When we move past the March 31 deadline to sign up for health insurance for 2014, will we know how many uninsured Washington residents have been helped by the Affordable Care Act, with all its angst, infrastructure and expense?
It’s a key question in judging the federal law’s performance.
But to the dismay of the law’s supporters, as well as its critics, that number is proving to be as slippery as a moss-covered sidewalk in springtime Seattle.
“Isn’t the goal of the entire act supposed to be about covering people who were not covered before?” asked State Sen. Bruce Dammeier, R-Puyallup, who grilled Richard Onizuka, CEO of the Washington Health Benefit Exchange, in a recent legislative committee work session. “This is a critical number that really should determine the success or failure of the program.”
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At the outset, the calculation seems simple: Washington began 2013 with about 990,000 people without insurance, according to the state Office of the Insurance Commissioner (OIC).
Ultimately, the state’s goal is to enroll more than 809,000 people in health insurance through the exchange by the end of 2017 — 471,000 in private health plans and 338,000 into Medicaid.
Nobody disputes that enrollment in taxpayer-supported Medicaid, already above its 2017 target, will make a serious dent in the numbers of uninsured. But the ACA, in the end, hinged on bringing the uninsured into the private marketplace.
When the dust settles, will Washington, one of the most successful states in enrolling residents in health insurance plans through its exchange, have accomplished that goal?
Now, about a week away from the March 31 deadline for 2014 insurance, the Washington Health Benefit Exchange has spent more than $83 million in federal grants to create the Washington Healthplanfinder online exchange marketplace, advertise and otherwise keep the sign-up machinery running.
At last report, nearly 470,000 individuals had signed up either for Medicaid or individual insurance through Healthplanfinder. Of those, 112,225 bought commercial health insurance plans — far behind the exchange’s Jan. 1, 2015 goal of 280,000 enrollees.
And the nagging question continues to lurk: How many of those 470,000
were previously uninsured?
According to state figures, 265,969 people had individual coverage in September 2013 before Washington’s Healthplanfinder launched. And 11,500 were individuals covered in association plans.
About 238,000 individual-plan holders, plus the 11,500 in associations, got notices last fall that their plans were being discontinued for 2014 because they didn’t meet ACA requirements.
Many — or most — of the 112,225 who have purchased private health insurance on the exchange could have been those who considered themselves insured in 2013.
In addition, some of those signing up for Medicaid may have dropped private insurance to get a better deal. Or perhaps they qualified because their work hours were cut by a company to avoid requirements to insure full-time workers.
In the legislative work session, Dammeier, Sen. Andy Hill, R-Redmond, and Sen. Randi Becker, R-Eatonville, all demanded a number from Onizuka: How many of those who are getting health coverage through the exchange were previously uninsured?
Onizuka couldn’t satisfy the lawmakers. “That’s a harder number for us to get,” he said, stumbling to find the right phrases. “We’re trying to get that.”
Why is that number so elusive?
Here’s one reason: At this point, there’s no good way to track individual people’s insurance choices. It would be easier if Carol M. Ostrom had to report her insurance status monthly to Insurance Commissioner Mike Kreidler. Then we would know whether she used to be uninsured.
But that’s not the case, at least not now.
So, the lawmakers asked Onizuka, did the exchange at least ask those signing up: Do you have insurance?
It sounds simple enough but, in fact, it’s complicated, too.
Last year, the Healthplanfinder application caught people in the midst of transition, and people who had a plan that was being discontinued might reasonably have answered: “Sort of.”
If they had insurance at the moment they signed up, and answered, “yes,” the website sometimes wouldn’t allow them to move the application ahead, local sign-up assisters say. If they eventually answered, “no,” will they be counted among the “uninsured”?
Now, Healthplanfinder instructs applicants that if they have insurance that will end by Dec. 31, 2014, to say “no” to the question, which can be equally confusing.
Another basic problem: Even if the exchange reliably tracked how many previously insured people signed up through Healthplanfinder, what if many uninsured people in Washington landed elsewhere?
Not all uninsured people went through Healthplanfinder, where they might qualify for a subsidy under the ACA or coverage under Medicaid — and be counted. Some, spurred by the prospect of a penalty for going bare, signed up directly with insurers. Others may have chosen other options — signing up on a spouse’s workplace insurance plan, for example.
Some uninsured may be still pondering what to do. Those with incomes too high to qualify for a subsidy may have chosen to simply stay that way. Yes, they may be liable for paying a penalty of at least $95 or 1 percent of income, whichever is higher. But an insurance policy, depending on their age and income level, could cost more than that much each month.
People’s insurance situation also changes, sometimes a result of big shifts — say, an economic downturn, or a hiring boom, or a python-belly full of Baby Boomers aging into Medicare.
Sometimes a big company changes its plans so it costs an arm and a leg to cover spouses and children. Businesses move workers to part-time status or change insurer — sometimes contracting with out-of-state companies that don’t report numbers to this state’s insurance office. Boeing, for instance, now contracts with an Illinois “Blue” insurer that administers plans.
To capture these and other slippery statistics, the state’s insurance office uses myriad sources, says Jim Keogh, the state OIC’s economic policy analyst, who has done much of the estimating in the past.
“We do try to go to as many sources as humanly possible,” says Keogh, who notes that his spreadsheet runs down 80 rows. “We have a stronger grasp on enrollment now than when I came in 2008.”
So what numbers do we know, and what don’t we?
• Medicaid: At last count,
more than 235,000 adults newly eligible for Medicaid, also known as Apple Health, had signed up. And 122,000 signed up who were previously eligible under the old rules. Some of those may have previously paid for private insurance, but that’s not tracked.
• Individuals: The OIC has estimated that, by March 31, enrollment in individual insurance plans, both inside and outside the exchange, would break 300,000, reversing a steady downtrend that began in 2010.
• Large groups and self-insured: The OIC’s last estimate, at year-end 2012, counted about 2.1 million state residents with coverage through self-insured private company and government plans.
• Associations: Of the approximately 250,000 people who were covered last year through associations, 11,500 were kicked to the individual market, and potentially as many as 150,000 could get discontinuation notices in the future, Keogh says.
Overall, Onizuka suggested that a global count wouldn’t happen until sometime in 2017.
Michael Marchand, the exchange spokesman, says it’s important to keep in mind that the ACA wasn’t meant to be a quick fix. Like Medicare’s Part D prescription-drug coverage, which took years to be deemed a success, the ACA is a long-range plan, says Marchand, a former Medicare spokesman.
“I don’t think the first six months of this program will be the indication of success,” he says. “It may take six years for us to be able to say whether it was a success.”
Carol M. Ostrom: 206-464-2249 or firstname.lastname@example.org. On Twitter @costrom