Health Exchange Enrollment Picked Up in December – NYTimes.com

Health Exchange Enrollment Picked Up in December –

NYTimes.com.

Let’s look at this data and drill down under the surface.   You could probably spin it to the positive or negative, depending on your over-all view and outlook for the ACA.  If, however, you look at it in terms of what was predicted to have occurred by now and what is needed for look term success, the ACA’s long term financial health doesn’t look so good.

Maybe the ACA qualifies for a preexisting waiver!

For instance, the percentage of younger, healthier enrollees sits at 24% for the nation as a whole (range 17% in W.VA and AZ and 44% in D.C.)  Insurance analyst and economist had estimated it would take about 35 – 40% participation by these risk pools to keep them viable.   Aside from Washington D.C showing much higher young people participation (demographic and income driven, no doubt), the range is pretty tightly clustered around 24%.  There isn’t much reason to expect that will change much over time, if prices stay where they are and absent any additional incentives.

The other finding worth noting, and predicted by budget hawks and some opponents of the ACA, is that over 20% of those applying for coverage were deemed eligible for Medicaid or sChips, which means they don’t have a choice but to go into the government sponsored plans once application has been submitted.

Now consider that if you look how many people actually enrolled, not just applied, Medicaid makes up about 43% of the total, with the other 57% purchasing a private plan!  This leaves about 4 million folks (52% of applicants) that did not pull the trigger and are not likely eligible for Medicaid, since Medicaid eligible folks were likely automatically placed on coverage if the application went to completion.  There could be some applications in process that might alter these percentages; can’t be sure.

If this ratio holds true for roughly 30 million (predicted) eventual enrollees, then we are talking about nearly 13 million more people on Medicaid.  With that many more covered individuals, I am sure more doctors will start taking Medicaid, but it is unlikely to be enough to compensate for the increase in Medicaid rolls.

Now consider that pre-ObamaCare Medicaid recipients in Oregon have been shown to utilize the ER at a rate 40% higher than the cohort group from which they came that did not receive Medicaid.   This is the exact opposite of what was predicted to happen once these folks received coverage.  It was predicted that they would stop going to the ER so much and land in the primary care office for care.  It turns out, they weren’t going to the ER as much as we thought.  It makes sense when you think about it.  Why would the indiscriminately go to ER and risk receiving a huge bill they couldn’t pay and the negative economic consequences that result, when they are uninsured?

Let’s look at it a little differently and assume all 45 million estimated “uninsured” apply and 52% don’t complete enrollment for whatever reason (see above), that leaves 23.4 million still uninsured, about 9.3 million enrolled in Medicaid (43% of remaining processed applications) and 12.3 who purchased private coverage on the exchanges.

So in the end, we could still have over 20 million uninsured, anywhere from 9 to 15 million more Medicaid recipients and only 12 million purchasing private insurance.  Can you say budget-buster!?  It’s almost like it was designed to fail! Who knew?

I don’t know about you, but I am pessimistic about the plan.

Like I heard someone say a few years ago and I am found of repeating: Coverage does NOT equal care!

This could get ugly!

Robert Nelson, MD

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