purchased directly from an insurance company, from a state or federal health insurance marketplace, or through a health insurance agent or broker (Q35 in questionnaire) 


As for the results? Lo and behold:

The survey finds that roughly two-thirds of those with non-group coverage are now in ACA-compliant plans, while three in ten have coverage they purchased before the ACA rules went into effect (referred to as “non-compliant plans” throughout this report). About half of all non-group enrollees now have coverage purchased from a Health Insurance Exchange, and nearly six in ten (57 percent) of those with Exchange coverage were uninsured prior to purchasing their current plan. Most of this previously uninsured group reports having gone without coverage for two years or more, and for many the ACA was a motivator in seeking coverage; seven in ten of those who were uninsured prior to purchasing a Marketplace plan say they decided to buy insurance because of the law, while just over a quarter say they would have gotten it anyway.

57% of EXCHANGE-based QHP enrollees report being uninsured prior to purchasing their current plan, most of whom were uncovered for 2 years or more.

Even better than I had thought.

Annnnnnd...another GOP talking point bites the dust.