This column originally appeared in Politico on October 27. Dr. Altman’s future Politico columns will be posted on kff.org one day after publication.
The battle over the Affordable Care Act and its problem-plagued rollout is fast becoming a numbers game: How many people have gone to HealthCare.gov, established an account or actually enrolled in a health plan? How will the website’s problems affect enrollment in the first year? Will the administration need to make major changes, such as extending the open enrollment period or delaying the individual mandate penalty?
Obviously, the website must be fixed soon, or the ACA will be in deep trouble. If it is not fixed, the political fallout will worsen, and one of the ACA’s gateways to coverage, the federal exchange, will remain dysfunctional. But assuming the website is repaired fairly soon, the public’s judgment about Year One will be based much more on whether people believe the coverage they get is a good deal than on early website numbers or projections made in Washington for first-year enrollment.
And what about those numbers? The figure most frequently used as a metric for first-year enrollment under the ACA comes from the Congressional Budget Office. The CBO estimated that 7 million people will be covered in the state and federal insurance exchanges and 9 million more by expanded state Medicaid programs in 2014. The CBO does estimates to gauge impact on the federal budget, not to evaluate the implementation of laws, but these numbers have taken on a life of their own. The 7 million figure, in particular, has become the yardstick for measuring the ACA’s success or failure in Year One. But that’s sort of like mistaking fantasy football for real football.
Let’s be honest: Any projection like this is largely an informed guesstimate about something that has never been done. It’s not an exact science. Just last week, Ohio changed the numbers when it decided to expand its Medicaid program. There’s no way the CBO’s number crunchers could have anticipated either that eleventh-hour expansion or the troubled rollout of the federal exchange website, which could have an impact on both the mix and number of people enrolled in the first year if it is not fixed soon.
But the impact of these serious website problems on the total number of enrollees may not be huge, since the majority of the uninsured projected to be covered in the first year will be enrolled through state Medicaid expansions and state-operated exchanges. Medicaid and state-exchange enrollment seem to be working more smoothly than enrollment through HealthCare.gov. While some people of low income will be directed to Medicaid through the federal exchange, states are conducting outreach and many applicants will enroll directly through a state program. The impact on the mix of enrollees could be more problematic if younger, healthier people are turned off and stop trying to enroll. There is concern about this but no evidence yet that it is actually happening.
One misconception about the 7 million number creeping into the conversation is that it is a target necessary to achieve a viable insurance pool with a good mix of healthier and sick people. The principle is right — the larger the number, the better the chances of spreading risk — but the CBO was calculating the number who might be covered in the first year to estimate federal spending, not to lay down a threshold for the program’s success.
So let’s not make too much of the CBO estimate: What people should be paying attention to at the end of the first year is not whether a specific projection is attained but whether people feel the coverage they are getting is a good deal and whether the states that have chosen to move forward with the ACA are satisfied. For instance, let’s say 10 million people are covered in the state and federal exchanges, substantially more than the 7 million projected by the CBO. If people widely complain about the individual mandate or affordability of coverage, and states that have embraced the law balk, would that be a success?
Imagine, on the other hand, that enrollment ramps up more slowly than the CBO expected simply because it takes more time than expected to enroll the uninsured. That could happen not only because of early website problems but because the uninsured are largely uninformed about the law and many do not know that they are eligible for tax credits. Say 5 million people enroll in the state and federal exchanges (plus millions more in Medicaid), but most people are happy with their coverage and enrollment reflects a good mix of healthier and sicker folks. Media reports would become increasingly upbeat, or at least they should, and states that have chosen to sit on the sidelines might take notice. ACA’s first year could be judged a success despite the early hiccups.
Maybe it’s asking too much to expect the pundits and partisans on both sides to resist turning this into a ballgame scorecard, with a simple measure of whether Obamacare wins or loses in its first year. But for those of us just trying to understand whether the ACA is really working or not, it’s definitely too early to say which way things will go, and there is no single magic number that will tell us whether the law succeeded or failed in the first year.