Thursday, April 03, 2014

The health insurance market is an ocean, endlessly churning

Long, long ago, back on March 22, I noted of the ACA signup count that it ain't over when it's over. Medicaid enrollment, including those newly eligible under the ACA expansion, is open all year. And in this interval between open enrollment periods, many people will become eligible for a two-month "special enrollment period" if they experience a "qualifying event" such as job loss, divorce, marriage (if, say, one of the couple has no income), or childbirth. I also noted with some wonder how fluid health insurance markets are: according to an estimate by healthcare scholars Rick Curtis and John Graves, less than half the people who will be eligible for ACA enrollment at the end of 2014 will have been eligible a year prior. [Update, 4/4: Graves has just made the case anew with Jonathan Gruber.]

Today's news brought several further snapshots of this fluidity. The LA Times' Chad Terhune noted another large category of pending special enrollments -- college graduates:
it's estimated that several hundred thousand more Californians could qualify for a special enrollment period as college students graduate, families move and workers change jobs.
In the short term, also in California, extended enrollment for those who started but could not complete applications before 3/31 is going to be huge, reports Marketwatch's Russ Britt:

Peter V. Lee, the executive director for Covered California, Obamacare’s incarnation in the Golden State, said Thursday 500,000 people who started the enrollment process online didn’t get a chance to finish. It’s unclear how many of those will sign to public exchanges — Lee says about half could end up on the state’s Medicaid program, Medi-Cal – but the numbers at the end of the Obamacare enrollment period on March 31 are likely to go up.
As for those "unpaids" that Republicans are screaming about:  it had occurred to me, after reading about normal churn in the health insurance market, that a portion of the total at least was probably a feature, not a bug. Kaiser Health News confirms this, with a snapshot of normal market volatility in California:
A new analysis finds that many people who signed up for a Covered California health insurance exchange plan are likely to drop the coverage for a good reason: They found insurance elsewhere.

Researchers at the U.C. Berkeley Labor Center released estimates Wednesday showing that about 20 percent of Covered California enrollees are expected to leave the program because they found a job that offers health insurance.

Another 20 percent will see their incomes fall and become eligible for Medi-Cal, the state’s insurance program for people who are low income.

In addition to the 40 percent of enrollees who move to Medi-Cal or job-based insurance, between 2 and 8 percent of those who sign up for Covered California are estimated to become uninsured, the analysis noted.
The Berkeley study reinforced the overview of market turnover by Rick Curtis and John Graves cited above (as well as with Kaiser Family Foundation research):
According to the report between 53 and 58 percent of Covered California enrollees are expected to stay in a Covered California plan for 12 months. This analysis is consistent with a Kaiser Family Foundation study published earlier this year. It found that of people who enrolled in an individual insurance plan in 2010, years before the health law fully kicked in, only about 48 percent were still in the individual market two years later.
Also today, healthcare reporters' favorite font of info, Kaiser's Larry Levitt, delivered further essential perspective on the politicized mystery of the unpaids in a Twitter mini-essay :
The process leads to some natural payment drop-off. U pick a plan on the exchange and get billed separately by the insurer. Not ideal. (1/7) People may be pursuing multiple insurance options in parallel (e.g., on and off exchange). (2/7) Some people may have landed a job with health benefits in between picking a plan and getting billed by the insurer. (3/7) Some people may have decided they couldn't afford the insurance so decided not to pay. (4/7) Before there was a plan browsing function on, the only way to window shop was to apply. No longer the case. (5/7) The pre-ACA individual market is not comparable. You had to provide a medical history and pay a deposit to apply. (6/7) At any point in time, some people just won’t have paid their premium YET. We need to be patient to get the full story. (7/7).
That last admonition is Larry's watchword. It's true on multiple fronts. Over time, we will get some clarity as to the compositions of the risk pools that have formed in each state, and so of the viability of next year's market; data will also accrue as to the degree to which the ranks of the uninsured shrink. But the "signup" number will always be something like the cash on hand in your checking account: blurred at least a bit by a constant if uneven in-flow and out-flow.

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