Get the Facts on ACA Sign Ups

The ObamaCare enrollment numbers. Let’s look at the ObamaCare signups and enrollments and figure out who signed up, who enrolled, who paid, who lost coverage, who got subsidies, what type of coverage people got, and where they got it.

ObamaCare Enrollment Numbers Overview

Over 15 million folks who didn’t have health insurance before the ACA was signed into law in 2010 are now covered bringing the total uninsured adults in the US from 18% to 13.4%.

We won’t know exact enrollment numbers for each insurance type for some time. For now the best we can do is present the data we do have, analyze it and give you our educated estimates. Let’s look at some quick facts on the ACA signups and the start our detailed look at what factors contributed to the current enrollment numbers.

Enrollment Number Facts

During open enrollment (Oct 1st, 2013 – March 31st, 2014. And then until April 19th, 2014 under special enrollment) over 8 million Americans enrolled in a marketplace plan, coupled with other sign ups under the ACA (Medicaid, CHIP, Employer based coverage, young adults staying on plans till 26, etc), total newly insured increased by about 15 million. Below are some key factors in understanding these basic sign up numbers.

• 8 million Americans enrolled in a marketplace plan during open enrollment 2014 according to HHS.

• Of the 8 million about 7.2 million are expected to have paid their first months premium.

  • Of the more than 8 million:
    • 54 percent are female and 46 percent are male;
    • 34 percent are under age 35;
    • 28 percent are between the ages of 18 and 34;
    • 65 percent selected a Silver plan, while 20 percent selected a Bronze plan; and,
    • 85 percent selected a plan with financial assistance.

• 7 million Americans enrolled in Medicaid and CHIP with about 1.5 million waiting for their enrollment to go through.

• Almost 1 million more were enrolled earlier in Medicaid Expansion plans in seven states.

• Taking into account those who lost eligibility, enrollments in either Medicaid or CHIP increased by over 6 million during open enrollment.

• About 2.6 million young people under 26 were able to enroll on their parents plan.

• An April Gallup poll shows the current uninsured rate among adults dropped to 13.4%, under open enrollment in the health insurance marketplace. Their May poll confirmed this number.

• Many other factors contributed to the final sign up numbers including those who lost their plans, those who got employer based insurance, those who enrolled in Medicaid early, those who are enrolling late, etc.

More ObamaCare Sign Up Statistics

Here are some additional sign up statistics about the number of uninsured from a July study by the Commonwealth Fund. This data looks at open enrollment only (unlike our total numbers which take into account all ACA related sign ups since it was signed into law). Notice that their data for uninsured rate is a few points higher both before and after the ACA then the April Gallup study.

• The uninsured rate for people ages 19 to 64 declined from 20 percent in the July-to-September 2013 period to 15 percent in the April-to-June 2014 period.

• An estimated 9.5 million fewer adults were uninsured during the above period. Young men and women drove a large part of the decline: the uninsured rate for 19-to-34-year-olds declined from 28 percent to 18 percent, with an estimated 5.7 million fewer young adults uninsured.

• By June, 60 percent of adults with new coverage through the marketplaces or Medicaid reported they had visited a doctor or hospital or filled a prescription; of these, 62 percent said they could not have accessed or afforded this care previously.

obamacare sign ups

Other Enrollment Statistic Estimates

Other enrollment number estimates have come out from different sources. If you are interested in getting a different take, look at Kathleen Sebelius’s claim that 22 million got ‘affordable coverage‘ or see enrollment breakdowns at ACAsignups.net. Both of these estimates use the same data and draw similar conclusions that enrollments were in the 15 million to 22 million range.

Could All These Estimates Statistics Be High?

Opponents of the law clam a wide variety of numbers for enrollments. First you have to remember when we say enrollments under the ACA we mean all insurance types, not just the 8 million through the marketplace. If you take the 4.7 million who lost their plans and subtract that from the 8 million who got plans on the marketplace, and then subtract those who may not pay you get a number more like 4 million. Of course the 4.7 million who lost plans got insurance through more places than just the marketplace. The real numbers when taking all data into account truly seems to be closer to our 15 million estimate which as you can read below is actually pretty conservative.

Enrollment Numbers Vs. Canceled Plans

It was estimated that 4.7 million people (of the 270-ish or so million folks with health insurance in the US) had plans that would be canceled due to the ACA come 2014. It’s important to note that this number is not exact and is rather an average and omits a number of factors we will cover in depth shortly.

Of those 4.7 million many were able to stay on their plans due to a fix from the White House which lets Americans keep non-compliant plans until 2017. Some states and insurers didn’t comply and a number were left with no other option but to switch to a new plan. Others switched because they were offered better plans for less money. Final estimates of the total reduction of uninsured obviously include those who lost their plan.

Please note that almost all of those who lost their plan were able to switch to another type of coverage. In some cases this meant better coverage for less money and in some cases this meant either paying more or getting lesser coverage. Note that all plans that were canceled were canceled because they failed to offer all the benefits required by the new law.

This group who lost their plans include about 1.4 million who qualified for free coverage from Medicaid and about 2.35 million who qualified for subsidies. All Americans who had canceled plans qualified for a hardship exemption, meaning if they chose not to sign up they wouldn’t pay the fee for not having insurance in 2014.

Please see the discussion on canceled plans for more detail.

ObamaCare Enrollment Numbers and Sign Ups In-Depth

Now that we have given you the currently semi-unannotated ObamaCare enrollment number overview above we can dig into the some of the complexities. Let’s take a more in depth look at sign up and enrollment data under the Affordable Care Act.

Over 15 Million More Americans Have Health Insurance Due to The Affordable Care Act


by Paul Mullen

Both proponents and critics of ObamaCare have been very vocal. One thing they agree on however are its aims: Here opponent John Ammon MD states them as he sees them:

ObamaCare was advertised to the American people as a fix for two problems: Reining in the runaway cost of health care and extending health insurance to the uninsured. Long before the law was passed, physicians agreed that major reform of health care financing, taxation and insurance could help fix these issues, which were very real. The cost of health care had ballooned from coast to coast. These steady increases simultaneously made it harder for many to afford health care or health insurance for their families, thereby driving up the number of uninsured.(1)

Ammon continued: “Intentions didn’t equal results with ObamaCare. Neither of these two problems have been addressed by the law. Health care experts at Harvard University and Dartmouth College still estimate that health care costs will continue to grow faster than the economy for at least the next 20 years. Most troublesome, the federal government estimates that 31 million Americans will still be uninsured by 2024”.

This article is about the effect ObamaCare has had on the uninsured up to April 2014. Based on the experience of health care expansion in Massachusetts, it will take at least three years to see the full effect. Without controlling the ever-rising cost of healthcare no system can keep people insured. America relies mainly on employer based insurance and this has been decreasing each year since 2001. Medicare is the major source of insurance for those over 65 and this too has come under severe pressure from both the rising number of people over 65 and rising costs, particularly for the increased numbers of very elderly. But costs are a topic for another day.

On the numbers insured we have all heard the news that 8 million people enrolled through state and federal health exchanges. But how many of those will pay? How many lost insurance when their previous inadequate policies were canceled? You may have heard some politicians claim that cancellations and non-payments outweigh exchange enrollments: claims which earned them “Four Pinnochios” from the Washington Post FactChecker (2). On the other hand some politicians have made exaggerated claims of the success of the Affordable Care Act.

At ObamaCareFacts.com we aim to give you unbiased facts about ObamaCare, as accurately as possible. So we have been asking what effect has the Affordable Care Act (aka ObamaCare) really had in reducing number of uninsured in America? To find out we looked at all available information from many different sources. We looked at how many really paid, how many were able to buy new policies off the exchange, how many kept old non-compliant policies, how many are newly covered by Medicaid, and how many have gained or lost employer coverage so far.

The analysis is complicated by the fragmented nature of health insurance in America. Apart from the over 65 population served by Medicare, the rules for health insurance were (and to some extent still are) different in each of the 50 States (+DC). So we have a fragmented collection of different employer provided insurance, individual health plans (which varied widely in quality many providing only limited benefits) and government assisted programs including Medicaid (which is different in every state), VA, Indian Health Service, plus many state-run programs).

Data on many of these numbers is not as easily available as exchange enrollment, and some data overlaps other data (for example the elderly may be covered by both Medicare and a retirement plan provided by their former employer) so we have used information from a variety of sources, and cross-checked it against other sources. While many of the numbers are necessarily best estimates, and so could turn out to be a little smaller or larger, we have compared different sources and found they point to the same overall results.

Our best estimate is that as a result of ObamaCare over 15 million people, who otherwise would have been uninsured, now have health insurance.

ObamaCare Enrollment: Evidence From Gallup Surveys

With so much uncertainty about who already had insurance, and the constant “churn” between employer, individual, Medicaid and uninsured as people’s life circumstances change, it is very difficult to look at one set of numbers in isolation. A much better way to estimate the overall effect of the ACA on the uninsured is by surveying a representative sample of the population. While the Census Bureau gathers health insurance through two very large annual surveys, The Community Population Survey, and the American Community Survey, the results from these big surveys will not be ready for a long time. Nor will the CDC’s National health Interview Survey, whose quarterly results are published about 6 months after the end of each quarter.

In the mean time the best data comes from the Gallup-HealthWise survey, which interviews 500 people a day, or almost 180,000 people each year. We have undertaken our own analysis of this data, and  compared its results with several other polls, and with available data from exchanges, and insurance companies.

Let’s start my looking at how the results of the Gallup Poll compared to exchange enrollment:

Period

2013-Q3

2013-Q4

Jan

Feb

March

April

Mean Poll Date

8/14/13

11/13/13

1/15/14

2/14/14

3/15/14

4/15/14

Exchange Enrolled

0

1.08

2.73

3.77

5.10

8.01

% Adults Uninsured

18.0%

17.1%

16.2%

15.6%

15.0%

13.40%

Decrease Uninsured

0.9%

1.8%

2.4%

3.0%

4.6%

Note that any sample survey will have three kinds of error in its estimates. The first comes from the size of sample, and with almost 15,000 interviews a month Gallup is far larger than most. Nevertheless some sampling variation will result. For example they announced at a press conference in mid April that the uninsured rate had fallen to 12.9%, based on just half a months results. That looked rather low at the time and when the complete month was analyzed April’s result turned out to be 13.4%. To minimize sampling error Gallup prefer to work with quarterly averages, so we will have to wait until early July to see the final value for this quarter. Still previous monthly averages have turned out to be remarkably consistent, so I doubt if the next two months will bring any major surprises.

The second kind of error is in sampling bias. For example if you just randomly dial phone numbers you will have a much greater chance of finding someone who has both a home telephone and a cell phone than someone with only one phone. Then some self-employed people like to have separate cell and land line numbers for personal and business calls. Gallup are by far the most expert in removing as much as possible of this variation. However even they can’t do anything about the small number of people who have no phone at all! By carefully controlling the sample compared to known numbers of people in different categories they can eliminate a lot of this bias.

Third whenever you ask a question you have to be very careful in how you phrase it and even then you are likely to get the answer to the question the interviewee thought you were going to ask, rather than the question actually asked. It is well known that almost every health insurance survey understates the number of people covered by Medicaid. Even here when I compared the number of people reporting they were insured with the exchange enrollment and then with estimates of the number of those policies that had started, it was clear that people reported themselves as insured when they had enrolled for a policy that would not start until the next month (or even the month after). This is likely why the reported uninsured in Q4 of 2013 had dropped compared to the previous quarter, even though none of the new Exchange plans started until January 1st. Another explanation though is that some had already enrolled for Medicaid through the various State exchanges. Also in October and November of 2013 there was a surge in last minute enrollments for older pre-Obamacare insurance plans, which offered fewer benefits but were cheaper. While state rules differed, in many states these plans could be sold up until 30th November 2013.

The decline in the uninsured is not solely due to plans sold on the exchange: expanded Medicaid and CHIP enrollments were a large part of it (3) and many new individual plans were sold off the exchanges direct from the insurer or through brokers (4). The threat of individual mandate penalties may also have increased enrollment in employer plans (5). However when we compare the decline in the uninsured with exchange enrollments, we find a remarkable correlation, suggesting that the wave of interest in signing up for insurance drove these alternatives too.

obamacare enrollment numbers

Since the opening of the exchanges, Gallup has seen the percentage of all adults (18+) without health insurance fall from 18.0% (in Q3 2013) to 13.4% April. Given the last minute enrollments and continuing special enrollments, plus continuing Medicaid enrollment all year, it is likely to drop still further.

So we have a 4.6% drop in uninsured adults (18+) Since there are approximately 240 million adults in the USA, this represents 11 million adults. To this we must add about 1.5 million children (including exchange plans, off-exchange plans and Medicaid+CHIPS. This brings us to a 12.5 million decrease in reported uninsured since Q3 of 2013.

In addition some groups gained cover through the ACA even before open enrollment. In a separate analysis of data from both Gallup and the National Health Interview Survey, I found that around 2.6 million uninsured young people under 26 gained insurance through their parent’s plans (6). Then the CMS Medicaid and CHIPS report for March 2014 (7) reports that 949,821 individuals in California, Colorado, Connecticut, District of Columbia, Minnesota, New Jersey, Washington had enrolled for expanded Medicaid before the start of Open Enrollment under “Early Option” programs.

Of course there are going to be some who enrolled on the exchange and end up not paying, the statistics on this have been greatly distorted by the inclusion of people whose payments were not even due. For example the House Committee on Energy and Commerce estimated that in Federal exchange states, 67% of those enrolled had not paid by April 15th. However those states had a particularly great last minute surge in enrollment, so 41% of those enrollees did not have a payment due until at least April 30thor later. Most would not even have received their first premium notice by then. Even if we assume that 25% of these late enrollees had paid more than two weeks before they were due to pay, at least 95% of the earlier enrollees must have paid on time!

In general the assumption that at least 90% will pay seems to be a reasonable estimate, and has been confirmed by many major insurance companies, such as Wellpoint. So let’s knock off 0.8 million for non-payment.

So in total we have:

11 million adults

+1.5 million children

-0.8 exchange non-paid

+2.6 million under 26

+0.95 million early expansion

Total= 15.25 million gained insurance due to the ACA as at April 2014.

ObamaCare Enrollment Number Resources:

We suggest checking official releases from HHS, the CBO, the US census, and popular polls like Gallup for the most current signup information (we used all of these sources in our breakdown). Bear in mind that different surveys use different definitions to collect numbers of uninsured, some express it as a percentage of the whole US population, others adults (18+) and still others only look at adults 18-64, since almost all those over 65 are covered by Medicare. Another great resource is acasignsups.net which provides pretty detailed and unbiased looks at sign up numbers as well. Another great resource is acasignsups.net which provides pretty detailed and unbiased looks at sign up numbers as well.

1. John Ammon MD – ObamaCare versus the Hippocratic Oath. Washington Times May 16 2014

2. Washington Post FactChecker – The Bogus Claim that the Number of Uninsured Has Increased April 25th 2014

3. Paul Mullen – New Enrollment in Medicaid and CHIP

4. Paul Mullen – The Numbers covered by other Individual Plans

5. Paul Mullen –Changes in Number of People Covered by Employer Group Coverage

6. Paul Mullen – Number of Uninsured Young Adults added to Parent’s Plans

7. CMS Medicaid & CHIP March 2014 Monthly Applications, Eligibility Determinations, and Enrollment Report. May 1st 2014

Exploring Enrollment Numbers Under the ACA

Above you have both a quick and detailed breakdown of general enrollment numbers under the Affordable Care Act. Please continue to explore this section for more detail on things like enrollment in Medicaid, marketplace enrollments, employer enrollments, and enrollments outside of the health insurance marketplace. We will continue to update this section as new signup and enrollment data is released.

 
Understanding ACA Signups and Enrollment Numbers
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