6 Big Unanswered Questions About Obamacare

Obamacare supporters are taking
a bit of a victory lap today after yesterday’s administration
announcement that six million people have signed up for private
plans under the law, equaling the revised projection put out by the
Congressional Budget Office after the botched launch of the
exchanges last October. 

It’s a weak cause for celebration, given that success, according
to Health and Human Services Secretary Kathleen Sebelius, was
originally “at
least” seven million people getting covered under the law
by the end of March. And as an Obamacare factoid, the six million
sign-ups figure just doesn’t tell us all that much about whether
and how the law is working. There are still a lot of major
unanswered questions about the law and its future.

1. How many people have actually enrolled? This
is the big one. I’ve written about it a lot for a reason: The
headline sign-up numbers are often described as enrollment numbers.
They’re not. A significant portion of people who sign up for
coverage aren’t paying their first month’s premium, and are
therefore never enrolled. In California, it’s about
15 percent of sign-ups. In Wisconsin and Georgia, it’s closer to 20
percent. In Nevada and Vermont, it’s more than 30 percent. Until we
know how many people have paid, we won’t know how many people got
covered.

2. What percentage of those who are enrolled are between
the ages of 18 and 34? After the launch of the exchanges
last October, the White House repeatedly emphasized that they were
less focused on the total number of enrollments and more concerned
with the demographic mix—specifically, the number of young adults
signing up. Young adults tend to be less expensive to insure, so
their premiums are needed to balance out the costs of the older,
more expensive enrollees. Early on the administration had been
clear that it was aiming for 40 percent of enrollees to be in the
youngest cohort. But so far, the administration’s reports have
indicated that only about 25 percent of sign-ups are young
adults.

3. Are the young people who are enrolling actually
healthy? This one will be hard to answer, but it’s
important. In the population as a whole, young adults tend to be
healthier, and therefore less inclined to use lots of health care
services, than their elders. But the characteristics of the 6
million or so folks who end up in the exchange population may not
mirror the population as a whole. It’s entirely possible that the
young adults who do end up signing up will be sicker, on average,
than their peers. If so, that will complicate premium pricing down
the road.

4. What are the sign-up totals, demographic breakdowns,
and overall health of the individual state markets? The
headline national numbers only tell part of the story. By the
middle of this month, 13 states had exceeded initial enrollment
projections,
according to a count by Philip Klein of The Washington
Examiner. But another 12 states were at less than half
their projected sign-ups, and 24 were at less than two-thirds of
sign-up expectations. What this means is that Obamacare is going to
look very different depending on what state you live in. Some
states will meet or beat enrollment expectations and presumably end
up with viable insurance markets in the process. But others will
have low enrollment totals and bad demographic mixes, and are
likely to face higher premiums and fewer plan choices as a
result.

5. How many of the people enrolled under the law were
previously uninsured? And how many of them were previously among
the long-term uninsured? Even once we find out how many of
the people who have signed up for coverage have actually enrolled,
we still won’t know the answer to another big question: How many of
the enrollees were previously uninsured? Surveys and word from
insurance industry insiders suggest that anywhere from a quarter to
half of enrollments were previously uninsured—meaning it’s possible
that the majority of enrollments are for people who were already
covered before the law’s insurance expansion took effect. Moreover,
when trying to figure this out, it’s worth thinking about who
counts as previously uninsured: Many counts of the nation’s
uninsured population count people who went without insurance for a
few months, often while transitioning between jobs. But it’s the
long-term uninsured—those who have gone years without coverage—we
should be focusing on.

6. What will premiums look like next year? This
matters both for the politics of the law and for its success as a
policy mechanism. President Obama initially sold the health care
overhaul as a way to reduce premiums, but recently the
administration has trimmed back its promises, saying instead that
premiums will still rise, just not as fast as prior to the law. But
there are early rumbles from insurers suggesting that, when they
set rates for next year, premiums could jump dramatically, with
some warning that
rates could double, or more. Because of the state-by-state
nature of Obamacare’s insurance markets, those effects won’t be
felt evenly. But if big hikes do appear in many markets, then you
have to wonder: How many people will want to stay with their
current plans? And what will this do to the already weak political
support for the law?