Obamacare friends and foes alike are eagerly watching the law's insurance-enrollment tally, ready to trumpet every success or pounce on every failure.
But as the final figures before the end of open enrollment are posted, a significant chunk of people who bought insurance under the law will be missing from the official tally.
That's because people who bought insurance directly from insurers, and not through the law's exchanges, will not be included. And just how many people that represents is a figure that will not be available in time for the big enrollment-total reveal—and likely not for a long time after.
Off-exchange enrollment is the forgotten piece of the Affordable Care Act, but it could represent millions of people who are also getting covered as a result of the health care law—many of whom are the young, healthy customers the administration is so aggressively pursuing.
Unfortunately for the White House, no one really knows what those numbers are, and few are talking about them at all.
People who enroll outside of the exchanges are simply using a different means to buy what are often the same ACA-compliant plans available inside the exchanges. They are part of the same risk pools and have the same impact on premiums.
When HealthCare.gov was not functioning in first month or two of open enrollment, officials encouraged consumers to enroll in coverage off the exchanges—an option that bypassed the glitchy enrollment sites and allowed consumers to work directly with insurance companies. The administration then made the option even easier by making the law's premium subsidies available to people who signed up directly with an insurer.
The number of people who have actually taken that approach remains a mystery, but anecdotal reports suggest it could be significant.
In Washington state—one of the only states to release this information—more people have signed up outside the exchange than inside of it. The state insurance commissioner's office says 183,618 people had enrolled in private plans outside of the exchange as of the end of February, compared with 125,000 paid enrollments the state exchange is reporting as of March 23.
Insurers' data paint a similar picture. WellPoint has reported that as of the end of January, 20 percent of its 500,000 new customers did not enroll through the ACA's exchanges.
Highmark said that as of mid-February, about one-third of the over 110,000 people who bought ACA-compliant plans enrolled directly with the company. The insurer offers plans in Delaware, Pennsylvania, and West Virginia.
Neither WellPoint nor Highmark responded to requests for updated numbers.
The Blue Cross Blue Shield Association, America's Health Insurance Plans, and the National Association of Insurance Commissioners all said they do not have direct-enrollment data available. Several state exchanges and state insurance commissioners said they do not collect that information.
Information released by eHealth—an online broker that predates the health care law—indicates that the coveted young-adult demographic is signing up outside of the exchanges. About 45 percent of people applying for ACA-compliant plans through eHealth are between 18 and 34, the company said—compared with roughly 25 percent in the exchanges.
Brian Mast, vice president of communications for eHealth, says the company has historically had a high portion of young enrollees—around 50 percent—since young people are particularly inclined to favor completing tasks quickly and online.
Roughly 170,000 people applied for insurance plans through eHealth during the first three months of ACA open enrollment—a 50 percent increase from the same quarter the year before. Mast attributes the increase to the health care law.
"The purpose of our releases [Tuesday] and in late February was to draw attention to the fact that there is a robust market outside the exchanges," Mast says. "It would be great if there were an aggregate number for on and off [exchanges], because it would give a clearer picture of how enrollment is going."
There is still a fair amount we don't know about Obamacare enrollment—the final tally from the Health and Human Services Department will likely be skewed by the number of individuals that the White House is counting as enrolled, but who have not yet paid their premiums; and the health status of the risk pool is still largely a question mark.
But in the conversation of what remains a mystery, off-exchange enrollment is largely left out. It's quite possible this number would more than balance out the premium payment discrepancy—but unfortunately for HHS, we might not know for a very long time.