ACA signup: it ain't over when it's over

[Update, 3/26: Yesterday's announcement that a "special enrollment period" will be granted to anyone who claims s/he tried to enroll before 3/31 underscores the year-round fluidity of enrollment outlined below.]

Anyone who's paying attention knows that March 31 is the open enrollment deadline. After that date, you can't "get covered" for 2014.

Unless, that is, you qualify for Medicaid -- or experience a "qualifying life event" such as a job loss or divorce or childbirth. That's a lot of people.

Roll on, Medicaid, roll on

Medicaid enrollment is continuous. State agencies and private-sector partners work year-round to get kids enrolled in CHIP.  Adults newly eligible in states that have enacted the ACA's Medicaid expansion can enroll year-round too. Enrollment won't be possible through Healthcare.gov, but individuals can apply through conventional channels, and nonprofits working to enroll the uninsured will continue their outreach after 3/31.


Here in my home state of New Jersey, Nicole Brossoie, Assistant Commissioner of Public Affairs for the NJ Department of Human Services, tells me,"Our focus has been, and will continue to be, to increase the enrollment of eligible, uninsured residents into NJ FamilyCare" after 3/31. After that date, "We will continue our outreach as we always have. NJ FamilyCare enrollment is rolling. There is no deadline or timeline for enrolling eligible residents."

QHP enrollment after March 31

Another locus of post-March 31 ACA signups is year-round enrollment for people experiencing a "qualifying life event" such as a sudden drop in income (as after a job loss) or a marriage or divorce. How many people are likely to enroll in the ACA's Qualified Health Plans (QHPs) between March 31 and November 15, the start of the next enrollment period?

A lot. Or at least, a surprising number will become newly eligible -- or newly ineligible. Americans' health insurance status is far more dynamic than most of us imagine.

A Nov. 2013 Health Affairs blog post by Rick Curtis and John Graves article projecting QHP eligibility post-March 31 makes this clear. For starters, at any given moment in the pre-ACA world, 60 percent of the uninsured remained uninsured for less than a year. That suggests massive turnover year-round in the ACA exchanges. Graves and Curtis spell this out.  My emphasis below:

Our analysis also indicates that 12 percent of non-elderly adults will be eligible for subsidized exchange coverage by the end of 2014, having had full-year incomes in the tax-credit range and lacking employer coverage at year end. But less than half of this total (42 percent) were in the eligible group a year prior.

 The volatility of Americans' insurance status is really kind of staggering:

For example, a study by Mathematica Policy Research found that 7.7 percent of non-elderly persons were uninsured for the entire year, while on average 15.9 percent were uninsured in a given month, and 27 percent were ever uninsured at some point during the year.  And most people enrolling in non-group coverage have only done so for a limited period of time:  During an average month, 5.3 percent of the non-elderly population had non-group coverage, but only 2.1 percent held non-group coverage for the entire year, and 9.7 percent had non-group coverage at some point during the year.  Finally, while employer-sponsored insurance (ESI) is substantially more prevalent and stable, 56.4 percent held ESI for the entire year, and 76.1 percent held ESI at some point during the year.

Here are a few other markers of  how steadily people may flow in and out of the QHP (or Medicaid) market and find themselves eligible for a special enrollment period outside of open enrollment. Every month in 2013, approximately 4.3 million people lost or quit their jobs, according to  Dept. of Labor data gleaned from employers  Many, it's true, leave because they've found another job, and many more are contract workers who are constantly being laid off and rehired. Another snapshot: Of the approximately 10.4 million Americans counted as unemployed according to the DOL's Feb. 2014 household data, about 6.6 million have been unemployed for less 26 weeks or less. The gap between ACA open enrollment periods is 31 weeks.

In another qualifying event category, perhaps 500,000 divorces will occur in the 7.5 months between enrollment periods. According to CDC, there were 877,000 divorces in 2011. Curtis and Graves point to other eligibility triggers:

In addition, a considerable number of other individuals will have qualifying conditions not observed in this SIPP analysis. Examples include young adults who graduate and move off of their college plans or who turn 27 and no longer qualify for their parents’ employer coverage, and workers who have employer coverage at the beginning and end of a year, but have a shorter term loss of such coverage.

A lot of laid off and newly divorced people will have access to their former employer-sponsored insurance via COBRA. For young people in particular, however, Curtis and Graves point out, QHP in the marketplace are likely to be a lot cheaper (though the coverage is likely to be skimpier).

For the newly uninsured, of whom there are millions every month, what effect will the individual mandate to maintain coverage have, and how aware of their ACA options are they likely to be? We don't know. I'll leave the last word to Larry Levitt of the Kaiser Family Foundation, who pointed me to the Curtis and Graves post:

One big area of uncertainty is what people do when they lose their jobs. If they think it’s temporary (as many do), will they go to the exchange, stay uninsured (since they can have a three month break and be exempt from the mandate), or maybe use COBRA (which provides a grace period and retroactive coverage)

Stay tuned through 2014 (and beyond). ACA enrollment ain't over when it's over.


UPDATE 4/3: Chad Terhune of the LA Times looks at post-enrollment signup prospects in California today and cites an "expert" estimate that about 4 million people nationally may be eligible for special enrollment periods.Terhune also highlights another important category of newly eligibles: graduating college students.