JAMA Forum: What Do We Now Know About the Affordable Care Act?

Gail Wilensky, PhD

Gail Wilensky, PhD

Now that the 2014 enrollment period has (finally) ended for signing up for a plan in the Affordable Care Act’s (ACA’s) health insurance exchanges, many of us policy analysts and political observers are trying to figure out what we know about the ACA’s early effects and what else we need to know to begin a reasonable assessment of the law.

Here’s my take.

About 7.5 million people had signed up for coverage in the exchanges by the end of March, following a late surge in enrollment during the second half of the month. A surge had been expected, although the number that would result was unknown. Because the exchanges had trouble accommodating the large number of people trying to enroll on the last weekend, the Obama Administration decided to allow anyone who said they had tried unsuccessfully to enroll to do so through April 14—a rather generous extension of time with no proof of prior enrollment attempts required.

This additional 2-week extension pushed the enrolled number to 8 million, with almost 200 000 of the latecomers reportedly coming from California. I assume that if the administration had decided to leave the enrollment period open another 2 weeks, the number would have gone higher still.

In addition, approximately 3 million more people enrolled in Medicaid through the end of February compared with enrollment before the ACA’s Health Insurance Marketplace opened last October. Because of the normal churn that happens with Medicaid enrollment and the need to periodically reenroll, the number of additional people covered by Medicaid is only an approximation. And because Medicaid enrollment (unlike the enrollment in private insurance through the exchanges) is allowed to continue throughout the year, the ultimate 2014 number is not yet known.

Exceeding Expectations?

What do these numbers mean?

Getting more people covered with insurance is one of the ACA’s major goals, along with stabilizing the availability of insurance for those without an employer-sponsored plan and moderating health care spending. So, more coverage is better.

Some have described the 7.5 million enrolled by March 31 (and then the 8 million by April 14) as “exceeding the goal” for the first year’s enrollment. But this is a misunderstanding of the number that the Congressional Budget Office (CBO) offered as an estimate of how many people would enroll in the exchanges in 2014. Such a figure was needed to determine the estimated cost of the program for 2014. So the CBO said it “expected” 7 million, a figure that was later revised downward to 6 million after the disastrous rollout of the exchanges last fall (and it’s not surprising the CBO didn’t propose an enrollment of 8 million; the CBO wouldn’t have anticipated the administration’s “flexibility” in the enrollment end date). Even so, the 7.5 million enrolled was a little better than the expected 7 million.

Little Data About Enrollees

Beyond the total number, however, we know almost nothing about those who’ve enrolled, not even the most basic demographic data. This lack of information is frustrating and has led many to wonder why the administration has only chosen to dribble out favorable information while refusing to make basic facts easily available.

For example, enrollment of young adults has been a key concern because they tend to have lower health care use and are therefore important for keeping health insurance premiums affordable. Previous estimates have indicated about 25% of the enrolled were between the ages of 18 and 35 years, lower than the desired 38% to 40%. In announcing the 8 million number on April 17, President Obama mentioned that 35% were younger than 35 years, but offered no other details. If the 35% includes those younger than 18 years, it is consistent with previous estimates and remains less than the desired share. Otherwise, it is a big increase from previous estimates. At this point, who knows which is the case?

Unfortunately, a decision by the Census Bureau to change how the Current Population Survey (CPS) asks about insurance status will make it more difficult to analyze the effects of the ACA’s insurance expansion. Although there are other or better sources of information on insurance coverage, the appeal of the CPS has always been its frequency and availability every September. I agree that the wording needed to be changed—people appeared to be responding to whether they were uninsured at the time of the interview although the wording referred to any time during the whole year—but this is a problem that has existed for years. If the Census Bureau decided that the wording change was absolutely needed for the 2014 survey, it should have used a strategy that would clearly show the effects of the wording change (by doing split samples using the old and the new questions for different parts of the sample for the next few years, a strategy it is using for collecting data on income and poverty).

Not surprisingly, some Republicans are questioning the timing of the Census Bureau’s decision as an attempt by the administration to manipulate information. I disagree with that conclusion and agree with Michael Strain (an American Enterprise Institute Resident Scholar and previously a researcher at the Census Bureau) that this change doesn’t signify  a conspiracy, just a dumb decision.

At some point, I assume we will know more about the enrollees, including information about income, age, and  health status. How many were previously insured and enrolled either because their insurance was cancelled or because they chose to avail themselves of the plans and subsidies in the exchanges? How many enrollees have paid their first month’s premium and how many continue to pay their monthly premiums? All of these are key issues to understanding the ACA’s most basic effects.

What remains surprising to me is how negative the country remains towards the legislation. In polling data recently released by Gallup, 54% continue to disapprove vs 43% approving of the law—essentially unchanged from November. I agree with President Obama’s assertion that this legislation is not going to be repealed. If and when it will be embraced by the American people is another matter.

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About the author: Gail Wilensky, PhD, is an economist and Senior Fellow at Project HOPE, an international health foundation. She directed the Medicare and Medicaid programs, served as a senior adviser on health and welfare issues to President George H. W. Bush, and was the first chair of the Medicare Payment Advisory Commission.  She is an elected member of the Institute of Medicine.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.



Categories: Caring for the Uninsured and Underinsured, Health Policy, The JAMA Forum

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