Four Questions On ACA Enrollment

One-point-two million enrollments -- and counting.

The Affordable Care Act’s first open enrollment period is over, and if raw volumes are a proxy for state-by-state success, the Golden State won in a landslide. Covered California had planned for fewer than 700,000 sign-ups. 

All told, California represents about one-fifth of national enrollment in the Affordable Care Act's insurance exchanges.

Supporters are ebullient. Topping out above 1 million sign-ups shows the "unprecedented" demand for the exchanges, Covered California Executive Director Peter V. Lee said last week.

But critics point to another seven-digit number: 1 million plan cancellations -- or more.

Does that take the steam out of Covered California's performance, or are fears over canceled plans just hot air? 

1. How should we judge Covered California's performance?

The initial enrollment figures are definitely "impressive," said Dylan Roby, who directs UCLA's Health Economics and Evaluation Research Program, which developed the predictive model that regulators used to set expectations."In our base scenario, we estimated 840,000 people getting tax credits and signing up through [Covered California] by 2014. Our enhanced scenario was at 1.2 million." 

Keep in mind that the number isn't final, given all the likely churn both on and off the exchange this year. But Roby believes the exchange will be "very close" to the enhanced scenario throughout 2014.

2. Why was there such a last-minute surge of sign-ups?

At least 340,000 Californians signed up through Covered California in March, according to initial estimates released last week.

Covered California's last-minute outreach efforts included radio and TV spots, and perhaps those campaigns played a role in driving sign-ups.

But a good deal of that last-minute surge is, frankly, because of human behavior, suggested Micah Weinberg of the Bay Area Council.

"I think that we can chalk a lot of this up to procrastination, particularly on the part of the young and newly insured," he said. "Also remember that (these enrollees) could avoid paying three months of premiums and still avoid the individual mandate."

3. Why was the target so off?

Unlike many other states, California may end up doubling its internal projections for enrollment in the exchanges.

"I think Covered California's initial target [of less than 700,000 sign-ups] was set conservatively," Roby said. Officials wanted to be sure that "they could raise enough money to sustain the exchange in the long-term with insurer fees."

Could the many uncertainties once the exchanges were up and running -- for example, the national problems with HealthCare.gov and the local stories about Covered California's website difficulties -- have played a role in driving traffic? Several experts say it's a possibility: The technical issues might have kept Covered California in the news and helped boost awareness.

4. How many people are really 'newly insured'?

Experts pointed out that many media reports are focusing only on Covered California while overlooking Californians who didn't use the exchange to get covered. The wave of new Medi-Cal enrollees, for instance, which include more than 600,000 residents who got covered through the Low Income Health Plan.

Observers also took issue with reports that more than 1 million Californians saw their plans get canceled under new ACA requirements.

"My hunch is that it's been overestimated," said Daniel Zingale of the California Endowment.

And the frightening terminology around "cancellations" also overplayed the actual transitions that unfolded in the market.

"The insurers didn't cancel anybody," said Anthony Wright of Health Access. "They basically told all those people 'we are transitioning you to another policy,'" and some of these individuals did choose to shop around instead.

Prior to the ACA, surveys had suggested that about 5 million to 6 million state residents were uninsured at any given time. So wherever the numbers end up, observers credit California for making a real dent in its uninsurance rate.

Dan Diamond is a managing editor with the Advisory Board company and a contributor to California HealthLine, where a version of this article first appeared.