The impact of ObamaCare on doctors and patients, companies inside and outside the health sector, and American workers and taxpayers

Has the effort peaked to sign up uninsured Americans for coverage? The announcement that the nonprofit organization Enroll America is laying off staff and redirecting its focus in the face of funding cuts comes amid inconsistent sign-ups during the second Affordable Care Act open-enrollment period and concerns about affordability.

A recent New York Times analysis compared Kaiser Family Foundation estimates of potential enrollees with sign-up data from the Department of Health and Human Services. While some states that signed up few people in 2014 recovered during the 2015 open enrollment, other states lagged: “California, the state with the most enrollments in 2014, increased them by only one percentage point this year, despite a big investment in outreach. New York improved by only two percentage points. Washington’s rates are unchanged.”

Most states could not post consistent gains in both open-enrollment periods. An official from Avalere Health, a consulting firm, told the Times that she was “starting to wonder if we’ve overestimated the whole thing.”

New analysis from Avalere finds that while exchanges have succeeded in enrolling very low-income individuals, they continue to struggle to attract middle and higher income enrollees.

Specifically, as of the close of the 2015 open enrollment period, exchanges using HealthCare.gov had enrolled 76 percent of eligible individuals with incomes between 100 and 150 percent of the federal poverty level (FPL) or $11,770 to $17,655. However, participation rates declined dramatically as incomes increase and subsidies decrease. For instance, only 16 percent of those earning 301 to 400 percent FPL picked coverage through an exchange, even though they may be eligible for premium subsidies.

“People receiving more generous subsidies are expected to enroll in the exchanges at higher rates. However, participation levels decline as incomes increase, even among individuals who would be eligible for both premium subsidies and cost-sharing reductions,” said Elizabeth Carpenter, director at Avalere.

During the recent oral argument in King v. Burwell — the Supreme Court case deciding if providing subsidies to buy health insurance in the 36 states utilizing federal health care exchanges is allowed under the Affordable Care Act (ACA) — Justice Kennedy suggested that disallowing subsidies might be unconstitutionally coercive because “states are being told either create your own exchange, or we’ll send your insurance market into a death spiral.” Are “death spirals” real, or just a way to frighten the public?

The death spiral will purportedly happen like this: disallowing federal exchange subsidies will make insurance less affordable for the 87% of federal exchange enrollees currently receiving subsidies. These people will no longer be required to buy insurance since the ACA’s individual mandate only applies to individuals who have access to affordable insurance. Since the ACA imposes community rating, requiring roughly the same premium for all individuals in a given plan with only small adjustments for their risk characteristics, and guaranteed issue of insurance regardless of the enrollee’s health, the old and unhealthy will continue to buy coverage but the young and healthy will forego coverage. The resulting higher risk pool of enrollees will increase the average cost of individuals remaining in the non-group insurance market, both on and off the exchanges, resulting in increased premiums that will drive out more low cost, healthy patients eventually destroying the market.

Two economic simulations predict that “adverse selection,” where healthier people leave the insurance market and sicker people stay in causing premiums to rise, will occur if the King plaintiffs prevail. The Urban Institute predicted discontinuing federal exchange subsidies would result in premium increases of 35% and enrollment declines of 69% in the individual health insurance market. The Rand Corporation made similar predictions.

But it is hard to reconcile these forecasts with studies of earlier state insurance market “reforms” that created market conditions similar to those that would result if federal exchange subsidies are disallowed. These studies suggest adverse selection would be minimal and would not lead to a “death spiral,” that is, it would not lead to a self-reinforcing cycle of adverse selection in which each time premiums rise, more people exit, leading to a sicker, more expensive risk pool and market collapse.

Obamacare reached age 5 on Monday [1]. As I’ve pointed out earlier, this anemic child is not exactly a picture of health, falling behind the lofty expectations set for it on many dimensions. But the one bright spot for its proud parents relates to how much the law has reduced the number of uninsured. The president’s Council of Economic Advisors ecstatically announced last December: “the drop in the nation’s uninsured rate so far this year is the largest over any period since the early 1970s.” A little perspective is in order.

First, taking the CEA’s figures at face value (which my chart below does), this decline amounts to a 2.8 percentage point net reduction in the rate of being uninsured, that is, above and beyond the decline that would have occurred anyway according to CBO [2]. It may well be the biggest one-year decline since the 1970′s, but CBO’s expectation at the time the law was passed was that uninsured risk would drop by 6 percentage points in 2014 alone. Even as late as May 2013, CBO was expecting the net decline to be 3.5%. In short, in its first year, Obamacare scored 46% if we use CBO’s original projection as the scoring standard and 79% if we used the May 2013 projection. Clearly we would like this child to perform better than that in future years. But that would require the number of newly covered Americans to increase an additional 79% this year compared to last year.

Reality check: that is certainly not going to happen. Charles Gaba at ACASignups estimates that estimated paid sign-ups on the Exchanges are only 10.5 million so far, compared to 7.06 million last April [the original post stated 10 million, see Update #1 for explanation]. That’s only a 49% increase, suggesting Obamacare will fall even further behind CBO expectations for 2015 [the original post stated 42%, see Update #1 for explanation]. Medicaid won’t fill the gap, since Medicaid evidently is growing by about 300,000 persons per month. Even if we assume all of these are uninsured, that would reduce the uninsured rate by only 0.1% monthly, or 1.2% over 2015 as a whole. That provides only about half of what’s needed to keep pace with CBO projections, leaving the Exchanges to fill the gap. But as we’ve seen, the Exchanges are lagging behind.

Can government get people to buy a product that millions think isn’t worth the price?

That’s the question that health care analysts are asking as they pore over the results of the Obamacare open season that concluded on February 15.

On the surface, the data released earlier this month by the Department of Health and Human Services are encouraging. Nearly 11.7 million people selected a plan this year, compared with just more than 8 million during the 2014 open season.

There are some cautionary signs. Despite the influx of new subscribers, the age profile continues to skew older. Nearly half are 45 or older and 26 percent are over 55. Interest among the young remains largely unchanged over last year.

So is interest among middle income people who lack coverage. Enrollment has been dominated by those with the lowest incomes. HHS reports that 83 percent of people who have selected plans have incomes between 100 percent ($11,770) and 250 percent ($29,425) of the federal poverty level (FPL). Medicaid, meanwhile, has grown by nearly 20 percent since Obamacare was launched, swelling its ranks to 70 million. Roughly 22 percent of the U.S. population is now on Medicaid, despite the refusal of 22 states to expand their programs.

More than a year after egregious security failures in the government’s healthcare website were exposed in congressional hearings, data remains compromised and the ill-fated site is still subject to cyberattacks and vulnerable to massive identity theft.

In fact, just this week Judicial Watch obtained documents from the government that show a possible mass breach of the privacy of innocent Americans involving the disastrous Obamacare website (Healthcare.gov). The records, from the U.S. Department of Health and Human Services (HHS), also reveal that top officials with the Centers for Medicare and Medicaid Services (CMS) knew of massive security risks with the healthcare website but chose to roll it out without resolving the problems.

When the Obamacare internet drama blew up in the administration’s face the Department of Homeland Security (DHS) was called to help clean up, according to the records recently made public by JW. Electronic mail exchanges between various DHS and CMS officials indicate that White House pressure to promote a “robust” digital Obamacare ad campaign allowed private information of Healthcare.gov users to be shared with advertisers. The email chain pushing this controversial use of citizen information includes a security expert’s assessment that security was an “afterthought” on the Obamacare website, that 70,000 Healthcare.gov records were easily viewed using Google and that the official in charge was fired for not signing off on the website’s security.

Health care premiums are continuing to rise in 2015. While the pace of change has slowed since the dramatic increases of 2014, the savings promised under the Affordable Care Act (ACA) have still not materialized.

Measuring changes in premiums is an important element in understanding the impact of the ACA. In previous analysis, The Heritage Foundation determined that the new regulations and benefit mandates put in place through the ACA caused premiums to increase drastically in 2014, with average premiums increasing more than 50 percent in some states.[1] This Issue Brief examines premium changes in 2015 and finds continued but slower premium growth, indicative of a market going through a sorting process.

ObamaCare is celebrating its fifth anniversary, but few Americas are cheering.

The Real Clear Politics average of the latest major opinion polls about the health law shows that 52.5% oppose it and only 42% approve. The 10.5% spread is identical to the average of polls taken when the law was signed five years ago. Approval numbers never have topped disapproval numbers since the law was enacted. It is not getting more popular and it is not settled law, as President Obama claims.

President Obama is touting the increased number of people who have health insurance as a result of the law. According to Gallup, the uninsured rate among U.S. adults averaged 12.9% in the fourth quarter of last year. The uninsured rate was 14.4% the year before the health law passed, also according to Gallup.

So our health sector has been thrown into turmoil, millions of people have lost their private health plans, $1 trillion in new and higher taxes have been imposed on individuals and businesses – and the uninsured rate has dropped a net of 1.5%.

If you like your health insurance plan, you actually might have been able to keep it this year.

Fewer than 1 million Americans had their health insurance plans canceled for 2015 for noncompliance with Obamacare rules, according to a report by the Urban Institute and Robert Wood Johnson Foundation.

The report, which called that number “quite small,” suggests that in the latest enrollment season there was relatively little disruption of either the individual or job-based insurance market due to plans not meeting Affordable Care Act-related regulations.

Those rules set certain minimum standards for coverage, including prescriptions, maternity care and mental health treatment, which were not required in plans prior to the ACA’s enactment.