The Obama administration released critical data yesterday on the aggregate levels of enrollment in the various individual Exchanges. Most of the journalistic and blogospheric effort in the aftermath has been in trending: do these numbers portend a massive leap forward in Exchange enrollment such that there can be some confidence that the Affordable Care Act will in fact work? Might this alternatively be some sort of temporary surge that is both too little and too late? All of this analysis is completely fine; I’ve engaged in it myself. But there are other issues that should be examined.
Here are five questions, mostly about data, I’d like to see other journalists or bloggers start to pursue. I’m doing some of it myself, but I would love company.
1. What is the distribution of enrollment among the various metal tiers?
If a lot of people are purchasing the gold and platinum plans, that is a sign that the people signing up have poor health and do not want to pay higher deductibles. This is particularly true if the same pattern exists among the enrollees receiving income-based subsidies: they, after all, are mostly purchasing gold and platinum because they need it, not because it easily accommodates their budget. If, on the other hand, the distribution is weighted towards the bronze and silver plans, that is some evidence that the people signing up may not be coming as disproportionately from the low or middle expense range. Unless one’s funds are very limited, it does not make sense for someone who knows they will have high medical expenses to purchase a bronze plan. Disproportionate purchase of gold and platinum policies heightens the potential for adverse selection problems to the extent insurers believed the federal government’s models, which assumed only mild “induced demand” for such policies.
Journalists should also continue pressing at the state and federal level for information on age distribution of enrollees; I can see no legitimate reason to withhold it.
2. What is the income distribution of those purchasing policies on the Exchanges? Is the ACA turning into welfare for the wealthy?
The report released by HHS on December 11, 2013, had an important statistic buried on page 7. I’ve highlighted it in the screenshot below.
Whoa! Only 41% of those purchasing policies are getting subsidies. The original Congressional Budget Office projections (see Table 3 of this Report) indicated that only 1 million of the 7 million enrollees (14%) would have incomes that high. This means 59% of the purchasers have household incomes in excess of 400% of the federal poverty level. Is the Affordable Care Act another form of welfare for the wealthy?
I’m working on some computations for a future blog entry, but my initial sense is that the data so far probably means that the sign up rate among those in the middle class living in families earning between 139% and 400% of federal poverty level is less than a third the sign up rate among the wealthier. There are more people with incomes in the 139% to 400% group than the 400+% group (look here); there are certainly considerably more people without insurance in the former group than in the latter (look here, in Table 1). It further means, by the way, that, so far, the individual Exchanges on the Affordable Care Act, with all of their overhead costs and all of the rhetoric expended on them, have probably helped fewer than 100,000 people in the middle class to date. Most of the prospective beneficiaries thus far are in upper income groups for whom a simpler system might have been all that was needed. Anyway, because distributional concerns are relevant to an evaluation of the Affordable Care Act, data on income distribution of enrollees is important.
By the way, for the reported cost of the fancy healthcare.gov website, $600 million, one could just have had a lottery and given a Silver or Gold policy to 100,000 middle class people for a year and probably had some change left over.
3. What is the distribution of enrollment by price ranking among the various plans?
If almost everyone is selecting the low-cost plans within each metal tier, what happens to the many more insurers who wrote plans with higher prices? If those insurance plans have high prices because they have bigger and better networks, those insurers will be concerned that they have attracted a few really, really expensive insureds who want to take advantage of that possibility. Plus, are there insurers who have just said that the administrative costs of insuring a tiny population are not worth whatever upside there may be? I bet there are insurers in many states that to date have fewer than five enrollees in at least some of their plans. Given that nine states (Alaska, Delaware, Iowa, Mississippi, New Mexico, North Dakota, South Dakota, West Virginia and Wyoming) have fewer than 1,000 enrollees to date and multiple tiers with multiple plans, that almost has to be the case. Are the “losers” in the Exchange thinking, therefore, of pulling out in the future?
4. What is enrollment in the SHOP Exchanges?
One of the forgotten but important features of the ACA is the ability of small business (<50 for 2014) to purchase group insurance for their employees and dependents in state or federally facilitated Exchanges (“SHOP Exchanges”). Insurers inside and outside of the SHOP Exchanges will no longer be able to rate based on the health or medical claims records of the insureds or surrogates for it such as gender. They will be able to rate only on the basis of the region, the employer’s mixture of employee ages and, in theory, employee tobacco use. (42 U.S.C. § 300gg). The area may have been forgotten because healthcare.gov, the federal website that was supposed to facilitate selection of plans by small employers and subsequent enrollment, abandoned efforts to get the small business portion of its website to work once the individual site failed. But enrollment is still supposed to be occurring by paper at the federal level and through various means in the various state exchanges.
Let’s get some data! How many small businesses have enrolled? Are employers enrolling? How many employees are selecting coverage? How many employers are taking advantage of substantial tax credits to purchase this insurance under section 45R of the Internal Revenue Code? Are insurers concerned that the employers who are enrolling in these health-unrated plans will tend to be those who have a problematic risk profile among their employees and that adverse selection could start to deprive small business of the opportunity the ACA purported to grant.
5. Are insurers in fact “uncanceling” policies where they have been permitted to do so and is anyone buying them?
One of the fears that I and many others raised following President Obama’s “about face” and decision not to prohibit renewal for one more year of certain insurance policies that did not provide Essential Health Benefits or comply with certain other provisions of the ACA was that such a move could destabilize the insurance markets. To make a long story short, if state insurance commissioners permitted the “uncancellations” and insurers then “uncancelled,” insurers selling plans in the Exchange based on a population that included those mostly healthy people would likely lose more money. We now know that many but not all states are permitting insurers to uncancel. What I have not seen data on, however, is how many insurers are taking advantage of the opportunity and how many insureds are accepting offers by these insurers to renew. The larger this number, the greater the threat to insurance sold through the Exchanges or the greater the hit to the Risk Corridors program to make the insurers whole. On the other hand, if few insurers are actually taking advantage of the opportunity and/or few consumers are re-upping, the hypothesized threat to the insurance Exchanges will have been reduced and the number of people potentially hurt by violation of the “if-you-like-your-health-plan-you-can-keep-your-health-plan” pledge will have been kept large.
Getting all this data is likely to be difficult. The Obama administration appears extremely sensitive to release of any data that could diminish confidence in the ultimate success of the Affordable Care Act. Moreover, some of the data will need to come from insurance companies who have different disclosure obligations than do the federal government and state governments. Still, the questions are important and neither journalists nor the public should ever confine themselves to just the information government is willing or eager to disclose.
Addendum of December 13, 2014
I decided last night that the best way to get something done was often to do it oneself. Hence, this morning, I sent off the following FOIA request to CMS. We will see what happens.
CMS FOIA Officer
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244
VIA FAX: (202) 690-8320
Under the Freedom of Information Act, 5 U.S.C. section 552, I am requesting access to the following records.
1. All records showing the age distribution of enrollees in all American Health Benefit Exchanges (Exchanges), including the State-Based Marketplaces (SBM) and the Federally Facilitated Marketplace (FFM). No request is made that would permit personally identifiable information to be disclosed. By way of examples, the following hypothetical records (paper or electronic) would be responsive to this request
a. a record showing that in the California Exchange, 20,000 enrollees are between the ages of 0 and 18, 10,000 are between the ages of 18 and 30, 30000 enrollees are between the ages of 30 and 50 and 40,000 are between the ages of 50 and 65.
b. a record similar to (a) above but for enrollees in Texas enrolling through the FFM.
c. a record similar to (a) above but aggregated for all states or for some subset of states or Exchanges.
2. All records showing the “metal tier distribution” of enrollees in all American Health Benefit Exchanges (Exchanges), including the State-Based Marketplaces (SBM) and the Federally Facilitated Marketplace (FFM). No request is made that would permit personally identifiable information to be disclosed. By way of examples, the following hypothetical records (paper or electronic) would be responsive to this request
a. a record showing that in the California Exchange, 20,000 enrollees have selected Bronze Plans, 30,000 enrollees have selected Silver Plans, 40,000 enrollees have selected Gold Plans, 10,000 enrollees have selected Platinum Plans and 3,000 enrollees have selected Catastrophic Plans.
b. a record similar to that described in (a) above but for enrollees in Texas enrolling through the FFM.
c. a record similar to (a) above but aggregated for all states or for some subset of states or Exchanges.
3. All data showing the number of employers by Exchange and/or by State or in any aggregation thereof enrolling in a health plan via a SHOP Exchange.
4. All data showing the number of persons by Exchange and/or by State or in any aggregation thereof enrolling in a health plan selected by an employer via a SHOP Exchange.
In order to help you determine my status for the purpose of assessing fees, you should know that I am affiliated with an educational institution (the University of Houston) and this request is made for a scholarly or scientific purpose and not for commercial use.
I request a waiver of all fees for this request. Disclosure of the requested information to me is in the public interest because it is likely to contribute significantly to public understanding or the operations and activities of the government and is not primarily in my commercial interest. This is so because both the age distribution of enrollees and the metal-tier distribution of enrollees is important to the stability of the individual Exchanges regulated by the Affordable Care Act. Disproportionate enrollment either by those age 50 or those in Gold and Platinum plans could cause insurers to lose money in the Exchange and trigger government obligations under the Risk Corridors program, lead some insurers to curtail offerings of health insurance through the Exchanges in the future, or result in calls for rate increases. The public has an interest in knowing the extent to which they can rely on insurance products sold through the Exchanges and the extent to which additional means, either regulatory or legislative, may be beneficial to provide for price stability.
I request that, insofar as practicable, the information I seek be provided in electronic format, either on a CD, DVD, or through access via an internet protocol such as FTP.
If you have any questions about handling this request, you may email me at [REDACTED] or telephone me at either [REDACTED] (office) or [REDACTED] (cell). My physical mail address is Seth J. Chandler [REDACTED]. If the amount of records requested is overly voluminous or if there would be much easy-to-cull duplication in a response, I am happy to discuss how this request might be narrowed.
Seth J. Chandler