Health Care

The Obamacare Enrollment Crash Is Coming

National Journal
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Sam Baker
Feb. 19, 2014, 3 p.m.

Obama­care’s en­roll­ment num­bers are sur­ging — for now.

After a dis­astrous launch, the law’s back­ers are breath­ing a sigh of re­lief as en­rollees flock to its in­sur­ance ex­changes. But the totals are built on a shaky found­a­tion, and at some point soon, the ex­change en­roll­ment fig­ures are go­ing to fall, per­haps by more than 1 mil­lion people.

Right now, the ad­min­is­tra­tion is count­ing the total num­ber of people who have se­lec­ted an in­sur­ance policy un­der the law, rather than the num­ber of people who’ve paid for it.

But at some point, likely this spring, the ad­min­is­tra­tion will be forced to dis­close how many people are ac­tu­ally pay­ing their premi­ums — a more ac­cur­ate, yet un­doubtedly lower count of who ac­tu­ally got in­sured un­der the Af­ford­able Care Act.

About 20 to 30 per­cent of people who se­lec­ted a plan did not make their first pay­ment, ac­cord­ing to an­ec­dot­al es­tim­ates from in­di­vidu­al in­sur­ance com­pan­ies. Those num­bers aren’t of­fi­cial or fi­nal, and could im­prove — but however they end up, that’s the real meas­ure of Obama­care’s first-year suc­cess.

It’s hard to see the re­vi­sion do­ing any real dam­age to the law’s long-term pro­spects for sur­viv­al, or its po­ten­tial to grow. And in real-world im­pact, it doesn’t mean that any­one has lost their in­sur­ance; it simply means they signed up to buy a plan that, for whatever reas­on, they’re not go­ing to ac­tu­ally buy.

Polit­ic­ally, however, it will be a Re­pub­lic­an field day, as it hands Re­pub­lic­ans a fresh at­tack — one that un­der­cuts Demo­crats’ emer­ging suc­cess story of high en­roll­ment — and could put vul­ner­able Demo­crats back on the de­fens­ive over a law they’re try­ing not to talk about.

The Health and Hu­man Ser­vices De­part­ment’s latest up­date re­por­ted that 3.3 mil­lion people had se­lec­ted an in­sur­ance policy on the law’s new ex­changes by the end of Janu­ary. It was a pos­it­ive re­port by al­most any stand­ard, and puts en­roll­ment on track to hit 5 to 6 mil­lion by the time the win­dow closes in March.

Demo­crats have touted the totals as a sign that the law is work­ing, des­pite Re­pub­lic­an in­transigence and early tech­no­logy dis­asters.

But if the early in­dic­a­tions hold and the more ac­cur­ate en­roll­ment met­ric shaves 20 to 30 per­cent off the ini­tial num­bers, it will be a pain­ful shift for Demo­crats. At cur­rent levels, it takes en­roll­ment from 3.3 mil­lion down to about 2.6 mil­lion. If, hy­po­thet­ic­ally, 6 mil­lion people choose a plan by the end of March, real en­roll­ment would be closer to 4.8 mil­lion.

That’s enough for the new in­sur­ance mar­kets to be sus­tain­able, health care wonks say. The Af­ford­able Care Act is already here to stay.

Still, the day the White House cuts its own en­roll­ment totals by 20 per­cent is prob­ably not go­ing to be a very fun day for vul­ner­able Demo­crats, who are already frus­trated with the ad­min­is­tra­tion over the delays and tech­nic­al head­aches that have riddled the im­ple­ment­a­tion ef­fort.

Re­pub­lic­ans are try­ing to keep the de­bate fo­cused on Obama­care, and to paint the law as not liv­ing up to ex­pect­a­tions. And a down­ward re­vi­sion in en­roll­ment — even one done in the name of more ac­cur­ate data — will put the law fur­ther away from the ini­tial tar­get of en­rolling 7 mil­lion people this year.

But there’s no way around it for Demo­crats. Party strategists say the White House has to re­lease the more ac­cur­ate fig­ures once it has them, and that the best strategy for vul­ner­able sen­at­ors is simply to ride out an­oth­er GOP at­tack.

“The White House has got to be as trans­par­ent as pos­sible from here on out. The last thing they can af­ford to do is get tripped up,” said Jim Man­ley, a Demo­crat­ic strategist and former aide to Sen­ate Ma­jor­ity Lead­er Harry Re­id.

Demo­crats don’t ex­pect the en­roll­ment re­vi­sion to do long-term polit­ic­al dam­age. Sign­ing up 4.8 mil­lion people in­stead of 6 mil­lion people is still sign­ing up 4.8 mil­lion people, they ar­gue.

“Over­all, I know there is a con­stant search for less than good news in the Health­ arena, but if you look at the data re­por­ted, it is over­whelm­ingly pos­it­ive, and the pre­dic­tions of fail­ure and doom and gloom that we saw — un­der­stand­ably, per­haps, giv­en how rocky the start was in Oc­to­ber and Novem­ber — have all come to naught,” White House press sec­ret­ary Jay Car­ney said last week when asked about people who had not paid their premi­ums.

There prob­ably wasn’t any way for Demo­crats to avoid the box they’re in now.

Even be­fore the Health­ launch made sign­ing up al­most im­possible, the Cen­ters for Medi­care and Medi­caid Ser­vices had al­ways planned to define en­roll­ment based on the num­ber of people who se­lec­ted a plan, a CMS of­fi­cial said. The of­fi­cial said CMS knew there would be a lag in get­ting more-com­pre­hens­ive data from in­sur­ance com­pan­ies.

That lag time, though, has grown longer as a res­ult of Health­‘s tech­nic­al prob­lems.

CMS is still build­ing the com­puter sys­tem that auto­mat­ic­ally pays in­surers and re­con­ciles en­roll­ment in­form­a­tion between car­ri­ers and the gov­ern­ment. It’s one of the back-end sys­tems that took a back seat as HHS struggled to re­pair the Health­ user ex­per­i­ence.

Al­though in­surers are get­ting paid through a work­around sys­tem, it only cap­tures con­sumers who get a tax sub­sidy to help pay for their cov­er­age — so it’s not a com­pre­hens­ive ac­count­ing of every en­rollee.

A full count of ac­tu­al en­roll­ment will be avail­able when that sys­tem is fin­ished, the White House has said.


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