The March 31st deadline for enrolling in Obamacare has come and gone. How fast time flies.
It was only late last year that the March 31st hard deadline was created. Oh, you don’t recall? The March 31 deadline for signing up was created in the end of October. Initially, you needed to have active insurance by March 31st, not just successful ‘enrollment’. Under the law, to successfully meet the rules of the individual mandate, you needed to enroll by March 1st, in order to have active insurance by the deadline of March 31st. And furthermore, this new deadline had been held as the final date; until, of course, the Administration allowed another waiver for anyone ‘enrolled’ to complete the enrollment process well into the month of April.
In any case, this is now, technically, the day by which most have pointed to as the first real target date by which the government should be making solid progress in insuring the uninsured, and providing an adequate pool of payers into the insurance exchanges.
What we know, and maybe more importantly, what we don’t know, is critical to understanding the debate that will revolve around health care for the next few months.
So what do we know, for certain?
We know that around 7 million enrollments have gone through the exchanges by the end of March. That is admittedly a relative success in and of itself for the administration, which had such a disastrous start to the enrollment period. In my piece in the end of December, I did believe they would get the exchanges fixed, but I still thought they would be hard pressed to reach the 7 million mark.
The problem now becomes what the definition of enrollments are. Enrollments are NOT people who have actually successfully been insured. They ARE people who have successfully chosen an insurance policy on the exchange, and placed it in their ‘shopping cart’ on the website.
I am sure many can already see the problems with this. First, the system has no way of telling if you are a repeat customer. I for one have two accounts that have insurance policies in my cart, neither which I ever plan to purchase. I was simply testing the exchange website. Am I being counted? I am unsure, but I do know I am receiving emails regularly to remind me to complete my purchase.
Second, until you complete the payment process, you are not insured. HHS has clearly stated this on many occasions. Health experts such as Bob Laszweski have stated that in his discussions with insurers, he puts the ‘unpaid policy’ number at somewhere in the range of 15-20%. My own personal discussions with insurers backs this up; and on March 30th, HHS Sec. Kathleen Sebelius stated the rate was around 10-20%. So there is general agreement on this issue.
The rate of people insured really is the crux of the issue for the overall cause of health care reform. The other metrics are far less important in the long run. Several surveys, including the Gallup survey, have shown a short-term decreases in the rate of uninsured, but it is uncertain whether this is statistical noise or a true permanent trend. A new RAND corporation survey that was leaked to the LA Times has also shown a trend in decreasing the uninsured.
My own opinion is that the rate of uninsured must be dropping. The real question is, by how much, and by what method?
Let us remember that initially, the CBO predicted that the vast majority of those purchasing health care insurance on the Obamacare exchanges would be uninsured persons, looking for access to the health insurance. If this had been the case, then we should see a dramatic decrease in the number of uninsured.
However, it is difficult to believe this is the case. The same RAND study referred to above also shows that only about 1/3 of those on the exchanges were previously uninsured. Jonathan Cohn of the New Republic uses specific state numbers, like the enrollments in Kentucky and New York, to show that the number of uninsured is outpacing CBO predictions. However, that doesn’t seem to be the case nationwide; I am willing to stipulate there are probably a few states that are doing well, but overall, it appears they will miss their target. Philip Klein of the Washington Examiner points out the counter case, that is that it appears the exchanges are underperforming when it comes to insuring the previously uninsured.
Even using Cohn’s arguments, even he accepts it is highly unlikely that even a simple majority of those on the exchanges nationwide were uninsured previously. Thus, the majority of those purchasing on the exchanges were persons who were buying insurance already, but simply were looking for government subsidies so they could get a better deal.
What does this mean in the grand scheme? It means that the decrease in the rate of uninsured will be less than expected by many. That doesn’t mean the rate will not decrease; Medicaid enrollments alone should decrease the rate of uninsured by a couple of millon, at least. It just means those actually purchasing insurance on the exchanges, by and large, were not the uninsured at all.
The next issue that will arise is how all of these factors affect premiums for the coming year. I have talked about the demographics affecting the exchanges; primarily that young people have not signed up at a rate as great as expected initially. The CBO and HHS had initially predicted that about 39% of those in the exchanges would be composed of those ages 18-35. The average, across the nation, appears to currently be less than 30%, a number that Kathleen Sebelius now has basically accepted publicly.
This is important because, to subsidize those that are older or in poor health, the insurance pools require more healthy (and generally younger) payors into the system. Without those payors, the general cost of premiums will increase. Liberals argue that age is a poor metric to calculate whether people are healthy or not. This is true. However, do they really believe that the people rushing to buy health insurance are the healthy among us, and not the ill? There is a selection bias obviously involved here, and it is far more likely that those with poor health are the first to arrive in line for health insurance under Obamacare.
Almost everyone now stipulates that insurance premiums will rise more than the baseline expectations for 2015. In fact, overall costs are already increasing. USA Today reported that health costs are increasing at the fastest rate in a decade…and that is before these cost pressures arise to affect premiums.
The biggest question left this year regarding Obamacare really is, how much will premiums increase? If they increase at the same rate as the past 5 years (less than 4% a year on average) that will be a major success for the administration. However, if they increase at a rate above 6% a year (and there are rumors the rates could increase by double digits), that could be catastrophic for the popularity of the program.
These are the core issues, though many other issues do remain. Will people continue to be resentful to President Obama and Democrats for lying to them about being able to keep their insurance plans, and being able to keep seeing their same doctor? Will the changes in their insurance policies make them more or less content? Will increases in deductibles raise the ire of many Americans, who may or may not have understood those costs when they purchased their health policies? These and many more questions remain, all of which ultimately will be more significant than the enrollment numbers of March 31st, 2014.
The only advice I can give is, be patient; only time will tell.
This was cross posted at Neoavatara.