Wednesday, April 09, 2014

Some notes on the RAND survey

RAND has released its latest survey results on the health insurance status of American adults aged 18-64, spotlighting changes in health insurance enrollment since 2013. The results are based on survey responses from 2,425 people -- and since RAND surveys its panel monthly, it is able to track changes in health insurance status, pegging sometimes quite wide margins of error for each finding. The top line is that an estimated 9.3 million more people had health care coverage in March 2014 than in September 2013 (albeit plus or minus 3.5 million). That is, as Adrianna McIntyre frames it, "the uninsured rate among 18-64 year old adults in the United States fell by 23 percent—from 20.5 percent to 15.8 percent."

Adrianna also spotlights the report's biggest surprise: that the bulk of the increase comes from an estimated 8.2 million people gaining employer-sponsored insurance (ESI). RAND speculates that "some" of these people "may have taken up an employer plan as a result of the individual mandate; others may have newly found a job."  RAND found that only about 1.4 million people gained coverage from the new exchanges, as only about a third of the 3.9 million they found gaining coverage through the exchanges were previously uninsured.

A few thoughts and questions in response to the RAND findings are outlined below. My own confirmation bias may be at work, but I suspect that more than one third of ACA private plan signups were previously uninsured, for reasons outlined mainly in point #5.

1. The finding that 5.9 million adults gained Medicaid coverage is roughly congruent with Charles Gaba's tracking -- and higher than most quoted estimates, including HHS's cautious and outdated estimated of 3 million released a few days ago. Gaba, who tracks state as well as HHS data as it's released, estimates that 5.1 million people made newly eligible for Medicaid by the ACA expansion have signed up, and that another 2.0 million who were previously eligible but un-enrolled have now enrolled. Those 7.1 million include children newly enrolled in CHIP, however. Note also that RAND finds that just 3.6 million previously uninsured adults are now on Medicaid, indicating that 2.3 million new enrollees previously had other insurance.

2. RAND surveyed people through the first three weeks of March and completed many surveys early in the month.  Fully 40% of those who enrolled in ACA Qualified Health Plans (QHPs) through the exchanges enrolled in March, a disproportionate number of those in the last week.  RAND's estimate of the number who gained insurance through the exchanges is more than 3 million short of current HHS estimates. While some of the difference may be accounted for by no-pays and the normal volatility that changes millions of people's status every month, RAND's QHP total is clearly short of the current reality -- as RAND acknowledges.  Moreover, a higher percentage of late signups were likely to have been uninsured, as they flooded in in part to avoid the individual mandate (or avoid remaining uninsured when help was available).

3. RAND has a large category of "other" insurance, including military insurance, Medicare for disabled people under 65, other government plans, and retiree insurance. There was a large net loss of 7.1 million in this category, from roughly 27.5 million in 2013 to 20.3 million now. Of those who lost these kinds of coverage, RAND says, "most have moved to an alternative source..such as employer coverage, Medicaid, or the marketplaces." To my nonexpert eyes, this large shift is almost as surprising as the 8 million-plus gain in ESI. RAND estimates that 4.2 million of those in the "other" category accessed ESI this year and 4.3 million went on Medicaid. Honestly I don't understand the movements in this category.

4. Net totals in the off-exchange individual market -- always highly volatile -- look relatively stable, given that the exchanges are designed to in large part replace the prior market: the total dropped from 9.4 million in 2013 (a low estimate compared to several others) to 7.8 million in March 2014.  RAND estimates that about 5.4 million of last year's participants stayed in the individual market in 2014 and that just 800,000 of them have bought on the ACA exchanges. That's odd, as  the Urban Institute estimates that about half of the people in the individual market in 2013 were eligible for ACA subsidies, giving them a strong incentive to buy on the exchanges -- and I would have thought that if 2/3 of the people buying on the exchanges really were previously insured, many would have come over from the individual market. From the other end, it may be that a large number of people who were previously priced out of the market by preexisting conditions but also ineligible for subsidies bought off-exchange for 2014 (as I've noted elsewhere, subsidy-ineligible buyers have little incentive to buy through the exchange).

5. RAND's estimate of the percentage of QHP signups who were previously uninsured -- while modestly higher, as the RAND report notes, than McKinsey's previous estimate of 27% -- still strikes me as low. For starters, the flood of late March signups will probably boost the percentage in RAND's own tracking, as the uninsured were likeliest to move late to avoid the individual mandate. Secondly, over 80% of QHP signups were eligible for subsidies; it's hard for me to credit that most of them were paying for insurance elsewhere, given its high cost. It's true on the other hand that half those in last year's individual market were subsidy eligible, according to the Urban Institute, and they might be prime ACA signup candidates, as they are familiar with the insurance-buying process. But that's a potential pool of perhaps just 4 to 7 million, many of whom are likely to have accessed ESI -- RAND estimates that 1.8  million in last year's individual market did so, while, as noted above, just 800,000 bought on the exchanges. (Conversely,  RAND estimates that 1.3 million who had ESI in 2013 cycled into the individual market, and 400,000 into the exchanges. The churn is eternal.) Third, the handful of states that have tracked prior status have reported that large majorities of signups were previously uninsured - 59% for New York and  75% for Kentucky.

 I probably shouldn't speculate, given all the known unknowns. But I hope these thoughts and questions at least suggest some useful future focal points as more data comes in.

Update 4/10: I have edited this pretty extensively, taking more fully into account RAND's own estimates of movement in each category.

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