CMS Open Enrollment error in New York (updated, with CMS correction)

[Update 2/11/16: CMS has made  a correction -- see below.]

CMS's ACA enrollment snapshot for the final week of Open Enrollment 2016 contains an error, bolded below:

It is also worth noting that nearly 400,000 people signed up for New York’s new Basic Health Program, along with about 33,000 people who signed up for Minnesota’s Basic Health Program, during this Open Enrollment. Basic Health Programs are state based programs supported by the Affordable Care Act that provide health insurance coverage to low income individuals who would generally otherwise be eligible for qualified health plans [QHPs]. In fact, about 300,000 of the New York Basic Health Program enrollees for 2016 are people who enrolled in Marketplace coverage for 2015 and were included in last year’s Marketplace total plan selections.

Enrollees in New York's Essential Plan, the BHP formed under the auspices of  the ACA, come from two pools. The first is those who lack access to employer-sponsored plans and have incomes between 139% and 200% of the Federal Poverty Level (FPL). If the Essential Plan did not exist, these people would be eligible for subsidized QHPs in New York's private marketplace. Some of them were in fact enrolled in QHPs in 2015, but not 300,000.

Housekeeping note: Pennsylvania story in progress

A note re slow blogging: I've been engaged in my Pennsylvania project -- that is, exploring the implications of some odd enrollment figures in the state.. Specifically, though there's apparently over 140,000 Pennsylvania 2014 QHP enrollees who are now eligible for Medicaid, less than 40,000 2014 QHP enrollees had disenrolled as of March (or at least, to HHS's knowledge as of March). I've had the chance to interview one person newly eligible for Medicaid in 2015 who discovered that fact in February but only applied this month, in the interim paying over $300 per month for an unsubsidized private plan. The resulting story is written but not yet placed (or edited; I've got to cut it by 60%). I've learned a ton in the process.

One useful sidelight: an enrollment counselor at the Pennsylvania Health Access Network tells me that more than half of the people they enrolled in QHPs in 2014 did in fact have household incomes under 138% FPL and so are now eligible for Medicaid. While you might expect that a social service agency's client base might tilt toward lower income buyers, PHAN works all over the state, and that percentage is consistent with CMS's estimate of 141,000 households with QHP enrollees likely to be eligible for Medicaid in 2015.

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.]

ACA Signups: "Over 9.5 million served"?*

Charles Gaba has been tracking ACA enrollments during the off-season, as he did during open season. He estimates that approximately 9,000 people per day are signing up for private plans via "special enrollment" periods, with net attrition of about 2% per month as people drop plans for a variety of reasons.

Tonight Gaba estimates that there have been about 9.5 total private plan (QHP, for Qualified Health Plan) signups to date That's a number that most people will mentally offset, as HHS recently announced that about 7.3 million are currently enrolled in QHPs. Perhaps a bit less than half of that 2.2 million difference is comprised of people who never paid, the rest dropping plans at various points.

It's natural and to a degree fitting to focus on the number of current enrollees. That number is important in that a) the ACA has a long way to go to full takeup -- CBO forecasts 25 million exchange users by in 2018 --  and b) the states' risk pools need to maintain critical mass to establish a viable market. Still, the total number served since the outset -- discounting, perhaps, most of those who never paid -- is also significant.

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.

Just how will Health Sherpa simplify ACA signup?

UPDATE: Health Sherpa is now live taking QHP applications, routing the subsidy application through healthcare.gov but claiming to streamline the process. The next post explains how an application initiated on Sherpa differs from one executed entirely on Healthcare.gov. 
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I am  glad to read that HHS is partnering with Health Sherpa, one of the first ACA comparison-shopping sites to turn up while Healthcare.gov was dysfunctional, to provide an alternate channel enabling people to sign up for Qualified Health Plans offered on the ACA exchanges. But the Washington Post story reporting the arrangement includes some misinformation and leaves the advantages unclear.

According to the Post's Brian Fung:

In November, the Department of Health and Human Services met with [Health Sherpa co-founders George Kalogeropoulous and Ning Liang]  to explore how to turn sites like theirs into a "modular" system -- where third parties could sit on top of the federal data hub and act as another online storefront for Obamacare.

Now, the integration is complete — making it possible to sign up for Obamacare using the Health Sherpa's Web site. Unlike Healthcare.gov, which was criticized for making visitors enter much of their personal information before verifying their subsidy eligibility and then showing them available plans, Health Sherpa  allows people to window-shop without entering much more than their Zip code, age and income.

It's not true that you have to enter intrusive personal information on healthcare.gov to comparison-shop. The shop-only feature is excellent and has been fully functional at least since late December. -- just about as easy as on Health Sherpa. You answer seven questions, and you're in -- able to view all available plans, fully priced with subsidy calculated according to your income estimate, and with access to plan details. No personal information is required (i.e., there's no personal identification attached to your income estimate).

If Health Sherpa is not needed in most states* for easy comparison shopping, what other advantage does it offer?  The Post story implies that Sherpa and other third party sites will be able to streamline the application process, particularly the subsidy application process, but it's not clear how it can do so. Here's the Post account:

Are most buyers on ACA exchanges previously uninsured?

ACA signups tracker Charles Gaba, extrapolating from recent New York state data, postulates that 85-plus percent of February signups for Qualified Health Plans (QHPs) on ACA exchanges are people who were previously uninsured.

If this inference is on target, it shouldn't be too surprising -- though it either contradicts or suggest a rapid reversal of trends asserted in prior reports from insurers and McKinsey & Co. We know that over 80% of QHP signups qualify for subsidies. That suggests almost by definition that a substantial percentage of signups would previously have found insurance on the individual market unaffordable. Moreover, we also know that less than 20% of those who complete the application process on the exchanges but do not qualify for subsidies actually sign up for a plan on the exchanges.