The first million

Welcome to the first million Americans getting health coverage under ACA.

the doctor is inThere’s one group of Americans who have a special reason to celebrate Thanksgiving: the million who now have medical insurance for the first time, thanks to Barack Obama and the Affordable Care Act.

I’ll justify the number after the jump. For now: welcome to civilisation.

I know, I know: ACA doesn’t create a fully universal system, it’s complicated and kludgy compared to single payer, the federal website was launched as leaky as a sieve and is being repaired as it goes, it’s uncertain whether ACA will rein in healthcare costs, there are over 30 million more uninsured to go, yadda yadda. We’ll be talking about these problems many times. For now, Americans should celebrate a milestone.

How do we get to a million?

Charles “Brainwrap” Gaba’s ongoing enrolment spreadsheet gives the total signups today as:
Private insurance through marketplaces:         230,324
Enrolment assured in Medicaid or SCHIP:  1,384,576
Total :    1,614,900

Adjustment 1
I propose to deduct 600,000 in California and 83,991 in Maryland who are being transferred from state low-income health plans to Medicaid, as these people are getting improved, not new cover. On the other hand, I’ll leave in the 54,000 new Medicaid enrollees in West Virginia, registering with state authorities independently of any website. If bead strings are more reliable, fine. It’s the results that matter.
Grand total revised 1: 930,909

Adjustment 2
On November 13, the HHS released a report  with standardised data on all the marketplaces as of 2 November. The 13 functioning state websites (charitably counting Oregon) have updated their information since at dates ranging from 12 to 27 November. Extrapolating their data to 28 November in a simple linear way, I add:
Projected additional private enrolments:                   26,574
Projected additional Medicaid/SCHIP enrolments:  59,905
Total additions:   86,479
Grand total revised 2:    1,017,388

Adjustment 3 wasn’t working too badly in October for Medicaid. It determined 183,396 people to be eligible, almost as many as the 13 state websites did (212,865). Very conservatively – and ignoring the marked improvement in the website and its greater usage – we can safely extrapolate this rate to 28 November and find another 149,009 enrolled.
Grand total revised 3:   1,166,397

Adjustment 4
As is well known – and to the exclusion of all the other informative metrics – only managed to get a paltry 26,794 people signed up to a marketplace insurance policy by November 2. Extrapolating this anomaly to November would be a waste of time. The website is certainly very much better now. We do know (here, page 6) that the site had determined 702,619 people to be eligible for marketplace policies, with or without subsidies. For the remaining 672,855, the applicants still had to choose a policy and sign up for it.

The shopping stage of the website still had some problems in November. The insurance companies are griping that the error rate of the 834 forms is still 5%, so the poor things actually have to do some work rather than having perfect files handed them on an electronic plate. We can also suppose that a few applicants are not in any hurry if their deadline is March – but it also stands to reason that those with cancelled policies needing coverage from January were heavily over-represented among early applicants.

Let’s try to model this. Assume that healthgov to all intents and purposes did not work at all until 15 October, and that the typical applicant takes 2 weeks to choose and sign up to a private policy from the eligibility determination, with 90% success rate. So by now 608,000 of those in this position on November 2 are now signed up. In addition, we need to add the cohort of those reaching the same point in the first 10 days of November (to 12/11), which by simple extrapolation is 219,568. The same proportion of these have signed up, or 198,000.

Grand total revised 4:  1,993,965

The first three adjustments are plainly very conservative, and get us comfortably over the million mark. I maintain that my fourth adjustment, while it’s only back-of-an-envelope guesswork, is conservative too. The delay I built in is long; the trend in signups on from the state sites is not linear, but accelerating; and has improved dramatically from October, as Ezra Klein, Paul Krugman and even John Boehner can attest.

I’ll go out on a short and stout-looking limb here. I predict that when HHS releases its full report for November on the health care marketplaces:

  • new enrolments in private insurance and Medicaid/SCHIP will together be well over 2 million, and more probably over 2.5 million;
  • over 1 million will be through private policies;
  • Rick Perry, Rick Scott, and all the other GOP politicians betting on Obamacare to fail will have egg on their faces.


Update 29 November

Before some irate commenter chides me on the point, let me admit that all the estimates include some people with cancelled policies. These should be deducted before one can give an estimate of those with coverage for the first time. If anybody has a link to a number, please post it. However:

  • the policies were substandard; insert “decent” before “coverage” and no correction needs to be made;
  • for a subset of the cancellees, the subsidies or eligibility for expanded Medicaid make up all the difference in price, so they are unambiguously much better off;
  • for a second subset, the subsidies are such that the price increase is small enough, and the coverage gain large enough, that it’s still a definite win for them on balance;
  • a final group (mainly healthy young single men) are being coerced, by their insurers and the law together, into buying better and more expensive coverage than they would freely choose. This is good public policy, but I admit that those concerned have no reason to celebrate.

Any reasonable estimate of the total of newly insured is so much larger than one million that deducting the last group still leaves it above the bar. My headline stands.






Author: James Wimberley

James Wimberley (b. 1946, an Englishman raised in the Channel Islands. three adult children) is a former career international bureaucrat with the Council of Europe in Strasbourg. His main achievements there were the Lisbon Convention on recognition of qualifications and the Kosovo law on school education. He retired in 2006 to a little white house in Andalucia, His first wife Patricia Morris died in 2009 after a long illness. He remarried in 2011. to the former Brazilian TV actress Lu Mendonça. The cat overlords are now three. I suppose I've been invited to join real scholars on the list because my skills, acquired in a decade of technical assistance work in eastern Europe, include being able to ask faux-naïf questions like the exotic Persians and Chinese of eighteenth-century philosophical fiction. So I'm quite comfortable in the role of country-cousin blogger with a European perspective. The other specialised skill I learnt was making toasts with a moral in the course of drunken Caucasian banquets. I'm open to expenses-paid offers to retell Noah the great Armenian and Columbus, the orange, and university reform in Georgia. James Wimberley's occasional publications on the web

46 thoughts on “The first million”

    1. It’s fun to speculate on the conversation in 2016. My guess is that it will more be about single-payer experiments than about repeal.

      One sign of a shift in attitudes is the surprisingly rapid new take-up of Medicaid. 54,000 in West Virginia of all places! It may have moved from being stigmatised “welfare” to a right like Medicare. Medicaid is safer politically than it it was only a month ago.

      Another curiosity is the way that many Republican governors have strengthened Washington against the states by their refusal to set up exchanges. It would now be expensive and practically pointless for Texas and Florida to set up their own exchanges duplicating a functioning, so they won’t do it. This encourages the further federalisation of health care.

    1. When I was a kid “They” made us take the oral vaccine for polio in school. Hell, “They” even made us get smallpox vaccine before attending school. I have never recovered from having my god given right to contract those disfiguring and fatal diseases stripped from me. I demand my freedom to die like a dog in the street!

  1. Your third prediction is almost surely false.

    Yes, they will look bad to the reality-based, but to their supporters and the GOP in general it won’t matter what ACA accomplishes. It will always and forever be a disaster. Until they can find some way to cast themselves as its defenders.

    1. “Until they can find some way to cast themselves as its defenders.”
      My money is in 3 decades we’ll have some new version of the tea party/Birch Society vowing to water the tree of liberty with blood because someone is trying to take away their ACA benefits.

    2. I think some, not all, of those GOP members that either use their Obamacare insurance or save lots of money will convert to supporters over the next three years. An interesting test that could be done right now is to compare attitudes to Obamacare for demographically similar 25 year olds, some of whom are on their parents’ insurance and the others who aren’t.

      A much smaller category is the GOP supporters who listen to the Koch groups and refuse to sign up on the exchanges. Of them, some will get sick or injured, and almost everyone in that case will instantly reject the GOP position. They will make great (if sad) real-person testimonials during the campaign season next year.

      Agreed that the main body of GOP supporters will, in the short term, reject the facts about Obamacare.

  2. One thing we don’t know is how many of the enrollers already had health insurance. Certainly some of them did; when we hear of people who are thrilled that their health insurance premiums have gone down because they now have subsidies, we know those people already had health insurance. So clearly, not all of the million are newly covered.

    Also, I have to agree with byomtov that all the GOP politicians betting on failure, or at least rooting for failure, will continue to see failure. Because socialism, or something.

    1. Para 1: quite right, see update to the post.

      Para 2: and byomtov: I wasn’t actually predicting a change of heart by the GOP, only another embarrassing confrontation with the the facts.

  3. “Rick Perry, Rick Scott, and all the other GOP politicians betting on Obamacare to fail will have egg on their faces?” Won’t happen as long as the media continue to look for bad news stories about the ACA.

    1. In a previous thread I made this challenge:

      Somebody ring my bell when they find one video of a person waxing grateful for the new coverage. Surely there must be someone trying to bridge the doughnut hole in coverage between retiring at 62 and Medicare at 65.

      I am still waiting for a link from any major media outlet interviewing someone grateful to finally have health care and join “civilization” as Mr. Wimberley so aptly put it.
      In the meanwhile I did find one print story to prove we aren’t a nation of ingrates and smug-faced libertarians:

      Before he turned 65 in August and became eligible for Medicare, Howard Barnes of Tucson struggled to survive without health insurance.His $1,000 monthly income was too high to qualify for Medicaid but too low to afford health insurance. So the retired computer programmer relied on a patchwork of free clinics, discount plans and help from church friends to get the doctor visits, prescription drugs and equipment he needs to manage a life-threatening respiratory disease. Barnes said the stress and high cost of care—like $25 for each oxygen tank—damaged his health and well-being. “It’s dramatically impacted my social ability and contacts with the world because I can’t afford to go out and about with people,” he said. Now, with the implementation of the Affordable Care Act (ACA), and the expansion of Medicaid in Arizona, Barnes can afford the health insurance he needs and also hopes others won’t face a similar struggle.

      Taking the Mystery Out of Health Law

  4. Two questions: A couple years ago, if I don’t have insurance and I’m diagnosed with cancer, I’m screwed. I’m uninsurable at any price. With the ACA in effect, if I’m “uninsured” and I’m diagnosed with cancer, I can sign up for a plan and pay about as much as a cancer-free person of my age and get treatment.

    Question 1: Have I got that about right?

    Question 2: Does this amount to catastrophic coverage for absolutely everyone?

    1. No. You cannot just sign up for a plan at any given point in time. You can only sign up during open enrollment periods (after the initial rollout, that will be October 15 through December 7 of the preceding year) or because of a “qualifying life event” (such as moving to a different state, having a baby, etc.). You cannot just not enroll and then only become insured when you become seriously ill. You can, however, cancer or not, sign up during open enrollment or because of a qualifying life event and insurers will not be able to stick you with increased premiums, deny you coverage, etc.

      The law is designed to ensure that you have catastrophic (and generally, better) coverage because you are required to have health insurance (aka the individual mandate). This is, of course, modulo you instead choosing to pay the penalty/tax/whatever for non-enrollment and some Republican states screwing over the poor by opting out of the Medicaid expansion.

  5. In the end Obama and Democrats will get blamed for everything that is wrong with health insurance and the healthcare system and they will get zero credit for all of the protections from the predations of insurance companies. The insurance companies have been left in the position to tell the story and as we have already seen they are quite willing to twist the truth to their advantage.
    That said, the ACA will improve the lives of americans and hopefully will, state by state eventually lead to single payer insurance.

  6. “the policies were substandard; insert “decent” before “coverage” and no correction needs to be made;”

    IOW, if you don’t like a policy, it doesn’t count as coverage, even if the person who had it liked it. That figures.

    1. Isn’t possible that at least some of those with these substandard policies had them because it was all they could get? It is wrong to assume that they necessarily prefer what they had to what they are getting, as the critics seem to be doing.

      I recall at one point shopping for an individual policy, before I lived in MA, and being able to find only policies with ridiculously low limits and so on. This despite the fact that I was healthy. I bought one, but would have gladly paid more for better coverage. There also were, and may still be, policies with no “tail.” That is, they cover only expenses incurred during the short policy period – say six months – and do not cover followup expenses even if the precipitating even occured during the coverage period. Those were worse.

      1. Isn’t it possible for liberals to occasionally agree that people are entitled to make their own decisions about what they prefer?

        1. Brett,

          Of course.

          My point is that in the health insurance arena, at least, what “people prefer” may not be available, even if it seems quite reasonable. I thought my example was pretty clear that that was so in my case. I preferred better coverage, and was willing to pay extra for it. It was unavailable. I couldn’t get a quote. In part that was no doubt due to information problems surrounding health insurance which mean that the market does not function in accordance with those graphs on page 3 of your book.

          Can you grasp that possibility?

        2. Dear Mr. Bellmore,

          There are all manner of reasons for preferences. One important reason is affordability: I may purchase a DenialCare policy with a $5000 deductible and a $5000 copay because it’s the only thing I can afford in the previous “marketplace”. (And with what the insurance companies were doing in individual policies the scare quotes are scarcely sufficient.)

          Besides which, what are the exchanges about if not allowing people to make their own decisions about what they prefer?

        3. It depends upon the situation. In the case of health insurance, the answer is very often, “No, people are not entitled to just make their own decision about what they prefer.” The reason for that, which we have gone over many times, is that it often involves a free rider problem. In the case of health insurance, people with these insufficient policies do sometimes get serious illnesses. And so we are confronted with either allowing them into the system after they are diagnosed without having paid the premiums necessary to support the system prior to that or just telling them that they are welcome to die in the street while we watch.

          I will ask you something I have asked numerous times before, inevitably to the sound of crickets: are you in favor of telling someone diagnosed with cancer who does not have adequate insurance that they should just feel free to die? Are you prepared to ask every person at a car accident scene, conscious or not, whether they have insurance or a sufficiently large bank account to cover all treatment before the paramedics touch them? If the answer to these questions is, “No,” how do you plan to deal with the problem of free riders?

          Feel free to actually answer this time.

          1. No, I’m not in favor of that, but neither am I unconstrained in my choice of ways to address it, since I’m not a believer that the end justifies the means, or that long term consequences should be ignored.

            What I think, actually, is that it seems nice to protect people from the consequences of their own choices. But when the government does that, it will eventually decide that it is entitled to take those choices away from them. So that, to the extent we so protect people from those consequences, we should do so through institutions not empowered to take those choices away. Private charity, IOW.

          2. Do you have any plan for how to accomplish this without involving the government? Or are you just running your mouth?

          3. Back in the day “come the revolution” papered those holes. Libertopia probably works similarly.

          4. Warren, threatening to shoot people is not the only plan. But it’s the only thing government has going for it that the private sector doesn’t: The ability to get away with shooting people who don’t do what it says. So if you think only the government can do something, that’s your plan: Threatening to shoot somebody.

            Sometimes, like war, that IS the only plan. Most times it isn’t.

            The whole “threatening to shoot somebody” aspect is pretty clear in Obamacare: The whole program is just lousy with mandates and prohibitions, all of which in the final analysis, boil down to a threat to shoot somebody if they don’t do as you say.

            I just wish ‘liberals’ had the imagination and faith in human nature to believe that significant things can be accomplished without that threat. Are they guaranteed to be accomplished? No. Neither is the government guaranteed to accomplish things you set out for it to do.

            Unless you want people shot, governments are historically pretty good at that.

          5. In other words, you say that you don’t want a society of free riders or a society in which people are left to die on the side of the road, but you are utterly unwilling to do anything that would prevent one of these two alternatives from being the one we live in.

            So, which one would you pick: free riders or people left to die? Apparently, those are the only societies you are prepared to contemplate.

          6. “but you are utterly unwilling to do anything”

            I’m unwilling to do what you want, but only in your mind is that the same thing as being unwilling to do anything. What I do, is donate to charity.

          7. Brett, I’m glad you are the sort of person who donates to charity. In general I think I abhor most every policy preference you have (with a burning passion!), but I’m nonetheless sure you are a good person. Albeit a good person with some odd susceptibility to conspiracy theories and mutterings of dark machinations.

            Still, charity as such just isn’t an answer. I’m sorry, it isn’t. It leaves people to die, because the local reserves of charity are exhausted. It’s also terrible health policy: if people cannot consult medical resources when they first suspect a problem, but instead tough it out fearing bankruptcy and the difficulty of obtaining charity, their medical outcomes are worse (at, I suspect, greater expense), and they are less able to contribute to the economy.

            The spectrum from single-provider through single-payer to the ACA (regulated insurance with subsidies and a mandate) is not the complete spectrum. We could imagine a weaker form of the ACA, covering only catastrophic needs once all else is exhausted – an accelerated route onto a more robust Medicaid would be the simplest form. We could even imagine bringing back Workhouses, in a medical form for the destitute in need of medical attention, a regime of enforced poverty and exploitation. I don’t like either of these plans (I think the latter especially is an affront to human dignity, and either would encourage people to suffer ailments untreated), but both would be less pervasive than the ACA and would affect the not-yet-unwell less. But: you have to have a plan. Saying you’d like people in need to receive charity is whistling past the charnel house.

            More generally: we, as a people, have come together to impose a consensus vision on our society. What is in the USA the Left side of the spectrum, from framing lefties through to blue-dog moderate conservatives, has a vision that everyone should have access to medical care, and that they should pay for that coverage if they can, and the taxpayer should chip in if needed. This is not the bootheel of fascism! This is a moderate and thoroughly compromised plan, enacted by a democratic process and endorsed by the Supreme Court as being consistent with the our Constitution. If you don’t like a guarantee of coverage for all, well, fair enough. But if you agree with that as a professed ideal, you’ll have to endorse some vision of ensuring it: polls already indicate people are unwilling to surrender major parts of the ACA, and as they encounter other parts those, too, will gain in popularity. Encomiums to Charity won’t cut it as an alternative vision.

          8. I’m less charitable than Warren. Brett knows damned well that charity isn’t actually a solution to the problem. Mentioning it is just another way of not admitting that he would rather live in a society where people are left to die than he would actually doing anything about it.

            Brett, in addition to everything else you’re a coward. You won’t come out and be honest about the consequences of your policy preferences. I suspect that you start by lying to yourself about it.

          9. Yeah, that’s what I was saying: Liberals are, strangely, unwilling to admit anything constitutes a “solution” unless it involves government threatening people who don’t fall in line. It’s part of what makes people who don’t want the government threatening them so hostile to liberals.

          10. Yeah, it’s funny how we’re unwilling to admit that something that doesn’t solve a problem constitutes a solution to that problem. Even by your standards this response is weak.

        4. “Liberal” in the strange American sense is particularly confusing here. Compulsory social insurance was originally a paternalist conservative idea, with Bismarck, and was later adopted as one of the central planks of social democracy. Both ideologies have been quite happy with the degree of coercion involved in the name of national or class solidarity respectively, and firmly hostile to the sort of ultra-liberalism Brett espouses, prizing the freedom of rich and poor alike to sleep under bridges.

        5. Brett, you mistake coercion, desperation, and necessity for “making one’s own decisions.” The choice of accepting terrible insurance (or no insurance) in the current market is not a choice for anyone–it is done out of financial desperation. Likewise most other bad decisions made by the poor and disenfranchised.

  7. Brett Bellmore says:
    November 29, 2013 at 11:51 am

    “Because nothing is really done, unless done by government.”

    Stop lying.

    1. Brett Bellmore says […] “Because nothing is really done, unless done by government.”

      Hey, at least that fits with Brett’s belief that government agents “facilitated” the Oklahoma City bombing.

      1. There’s akready a great, awesome charity alternative in place! It’s those big plastic jars that you see in convenience stores and gas stations, especially in rural areas, with a photocopied picture of a young man or kid who’s contracted lymphoma or kidney failure, taped to the jar, and pleading for donations of pocket change to help the patient’s family.

        Those nickels really add up!!!!!

        And when they don’t, we can comfort the family with the fact that in AMERICAN society, merit always wins, and winnows out the undeserving — unlike in nasty old Europe, where every citizen (no matter how worthless) has health care. What a horrible system they suffer under.

  8. I would argue that sign-ups for Medicaid/SCHIP of people who were previously eligible but not enrolled do not count as “new coverage due to Obamacare.” Medicaid does not have enrollment periods, so anyone who was Medicaid-eligible could enroll if their medical needs were high (and hospitals frequently had someone dedicated to enrolling people in Medicaid if needed).

    It’s also worth remembering that the law doesn’t provide subsidies for policies sold through (The administration has been ignoring this, but the suits saying “you can’t do that” are wending their way through the courts.

    1. SamChevre: thanks for commenting on my post and not “Obamacare, for and against, round 23”.

      Para 1: I don’t have a breakdown between the previously and newly eligible for Medicaid. The HHS report probably has something you can look up if you care that much. Apart from West Virginia, all the determinations of eligibility were made on the marketplace websites, created by ACA. So IMHO ACA clearly gets the credit for the coverage expansion.

      Para 2: you jump without argument from “there are nuisance lawsuits alleging something incredible” to “it’s illegal”. The subsidies were always an absolutely essential part of the law, as anybody looking at the legislative history will see at once. It’s hard to be certain about anything with the partisan Roberts Supreme Court, but after Sebelius it looks as if he at least will only make a partisan ruling to undermine ACA if there’s a half-way plausible argument. Plus the fact that by the time a case reaches the Supremes, if it ever does, several million voters, half of them Republicans, will have contracted insurance policies on the basis of a firm legislative promise of subsidy. It would be extraordinarily radical to unwind these contracts, highly damaging to the insurance companies, and probably ensure a Democratic sweep in the Congressional elections.

    2. There are much better times to get medical coverage, Medicaid or other, than when you’re in the emergency room. If the ACA leads to a lot of people getting coverage who wouldn’t have realized that they were eligible absent the law, I think it’s more than fair to give it credit for the signups.

      The one thing I will grant your second paragraph is that I suspect that there are some folks around here who were absolutely adamant that that the legislative history of what Congress actually intended with regards to platinum coins was totally irrelevant and the only thing that mattered was a stupidly literal reading of the words of the law who will exquisitely pivot now and argue that Congress clearly intended that anyone buying health insurance through an exchange, whether run by a state or the federal government is entitled to the subsidy. It’s worth pointing and laughing at these individuals if and when they are identified but that doesn’t change the fact that what Congress actually intended with a law does matter when ruling on its interpretation.

      1. Speaking for myself, I favoured the consols or high-coupon bonds over the platinum coin, but your argument applies to those too. However, the case was clearly different to any possible litigation under ACA.
        One: US government default risked a global financial panic which would have made the 2007 GFC look like a minor hiccup; the danger (bearing in mind the consequences of 1929) would have justified extreme and illegal measures. Salus reipublicae suprema lex.
        Two: the threat not to raise the debt limit put the President in the position of prospectively having to violate one of two laws read straight, the budget continuing resolution or the debt limit act. The problem was to find the course of presidential action that would have done the least long-term damage to the US constitution and the world economy, some being inevitable. A strained interpretation of the debt limit act seemed to me to fit the bill.

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