The Long Road to Universal Coverage: Observations on Early PPACA Enrollment Numbers

By Feb. 1, nearly 3.3 million people had enrolled in health plans through the Patient Protection and Affordable Care Act's health insurance exchanges, according to HHS.

That includes 1.4 million people who selected coverage through the state-based marketplaces and 1.9 million who used the federally facilitated marketplace. Despite a bumpy rollout for the federal exchange site, HealthCare.gov, HHS reports enrollment has grown notably since open enrollment began this past October, with January showing a 53 percent increase in overall enrollment compared with the prior three month reporting period.

HospitalIt's still early to say exactly how the exchanges will play out. However, based on early enrollment numbers released through December 2013, RAND Senior Policy Researcher Chapin White, PhD, and RAND economist Christine Eibner, PhD, wrote a Health Affairs blog entry offering key insights into the PPACA marketplaces.

They concluded the road to universal coverage under the PPACA will be a long one. In 2013, Drs. White and Eibner estimate there were close to 50 million uninsured individuals in the U.S. Therefore, although millions have gained coverage since the marketplace opened, the healthcare reform law has put a relatively small dent in the uninsured population.

Furthermore, a recent Gallup poll conducted last month found 38 percent of the uninsured say they will likely pay a penalty under the PPACA's individual mandate rather than obtain coverage. Although the exchange enrollment numbers are expected to continue to rise during the next few years, especially as the uninsured face larger penalties, policymakers will likely confront the limits of a voluntary opt-in approach to getting the uninsured covered, according to Drs. White and Eibner.

Dr. White says it isn't surprising and reflects the enrollment patterns in Medicaid—historically, many who were eligible for coverage did not enroll due to not knowing they qualify or not wanting to go through the hassle of signing up. He says hospitals, however, can help guide uninsured people on the path to getting enrolled.

"Hospitals have for a long time played a role in getting people signed up for Medicaid," he says. "They're going to be potentially playing a really important role in getting people signed up for ACA coverage."

Additionally, he and Dr. Eibner found people are falling into a coverage "doughnut hole" in states that have opted not to expand their Medicaid programs under the reform law to cover adults earning as much as 138 percent of the federal poverty level. So far, 26 states and the District of Columbia have decided to expand Medicaid this year.

In states that aren't extending Medicaid eligibility, people who earn too much to qualify for their states' Medicaid programs but don't make at least 100 percent of the poverty level (the threshold to qualify for federal premium subsidies to help pay for coverage through the exchanges) still don't have an affordable coverage option. In non-expansion states, 42 percent of those who completed applications have been found ineligible for both Medicaid and premium subsidies, many of whom are in the doughnut hole, according to Drs. White and Eibner. This creates a less-than-ideal situation for both patients and hospitals, which face reduced Medicaid payments under the PPACA under the assumption that expansion will lessen the burden of uncompensated care.

Still, Dr. White says this "closed door" to portions of the uninsured in some states will open with time, given the federal funds that come with a Medicaid expansion. That's what happened with the initial implementation with Medicaid, which some states initially refused to implement. Eventually, lawmakers reconsidered.

"Eventually, the availability of a big pot of federal money kind of changed their minds," he says. "I suspect that the same kind of trajectory is going to follow here. My impression is the financial arguments are on the side of taking the Medicaid expansion. The hospitals do better. It's better for patients, and physicians probably do better."

More Articles on PPACA Enrollment:
5 Key Statistics on PPACA Exchange Enrollment in January  
CBO Lowers Estimated Cost of PPACA Insurance Provisions By $9B 
The Importance of Outreach: How Hospitals Can Help the Uninsured Get Coverage 

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