For Republicans who want to repeal the Affordable Care Act, there is a major problem: many people may hate the law, but just as many like it.
“The thing that bothers me is people constantly forget that all politics is local, and that there’s great variation in the extent to which the law is accepted or is going to work. It’s state by state,” says Austin Frakt, an associate professor of public health at the Boston University School of Public Health and co-author of the popular Incidental Economist blog. “It’s not fair to say we’ll repeal the whole thing because there’s half the states that are cool with it.”
That may be even more true today than it was before, as the Obama administration released new figures saying that, through January, a total of 3.3 million people had signed up to get health insurance either through the federal government’s Healthcare.gov website or through the insurance exchanges run on the state level. That includes 1 million who signed up in January alone.
Obamacare is still about 1 million signups behind where the Obama administration expected it to be before the government botched the rollout of Healthcare.gov, but these numbers are still looking significantly better than worst-case scenarios from a month ago, when enrollment of 5 million or even 3 million looked possible. What’s more, a closer look at the data seems to indicate that even some state one would expect to be anti-Obamacare are having large numbers of people enroll in insurance through the exchanges – and that’s not counting those in Medicaid.
“We’ve known California and NY have been leading the way on total enrollment,” says Caroline Pearson, a vice president at consultancy Avalere Health. “Florida and North Carolina and Alabama – states that have been relatively anti-Obamacare — are in fact doing quite well on their enrollment relative to what we expected.”
Pearson took the data released by the government and paired it with a model Avalere developed to predict how many people each state would have to enroll in order to reach the projection of 6 million people enrolled in total, which was used in a recent Congressional Budget Office report. The results are presented in the map below, and in the state-by-state table at the end of this article.
When total enrollment is expressed as a percentage of Avalere’s projection, Alabama (60%) and Florida (74%) are actually lapping New York (39%) and Pennsylvania (35%). What’s more, the map makes clear that most states are at least 40% of the way to their expected totals, and almost all are at least 30%. Keep in mind that a state can enroll more than its projected total (California is already 118% of the way there). Pearson says the worst-performer, Alabama, may deserve an asterisk depending on whether it uses Medicaid money to enroll people in its exchanges.
Not that everything is rosy. Not everyone counted in these numbers is certain to actually get health insurance, because these numbers count people who signed up but who have not yet paid their first bill. Three-quarters of those who have signed up so far are getting subsidies to help pay for their coverage. For young consumers, as my colleague Avik Roy has written and others have also found, the Affordable Care Act may make insurance less affordable.
But the Department of Health and Human Services says that more young, healthy people are signing up. Pearson says she models that these customers, valued by insurance companies, are more likely to sign up as we reach the end of the sign-up period at the end of March. Insurance companies said on their earnings calls that the mix of customers signing up for their plans is getting better. “We are seeing enrollees skewing to the younger side,” Humana president and chief executive officer Bruce Broussard said a week ago. Cigna’s chief, David Cordani said those signing up are a “little older mix relative to population.” Aetna Chief Executive Mark Bertolini called the risk from the law “manageable” and also said that the ACA was part of a set of opportunities “unprecedented in the history of managed care.” There will be eight more weeks of data to see what happens.
The point is that even with all the law’s problems, there may be a substantial number of people who come to depend on it before there is any political chance of repealing it — before the midterm elections. A more likely outcome than repeal, Frakt believes, will be that Republicans, or the government as a whole, will eventually find a way to give more freedom to the states to change some of the parameters of the ACA, bringing states that have resisted marketing their own exchanges or enrolling patients in Medicaid into the fold. Says Frakt: “It may be a conservative means to a progressive ends.”
It probably won’t happen soon, but at some point there may actually be a need for compromise on both sides.
State Enrollment As A Percent Of Annual Projected Enrollment
Projected 2014 Enrollment
Total Enrollment, As Percentage of Projected
District of Columbia
This analysis, by Avalere Health, incorporates enrollment figures released on February 12, 2014, as well as updated state-specific tracking from publicly available resources. Projected enrollment is based on Avalere’s proprietary enrollment model, reduced uniformly based on the Congressional Budget Office lowered projections.