It could be a long, long time until there’s a verdict on what the effects of the first enrollment period are. Even the 6 million enrollment milestone can’t put an end to the debate. Uncertainty is the name of the game right now.
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Lucy Nicholson / Reuters
WASHINGTON — If you like the debate about the Affordable Care Act enrollment numbers, or even if you don't, you get to keep it when the first Obamacare enrollment period comes to an official end on March 31.
Despite some predicting sharp, immediate effects on the insurance market and politicians promising a dramatic change in the storyline once enrollment ends, health care observers say there's still a lot of uncertainty — it's not clear what effect the enrollment figures will have yet. The debate on Obamacare's here to stay, they say.
On Thursday, the White House announced 6 million people have signed up for health care under the Affordable Care Act, a moment that brought with it a lot of chest-thumping from the Obama administration.
While it was a good day for supporters of Obama and his health care reforms, it won't alter the political debate significantly, heath care observers say.
"Enrollment numbers will not alter public perceptions," said Robert Blendon, professor of health policy and political analysis at Harvard School. "What will be next stage in the controversy is who, if anyone, will be asked to pay a penalty. Millions will not have signed up. [It] will be very unclear who is exempt and who is not. The likely confusion will lead to a new set of political stories."
Blendon made his comments before the 6 million figure was revealed by the administration. He stood by his analysis after the number was public knowledge.
"No," he said when asked if the new figure would change the debate. "The issue is formed in people's minds."
Drew Altman, president of the Henry J. Kaiser Family Foundation said the 6 million figure is a big political win for supporters of the Affordable Care Act, but the number doesn't really tell the story of whether or not the law worked.
"Getting over the 6 million mark matters a lot politically because it's such a widely accepted target. It's an achievement to exceed the target after losing several months due to the website debacle," he said. "But the national enrollment number doesn't tell us much about what the impact of the ACA will be on people, because risk is pooled at the state level not nationally and rates are set in 501 rating markets across the country and vary based on the amount of competition in those markets and many other factors."
What happens next after the end of enrollment has been the question on the minds of political operatives, health care policy wonks, and White House staffers as the end of enrollment approaches. Well, sort of approaches. On Tuesday night, the Obama administration announced it had effectively pushed the March 31 sign-up deadline into April. For actuaries closely watching what happens with enrollment numbers as they set out to establish insurance premium rates in 2015 and beyond, the extension was an unwelcome reset to their plans.
"It is kind of like Groundhog Day," said Jim O'Connor, a principal and consulting actuary at Milliman. "It's been a continual change in rules or modification of rules, you know? We've kind of become to the point of expecting them now. But that type of expectation isn't good when it comes to setting rates."
Beyond this week's news, the ongoing administration extensions for health plans that don't qualify under the Affordable Care Act mean further uncertainty for actuaries post-March 31, O'Connor said.
Not knowing what's exactly going to happen makes insurers worried, O'Connor said, and that could lead to significantly higher premium rates next year. Premium rates rise just about every year, but the hope of supporters that Obamacare can flatten those increases considerably. A big jump in premiums would be seen as a failure of the law, especially by its existing opponents. But despite dire warnings from some that huge premium hikes are coming, O'Connor said it's too early to make that call. Why? Because no one knows what's going to happen once enrollment eventually closes.
"At this point, we don't know what kind of experience we're getting," he said. "All we know are some of the demographics of people who have enrolled in exchanges. So that remains an unknown. That will evolve over the year. But we as actuaries, and the insurance companies, need to start setting rates for 2015."
Those rates need to be set by the end of April or the end of June, depending on the state, O'Connor said. That's probably not enough time to understand what Obamacare has done to the insurance market.
"No matter what those dates are, we still will only have only very little claims experience information," he said. "Actuaries will use whatever they have to project into 2015, but as I say, it's going to be pretty scanty information."
No one really knows what March 31 means now that enrollment has been extended, and no one knows how long it will take after March 31 to figure out what happened with Obamacare in its inaugural enrollment window. The difficulty in setting expectations gives a lot of ammunition to Obamacare opponents, eager to cast everything since the start of enrollment on Oct. 1 as an abject failure.
But the uncertainty also works in Obamacare's favor, giving allies tools to push back against warnings of dramatic spikes in costs and enrollment demographics that cripple the system.
"This is the question everyone wants to know the answer to, and we simply can't know it," Jonathan Gruber, an MIT professor and an architect for both Obamacare and the Massachusetts health care plan on which it's based, said in an email when asked the "what happens next" question. "What matters is the health mix of enrollees RELATIVE [sic] to what insurers expected when they set their 2014 rates (which, were by the way, much lower than expected). So we won't really know anything useful about health mix until we see insurers' 2015 rates, sometime this summer."
"So really these enrollment numbers mean NOTHING [sic]," Gruber went on. "There is nothing we can say of any use until we see the 2015 rates."
For all the focus on March 31, the day enrollment opened may end up being the defining date of the first year of Obamacare. The politics surrounding the Affordable Care Act have shifted somewhat in the last year or so. Republicans, once laser-focused on full repeal, now talk of their own health care system reform package and some have plainly stated that "we shouldn't go back to the way things were before" Obamacare became law.
Democrats hope a conversation about Obamacare versus a Republican alternative favors Obamacare. Republicans hope to take the public desire for health reform and the frustration with Obamacare's stumbles and combine it into a national message that will win them the Senate in November. Despite the shifting sands in polling, the observers say, the sharp (and sometimes shrill) debate over every step of Obamacare will likely remain.
Nevertheless, the final national enrollment number remains a big deal. The Obama administration backed away from a predicted 7 million enrollees earlier this year, leading to victory laps from critics who said missing the target proved the law was a failure, but few of critics believed enrollments would hit the 6 million mark. Crossing that threshold before enrollment ended, and with weeks to go in the additional enrollment time added to the final deadline, means that final enrollment could come closer to 7 million than most anyone imagined.
But national enrollment numbers, which will be an actual known at some point after March 31 (once enrollment finally comes to an end, likely sometime in April) don't tell the story in any meaningful way, argued Altman. In an essay posted to the Kaiser Foundation website this week, Altman said the media fascination with national enrollment numbers are essentially a waste of everyone's time. In an interview, he said he worries about how the rancorous political debate will proceed while uncertainty continues to rule the day. Altman's convinced that, eventually, when it comes to the Affordable Care Act, "winners will greatly outnumber the losers," but in the meantime he worries about a continuing political debate when the final tally of Obamacare's success just isn't knowable.
"There's always a danger in something like this of 'death by anecdote,'" he said. "Anecdotes are great when they represent a larger group, but they're not great when they represent a story of one. And there will be plenty of stories of one out there. So I think that will be a big issue [post March 31]."
What really matters in terms of testing the law, Altman said, are the state-by-state — and often county-by-county — insurance markets and how the demographics shake out within them. Basically, there has to be a relatively high number of healthy people signed up for insurance to keep costs low when sick people who are no longer legally denied insurance join the rolls.
"I think gradually the reality and the way the law works in practice will replace the political debate," Altman said. "But that'll be a very slow process. It might not end until after the 2016 presidential elections."
O'Connor, the actuary, says that's too optimistic. The unknowables about Obamacare, and the endless political upheaval that surrounds them, will continue.
Asked to make a prediction of when he'll have a full understanding of how the Affordable Care Act is working, O'Connor first mentioned 2016, then said 2017 before settling on the date he thinks the "what happens next" question will finally be answerable.
"Maybe 2018 is better," he said.
