The first million: reality check

On November 28 I welcomed the first million enrolees under ACA, whether to marketplace policies or Medicaid/SCHIP. The post was based on the fragmentary data available at the time, brought together in Charles “brainwrap” Gaba’s invaluable running spreadsheet, with some extra tweaks and guesswork by me.

HHS has just released its ACA enrolment report to 30 November. It even has a chart! Heavens to Betsy! Here’s the rare bird (click for better resolution):

HHS Nov chart

How did I do?

  • My headline number: one million.
  • HHS:  “Number of Persons who have Selected a Marketplace Plan or had a Medicaid/CHIP Determination or Assessment: 1.2 million”.

My point. But on the more detailed predictions, I didn’t do nearly so well.

  • Me: “New enrolments in private insurance and Medicaid/SCHIP will together be well over 2 million, and more probably over 2.5 million.”
  • HHS: 1,168,000. (All numbers rounded to nearest 1,000)


  • Me: “Over 1 million will be through private policies.”
  • HHS: 365,000 (healthgov 137,000, state marketplaces 227,000)

Oops. Where did I go so wrong?

I made four adjustments to brainwrap’s data. The first three – taking out those transferred administratively from state low-income health plans to Medicaid, which HHS doesn’t count either; extrapolating the interim data from the state websites to the end of the month; and extrapolating healthgov Medicaid enrolments in the same way – were OK. They gave me an adjusted total of 1,167,000, as close to the outturn as only a fluke can be.

My mistake was grossly overestimating the number of signups to private policies on healthgov. My reasoning was that 673,000 people had eligibility determinations from healthgov on 2 November and had not yet chosen a policy. Surely they would chose one in November? Well, most of them haven’t. The total signups in November were only 110,000.

The number of such ditherers on healthgov has risen to an impressive 1,388,000, plus another 554,000 on state exchanges. On the latter, ditherers outnumber signups 2:1, with considerable variation between states; on healthgov, by 10:1.

On the well-functioning websites of California, Kentucky, New York and Washington, the dithering presumably reflects free choice. On healthgov, it’s very likely that the continuing problems with the shopping stage of the website, and with its communication with insurers, pushed up the number. If healthgov had the same ratio as the state sites, I’d have been 350,000 up, and less embarrassingly wrong.

By report, healthgov really took off in December, after the announcement that it was fixed. The leaked number for signups in the first three working days was 56,000  – half the total for all of November. It’s reasonable to think Healthgov will converge on the mean delay on the state sites, and that the latter will fall as deadlines near.

What of my third prediction?

  • Rick Perry, Rick Scott, and all the other GOP politicians betting on Obamacare to fail will have egg on their faces.

No egg is visible in their mirrors of course. Those conservative critics with an open line to reality are reduced to whingeing: people aren’t really enrolled until they pay the first premium (that must come as a shock to many!), there’s a big hill to climb to meet the March goal, etc. (Cf. Sybil Fawlty, “special subject – the bleeding obvious”. )

No news from Perry or Scott. Perhaps they are glumly contemplating these numbers in the HHS report:

ACA texas florida

It’s only going to get worse for them. Jeffrey Zients has saved the Affordable Care Act and with it Barack Obama’s legacy. I Told You So.

Update – postscript:
Zients may be a managerial genius, but he doesn’t know anything about visual presentation. Look at the difference I was able to make to the Florida and Texas data just doing three things: getting rid of the grocer’s Initial Caps; changing the order, so that Medicaid goes before the rows on marketplace policies; and indenting to give a sense of the nesting of the data. Basic stuff. The most important policy achievement of the Administration deserves far better. Zients should hire someone who has read and digested Tufte.

Update 2: 15 December
As a crosscheck on the very marked December acceleration in signups on healthgov, California have released recent data showing the same effect:

In the week of Dec. 1-7, an additional 144,146 applications for individuals (averaging 20,590 per day) were completed, and 49,708 individuals selected plans (averaging 7,100 per day).

Since the California website has worked well from the outset, their enrolment speedup presumably reflects decision-making by applicants, not the removal of technical logjams. Ockham’s Razor suggests that the same dominates at healthgov.
Brainwrap’s running unharmonised total of private policy signups today is 685,915, a remarkable 86% increase on the harmonised HHS total on November 30. I’m going to stop following this, game over.