What the enrollment numbers don’t tell us

Posted May 01, 2014, at 2:27 p.m.
Last modified May 01, 2014, at 4:30 p.m.

The final Obamacare enrollment figures have arrived, fodder for parsing and politics in the coming days. Much of the health insurance marketplaces’ fate lies in those eagerly awaited tallies, but why?

The more enrollees, the better the chances that the overall pool of insured people will include a stable mix of healthy and sick individuals. A so-called “balanced risk pool” helps to attract insurers and keep a lid on premiums in future years.

But total enrollment is just one factor in the complex equation of the marketplaces. And the marketplaces themselves are just one factor, granted, a big one, in the success of the health reform law as a whole.

Here’s some of what today’s enrollment figures don’t tell us:

How many Mainers use other forms of health insurance. Mainers signing up for policies through Healthcare.gov are getting the bulk of the attention, but most residents get coverage elsewhere. The marketplace was geared toward people who buy insurance on their own in the “individual market,” rather than get coverage through work or the government. That’s only a fraction of Maine’s population of 1.3 million. About 315,000 Mainers had coverage through a large or small employer in 2012, according to the state insurance bureau. Another roughly 220,000 work for self-insured companies, which pay their employees’ health expenses directly rather than through an insurance company. About 630,000 Mainers are covered through Medicare, Medicaid and military insurance. Before Healthcare.gov’s launch on Oct. 1, 2013, about 133,000 Mainers had no health insurance. These figures have no doubt changed some, but health advocates expected to enroll, at best, about 10 percent of Maine’s population through Healthcare.gov, said independent health policy consultant Mitchell Stein.

How many Mainers were previously uninsured. The federal statistics don’t tell us what portion of Maine enrollees lacked insurance before signing up through Healthcare.gov.

But the new report shows that of about 5 million people who answered a Healthcare.gov question asking if they had prior coverage, just 13 percent said yes, though HHS officials say that number is likely low.

Some argue that number will define the marketplaces’ success — who has health insurance now that didn’t before. Others take a broader view, noting the millions of Americans who were “underinsured,” with coverage that left them saddled with daunting medical bills in the event of a serious illness or accident.

A new Gallup survey found that about 12 million previously uninsured Americans have gained coverage since last fall, many of them during the final weeks of open enrollment. “If that bears out even partially, that would just be an incredible success,” Stein said.

Many appear to have gained coverage through work. A recent Rand survey found 8.2 million Americans have signed up for employer-sponsored insurance since September, most of them previously uninsured. The requirement that all Americans get health coverage or pay a penalty under the law likely spurred plenty of them.

How many people fully enroll in coverage. The federal government counts individuals as “enrolled” if they took the step of entering their information and choosing a health plan through the marketplace. Whether they actually enroll and pay their first premium, however, is another matter. Some people might decide they can’t afford it after all, or, among other possible reasons, they got a job or hopped on a spouse’s plan and ditched their individual policy. Even those who fully enroll might drop their coverage during the year, if, for example, they find coverage through a job, turn 65 and qualify for Medicare, or take a pay cut and become eligible for Medicaid.

Health experts call this “churn,” where life circumstances change throughout the year, sometimes leading to gaps in coverage.

Churn is more prevalent among poorer residents. About half of low-income Americans under age 65 experience a change in income or family circumstances in a given year, which can lead to involuntary coverage shifts, according to a March study published in the journal Health Affairs. In Maine, just 42 percent of adults experienced no changes in their eligibility for Medicaid or marketplace coverage over a year.

Also, coverage typically kicks in only after the policyholder pays the first premium. So many late-comers to Healthcare.gov will have to wait until until May 1 before their medical care is covered by insurance.

The number of new Medicaid enrollees. The latest figures show that 7,100 Maine residents learned they were eligible for Medicaid, known here as MaineCare, or CHIP through Healthcare.gov. But the federal site struggled to send their information to the state, which is now trying to track them down and follow up. Some may actually be eligible, others may not. Since Maine hasn’t expanded Medicaid under the law — on Thursday, the Legislature upheld Gov. Paul LePage’s latest veto against the measure — those who do qualify were already eligible under the existing standards. They just hadn’t signed up, for whatever reason.

The tally of Mainers who fall into the “coverage gap.” About 25,000 poor and uninsured Mainers will miss out on health insurance under the Affordable Care Act because the state refused to expand Medicaid, according to a national study by the Kaiser Family Foundation. Those individuals fall into the “coverage gap,” a health reform law no-man’s land. Adults who fall into the gap earn too much to qualify for existing Medicaid programs but too little to qualify for federal financial help to buy private health insurance in the marketplaces set up under the law.

The Cover Maine Now coalition, which advocates for Medicaid expansion, estimates the coverage gap’s a bit bigger than the Kaiser total, at about 36,000.

How many residents bought individual coverage outside of Healthcare.gov. People who wanted coverage didn’t have to use the federal website. The site’s major advantage was that it allowed individuals to access federal subsidies to help them afford coverage. But those who didn’t qualify for financial help could choose to buy a plan directly from an insurer or through a broker.

Both Anthem and Maine Community Health Options, the two insurers selling plans in Maine through Healthcare.gov, also sold plans off the marketplace. About 7 percent of MCHO’s plans were sold off the marketplace, according to CEO Kevin Lewis, while Anthem didn’t provide a figure. Harvard Pilgrim, which plans to sell policies through Healthcare.gov in 2015, reported about 250 individual plans. Mega Life and Health Insurance Co., the fourth and final player in Maine, didn’t respond to a request for comment.

Nationally, an estimated 5 million people purchased coverage outside of the marketplace.

If people like their policies and find them affordable. Drew Altman, president and CEO of the Kaiser Family Foundation, recently took the media to task for judging the success of Obamacare on the wrong metrics. Rather than zeroing in on total enrollment and the number of young, healthy enrollees, he argued the real questions are whether Americans think their coverage is a good deal, if the premiums are affordable, if premiums will spike next year in areas where the risk pool is sicker than insurers anticipated, and whether enrollment will ramp up in future years, leading to fewer uninsured Americans. “The current focus on national enrollment numbers and signups by young adults doesn’t tell us a great deal about the answers to these questions, and they are not a good metric by which to judge year one success,” he wrote.

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