Obamacare’s Invisible Victory

Why the total enrollment number is actually bigger than you think.

National Journal
Sophie Novack
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Sophie Novack
March 28, 2014, 1 a.m.

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.

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