Gallup misreads its state ACA data: state-run marketplaces no better at reaching uninsured

Gallup does a great service in tracking the decline in the uninsured rate state-by-state since ACA implementation. But they draw a misleading conclusion from their latest data set:

Collectively, the uninsured rate in states that have chosen to expand Medicaid and set up their own state exchanges or partnerships in the health insurance marketplace declined significantly more last year than the rate in states that did not take these steps. The uninsured rate declined 4.8 points in the 21 states that implemented both of these measures, compared with a 2.7-point drop across the 29 states that have implemented only one or neither of these actions.

In fact, the superior overall performance of these states in reducing un-insurance is due entirely to the Medicaid expansion. Collectively, their exchanges did not perform particularly well with regard to enrolling subsidy-eligible residents in private health plans.

Compare Gallup's chart highlighting state leaders in reaching the uninsured population by both means (Medicaid and private plans) with the Kaiser Family Foundation's snapshot of states that reached the highest percentage of subsidy-eligible private plan buyers. [Update: The initial comparison is of uninsured rates from poll data taken by Gallup throughout 2014 with Kaiser's up-to-date ranking of performance in the QHP market (through 2/15/15). Kaiser's 2014 ranking appears at bottom.]




Here's Kaiser's tracking of exchange performance as of Feb. 15, 2015. I'm afraid I can't line up the headings in a paste. The three columns are 1) actual QHP  (Qualified Health Plan) selection, 2) estimated potential QHP buyers, and 3) percentage of potential buyers enrolled.

1. Vermont	State-based Marketplace	31,552	45,000	70%
2. Florida	Federally-facilitated Marketplace	1,600,006	2,504,000	64%
3. Maine	Federally-facilitated Marketplace	74,792	124,000	60%
4. District of Columbia	State-based Marketplace	18,431	33,000	57%
5. Delaware	State-Partnership Marketplace	24,887	48,000	52%
5.Pennsylvania	Federally-facilitated Marketplace	471,930	899,000	52%
7. New Hampshire	State-Partnership Marketplace	52,944	104,000	51%
7. North Carolina	Federally-facilitated Marketplace	559,473	1,097,000	51%
9. Georgia	Federally-facilitated Marketplace	536,929	1,091,000	49%
9. Michigan	State-Partnership Marketplace	340,905	689,000	49%
11. South Carolina	Federally-facilitated Marketplace	209,773	441,000	48%
12.Connecticut	State-based Marketplace	103,007	224,000	46%

There is no overlap. Among Gallup's top ten in reducing the overall uninsured -- excluding Montana from the list above, as the state neither established its own exchange nor accepted Medicaid expansion -- the average 50-state rank for reaching the potential QHP market is 33.  In fact, two states in Gallup's list, West Virginia and Arkansas, were in the bottom ten for QHP takeup. Here are the QHP takeup rankings of Gallup's top ten (again excluding Montana, which ranked 14th among the states in QHP takeup):

State	QHP % reached	State Rank
Arkansas	26	43
Kentucky	39	24
Oregon	34	33
Washington	32	37
West Virginia	31	40
California	44	15
Connecticut	46	12
Colorado	24	46
Maryland	26	43
New Mexico	33	34

The relative success rates of various state exchanges in reaching target populations for QHPs  has yet to be explained as far as I know. Some state exchanges were poorly designed and harder to use than healthcare.gov. Some states had more effective federally funded outreach; some successfully tapped brokers. But QHP takeup most definitely did not move in lockstep with Medicaid expansion.

UPDATE: here's Kaiser's 2014 state-by-state ranking by percentage of potential target population enrolled in QHPs. Again, The three columns are 1) actual QHP  (Qualified Health Plan) selection, 2) estimated potential QHP buyers, and 3) percentage of potential buyers enrolled. I've extended to list to twelve to include Kentucky, as it's in Gallup's top 11 - as is Washington.

1. Vermont	State-based	38,048	44,000	87%
2. California	State-based	1,405,102	3,263,000	43%
3. Florida	Federally-facilitated	983,775	2,502,000	39%
4. Michigan	Partnership	272,539	699,000	39%
5. Rhode Island	State-based	28,485	73,000	39%
6. Maine	Federally-facilitated	44,258	124,000	36%
7. Connecticut	State-based	79,192	236,000	34%
8. Idaho	State-based1	76,061	229,000	33%
9. District of Columbia	State-based	10,714	32,000	33%
10. North Carolina	Federally-facilitated	357,584	1,098,000	33%
11.Washington	State-based	163,207	517,000	32%
12. Kentucky	State-based	82,747	265,000	31%

Viewed another way, the average rank of the 14 state-based marketplaces, 3 federally-supported marketplaces and 7 state-partnership marketplaces in 2015 was 27.5 (out of 51). In 2014, the average rank of 16 state-based QHP marketplaces and 7 partnership marketplaces was 24,8  While about half the state exchanges dramatically outperformed healthcare.gov in its initial months of dysfunction in fall 2013, half were equally or more dysfunctional, and several remained dysfunctional or highly problematic once the federal exchange's front end at least was functioning decently. State exchanges got good press when they were the only game in town, and the perception has perhaps persisted that they're superior to the federal exchange. But they're not.

UPDATE 2: Charles Gaba has posted the 2015 Kaiser state-by-state QHP takeup data, conveniently ranked by percentage of potential market reached. Charles noted the upshot here previously:

...this [ranking]shows a fairly even spread between state exchanges and HC.gov...in terms of the overall potential enrollments, all of the exchanges, federal or state, seem to have finally hit their stride, and are showing smooth proportional impact.