Friday, February 21, 2014

Obamacare: The Central Objective


This is the most recent enrollment status from the remarkable Charles Gaba, who appears to have put his entire life on hold for 6 months to provide really good reporting of the ACA numbers. We are all blessed indeed that Charles has made such a generous commitment. Today I want to focus on the Medicaid numbers - the big purple section in the middle of the graph.

Conservative pundits have attacked the gross Medicaid enrollment numbers (reduced only by renewals, which Charles has been able to separate out) - 7.16MM shown above - saying much of the volume comes from already eligible people signing up, not the newly eligible under the ACA Medicaid expansion. So he strips out all enrollment in the non-expansion states plus numbers of those enrolling in expansion states who were already eligible before ACA, and simply "came out of the woodwork", and gets a rock bottom number of 2.60MM. For a number of reasons, I think something closer to the 7.16MM is closer to the mark. Take a look at this chart from Kaiser:

Looking at this, I would have predicted a 55.5-56.0MM forecast for 2014, based on extending past trends. So anything over, say, a 1MM increase in enrollment for 2014 must be due to the ACA's impact: some people signing up will be newly eligible under the new ACA eligibility rules; but many will be listening to the national debate, paying attention, and finally signing up, though they had already been eligible.

So let's take 1.0MM off Charles upper range number, and we get 6.16MM for Medicaid through mid-February and 3.31 on the Exchanges (excluding unpaid and off-exchange). Where will that leave us by March 31? My guess: Exchanges - 5.5-6.0MM, Medicaid - 8.5-9.0MM (after deducting 1.0MM for normal growth). In other words - short of target on the Exchanges (7MM target) and pretty close on Medicaid (9.0MM target).

But here's what I learned today: Medicaid enrollment continues throughout the year through the Exchanges and direct to state Medicaid offices. Larry Levitt at Kaiser said a drop off in monthly enrollment is expected for Medicaid, but that the signup process will continue through the year.

So how many will signup by year end? Very hard to tell, but how big would that number have to be to make the original goal of reducing the number of uninsured in 2014 by 14MM? If 5.5MM is the Exchange result, and 2.0MM of these were previously insured on the individual market, then this is a 3.5MM reduction in uninsured. To hit the 14MM original target, Medicaid would need to generate 10.5MM new signups by year end. And this looks to me to be very achievable.

This is a big deal and my guess is that very few people know about it: Medicaid enrollment numbers will keep coming in after 3/31, and we may well be hitting the original overall target of reducing the uninsured by 14MM in 2014 around the November election day.

This should help Democrats in the coming midterms.


  1. If the goal, as you say, is "reducing the number of uninsured in 2014 by 14MM," then it's done, right? 4.3 million in QHP (so far), and the 6.16 million that you arrived at, PLUS the 3.1 million sub-26ers gets us to 13.5 million. Surely the other 500k will be a breeze. The uncounted off-exchange enrollment alone must be well over that.

    1. This is a very useful point: Will the 3.1MM sub-26ers that can now stay on their parents' policies end up reducing the number of uninsured in the US by that, or close to that amount? Quite possibly, though I'm not entirely sure if they are listed as Uninsured initially. My reason for focusing on the 14MM number, made up of Exchange and Medicaid is that this is what the CBO has done from the beginning. Initial targets - 7MM on the Exchanges, less 2MM of those coming from the old individual market, plus 9MM from Medicaid equals a net 14MM reduction in the unemployed from these two sources. Still, I very much like your question.