On November 13, 2013, the Department of Health and Human Services released its first monthly enrollment report for the Affordable Care Act health insurance exchanges.  The report is full of numbers, but two are certain to make the headlines:  Only 106,185 persons selected a plan through the exchanges during the period covered by the report (October 1 through November 2, 2013), and only 26,794 of them did so through the federal exchange.  Indeed, some in the media seem to believe that the most important number is one that is not in the report — the number of enrollees that actually paid for a plan.  That number that is certainly even smaller.

Of course, the number of enrollees is the smallest number in the report (other than the number of enrollees from individual states — 42 enrollees from North Dakota).  Most of the numbers in the report are much larger.  These include:

  • 26,876,527 unique visitors (apparently visitors from unique computers) to the federal and state exchange websites and 3,158,436 calls to the call centers.
  • 846,184 paper and electronic applications submitted to the state and federal exchanges (326,623 state and 519,561 federal) with sufficient information to begin determining eligibility for enrollment or financial assistance.  These applications covered 1,509,883 individuals.  Seventy-four percent were submitted electronically, 26 percent were submitted by phone or mail.
  • 1,477,853 applications processed to the point of an eligibility determination.
  • 1,081,592 individuals (378,973 state and 702,619 federal) determined to be eligible to enroll in marketplace plans.
  • 396,261 individuals determined to be eligible for Medicaid or CHIP.  This number only includes individuals who applied for Medicaid or CHIP through the exchanges, and not individuals who applied independently to state agencies.

Behind The Numbers

These numbers, large and small, tell us a number of things.  First, they tell us that there is tremendous interest in the plans available through the ACA exchanges.  The Congressional Budget Office estimated in May, 2013, that seven million Americans would enroll in plans through the exchanges in 2014.  To date, almost four times that number have visited the website and over one fifth have completed applications.

Second, the numbers confirm what we already know — the federal and many of the state exchange websites are not working and only the most tenacious applicants have been able to get through to the end.  The report covers only the first month of experience, not the intervening two weeks when presumably more applicants have been able to get through.  But anyone who has been paying attention knows how hard it has been to in fact to complete the plan signup process.

Third, the numbers also confirm lessons we have learned from past experience with other programs that require enrollment in health insurance plans.  People do not rush out to choose health plans as soon as an open enrollment period begins, particularly if the open enrollment period is long and begins well before actual coverage begins.  Our experience with the Medicare drug program, the Massachusetts Connector, the Federal Employees Health Benefit Program, and group employee coverage generally is that people tend to wait to enroll until an “action-forcing event,” particularly the end of an open enrollment period or, when applicable, the beginning of coverage. As has been oft-repeated, only 123 premium-paying enrollees signed up during the first month enrollment was open for the Massachusetts connector.  Twenty-two percent of FEHBP enrollees who changed plans during the 2012 open enrollment period did so in the last two days.

Fourth, there is no reason to believe that the 975,407 individuals who have received an eligibility determination but have not enrolled will not enroll eventually.  Many are no doubt engaged in serious shopping at this point — comparing networks and drug formularies for example — and will yet sign up for a plan.  The fact that relevant information for plan selection is only available on insurer websites makes this likely.

Fifth, although attention seems for some reason to be fixated on the number of enrollees who have actually paid the premium for their 2014 plan, it is not surprising that HHS did not release this number. First, premiums are paid directly to the plans, not through the exchanges, in the federal exchange.  This number may not, therefore, have been available.  But more importantly, why should we be surprised that people are not paying for a product they will not benefit from for two months and for which the bill is not due until mid-December?   As has been said, people do not buy health insurance on the lay-away plan.

A surprising result and what it means.  The most interesting number in the report to my mind is the number of those who were determined eligible for coverage who also qualified for financial advance premium tax credits—326,130, or about 30 percent of those determined eligible for enrollment in qualified health plans.  This is far below previous estimates of the percentage of exchange enrollees who would obtain subsidies — 88 percent, according to the May 2013 CBO Baseline Report.

This number likely means at least two things. First, those who are tenacious enough to  get through to enrollment at this point are higher-income, highly motivated individuals who know the value of health insurance but can afford it.  Many are likely people who are facing termination of their current coverage and are interested in seeing what is available on the exchange. Many probably have health conditions that have made coverage very expensive, or perhaps even unavailable, in the past.  This may be worrisome to insurers, who are hoping for a more or less normal distribution of risk in their exchange plans.

Second, lower-income Americans who will benefit most from the ACA, but who often have little experience with buying health insurance or awareness of its benefits, have not yet shown up, or at least not persisted to the point of enrollment.  These enrollees, likely to be younger and healthier, need to show up to normalize the risk pool.

But here another number is important — 18,000 assisters in the federal exchange states who have completed training and conducted over 2800 educational and outreach events.  Over the next four and a half months while enrollment is open, it is reasonable to expect these assisters — plus thousands of agents and brokers, web-brokers, and insurers who can enroll applicants directly — to reach millions of these potential enrollees and to sign them up for coverage and for subsidies.  As enrollment in Spanish becomes easier, Hispanics, the group most likely to be uninsured, are more likely to enroll.

The October report is clearly disappointing.  But the really important reports will be the December report, which will tell us how many will be enrolled for coverage that begins in January, and the March report, which will tell us how many will be enrolled for 2014.  If healthcare.gov is up and running by December, there is every reason to believe those reports will be much more promising.