Health care coverage is more than numbers
We’ve heard a lot about the HealthCare.gov website and its performance metrics recently.
But the Affordable Care Act metric that really matters isn’t error rates or response time. It’s enrollment.
Furthermore, what matters isn’t just how many people enroll – although that’s part of it. It’s also who enrolls – in particular, their age and health status. A mix that includes younger and healthier people is needed for a viable insurance risk pool. And whether that mix has been achieved may not be clear until later in the six-month open-enrollment season.
It’s possible that the psychology of low numbers will create such a negative perception of the whole venture that it damps enrollment even if the mechanics – the website etc. – fall into place. But it’s also possible that the numbers will look very different a few months from now. We just don’t know.
Inside the numbers
The only national enrollment numbers we’ve seen so far were the ones released in mid-November, and they underscored just what a big mess October was. The numbers were dismal: As of Nov. 2, just 106,185 people had chosen a health plan -- 26,794 who signed up through the federal site and 79,391 who did so through the states' sites.
That's a far cry from the half-million the administration had wanted for the first month.
Does the bad first month mean things will stay bad? Not necessarily. But it was a rough start and deepened a public perception of crisis, chaos and confusion. That can be self-fulfilling – or, if the website keeps improving and people sign up, the White House will have a second chance at getting the public invested in the sweeping new federal program.
The mid-November enrollment report contained a few other numbers that should be noted. There were 26.9 million unique visitors to the site, though many couldn’t proceed beyond the crashes and error messages. That's a lot -- and they weren’t all journalists, political operatives, or curiosity seekers. Many of them had to have been interested in the health-plan offerings.
In addition, 846,184 applications were completed. (Some were family applications, so they represent 1.5 million individuals.) That means people filled out the preliminaries, established their eligibility, but have yet to choose a health plan. Will all of them choose one? We don’t know that either. Some may decide they don’t like the choices, or don’t want to spend the money (even with a subsidy). But it’s a pretty good bet that a large share of them will come back and get coverage -- getting that far in October despite the balky site suggests they were pretty determined.
In addition, almost 400,000 people were determined eligible for Medicaid or the Children’s Health Insurance Program. That shows word is spreading about coverage options for low-income populations. But while Medicaid will make a dent in the insurance rate, it doesn’t solve the risk-pool problems in the exchanges. They're separate issues.
We’ll get more numbers from the Department of Health and Human Services in mid-December. What will those numbers tell us?
That report will still include several weeks when the website remained pretty lousy, so what we’ll want to look at is trends. Are the numbers rising? What’s the trajectory look like? What will HHS tell us about the age spread – how many enrollees are under 35? How many are nearly Medicare eligibility age? How many are getting subsidies, and how many are paying full freight? Are those who enrolled buying the cheaper “bronze” plans – which have lower premiums but potentially higher out-of-pocket costs -- or the higher-grade “gold” and “silver” plans?
And even these numbers will just be a glimpse of the future makeup of the exchanges. We can expect the early enrollees to be older and sicker than the general population. They need health-care coverage the most – and they’ve had the hardest time getting it. The general thought is that younger and healthier people are more likely to wait until the last minute, before enrollment seasons ends on March 31.
We’re also getting some figures – encouraging to advocates – about improving enrollment in key states, including New York and California, that are running their own health insurance exchanges.
Not over till it's over
In January, we’ll get data that will take us through December. And if HHS is right – if the website performance is good but not great – we’ll start seeing larger numbers and getting a more-detailed breakdown that gives us a lot more granular information about the new marketplace.
Even so – it won’t be over until it’s over. Open enrollment goes through March 31, and some lawmakers have called for the season to be extended given that the website problems basically ate up two months. Whenever the end is, that’s when we’ll really have some sense not only of numbers but also of the make-up of the risk pool.
You’ll often hear that the administration wants 7 million in the exchanges and another 8 or 9 million in Medicaid. That has in fact become the goal, but it wasn’t always a magic number needed to make enrollment a “success” and the risk pool healthy. It started as an educated enrollment guess by the Congressional Budget Office, calculating what the government costs would be the first year. That 7 million number has become so entrenched in the news coverage – and the White House’s own messaging – that it will be a key way we measure success or failure. The headlines will say “Obamacare hits 7 million target” or “Obamacare falls short of the 7 million target.” But that’s politics.
The insurers and the actuaries will be looking beyond 7 million – they’ll want to know how many peopl are healthy, how many are sick, and what the age and other demographic factors are. The health plans might prefer 2 million relatively healthy people to 10 million really sick people.
Reporters will have to write that 7 million story. But then they should explain why the number isn't all that counts.