Health Exchange Enrollment: Speed of Light or . . . Molasses

Much has been said and written about the dearth of new commercial health insurance plan enrollees on the federal and state exchanges and, by contrast, the excessive numbers of Medicaid expansion enrollees, the death spiral signified by the absence of Young Invincibles from the exchanges, etc.

The HealthBlawger suggests: Cool your jets.

As the chart reproduced above amply demonstrates based on the Massachusetts experience (credit: Jonathan Cohn aka @CitizenCohn at The New Republic), and as a moment spent considering human nature will confirm, it is unlikely that most folks who need to pay American cash money out of pocket to be counted among the newly insured thanks to the health insurance exchanges — be they state or federal — will do so until they have to (i.e., not until, say, mid-December). The notion that everyone who needed insurance would purchase coverage in the first week of October was always sheer fantasy. Yes, is broken. Yes, the federal procurement process for software and web development is broken. But neither of those facts requires the conclusion that “Obamacare” is a massive failure.

Yes, the folks most likely to enroll in December are NOT the Young Invincibles. However, thinking insurance companies eager to grow their customer base by tens of millions of subscribers have budgeted for the losses related to the rush of long-uninsured and underinsured enrollees signing up for Year 1, and the Young Invincibles will follow as the penalties for noncoverage increase over time. No death spiral is upon us.

(Would a single payor system have made more sense? Sure. But in a country where “Gummint outta my Medicare!” is seen as a reasonable political statement by many, we got about as good as we could get.)

Most of the high numbers of Medicaid enrollees have been onboarded automatically by states that had Medicaid expansion programs of their own in the past, and that are transitioning members to the new programs that are further subsidized by the federal government under the ACA. No mystery there.

Here’s hoping for some less hysterical coverage of health reform implementation. (As my old auto mechanic used to say: “Hope burns eternal.”)

David Harlow
The Harlow Group LLC
Health Care Law and Consulting


  1. says

    I patiently attempted enrollment for a week, and then realized that had likely only been optimized for native browsers (IE and Safari). Once I switched from Chrome to Safari, it was swift and easy. I enrolled a few weeks ago, and now await the bill for my first month premium.

    I call it a win. I’ve been uninsured since the end of Cancer Year in ’08, when my insurer re-rated me at a minimum of $1.5K/month for coverage that would have required me to pay the 1st $6K of my annual costs out of pocket before they covered anything, and after that there was 25% co-insurance. IOW, I’d have been out of pocket a minimum of $24,000 annually before the insurer deigned to cover Dollar 1.

    Again, I’m calling this a win. So the website was a mess. It’s much better now – works snappily with Chrome. I worry that those who have not bought their own insurance in the past might have some difficulty figuring out what plan is the right one for them. That’s the topic of our Health Care Price Transparency (#HCPT) link to tweetchat on Monday, Nov. 18. Join us!

  2. says

    So early enrollment is supposed to be slow because the experience in Massachusetts was ‘slow?’ Seriously? These two roll-outs hardly seem comparable:

    1. The ACA has been touted all over the media for 3-4 years now; and the ACA was front and center through a presidential election and a high-visibility Supreme court case.

    2. Hundreds of millions of dollars in paid marketing/advertising has been spent on the ACA. An equal or larger amount of exposure has been provided via supportive main stream media.

    3. Internet access and technologies supporting awareness and enrollment are way more ubiquitous now – nearly a decade later – than when MA was being implemented in 2006.

    4. ACA subsidies benefit those up to 400% FPL – Massachusetts up to 300%.

    So far only the easy to implement and no-cost/low-cost parts of Obamacare have been implemented: primarily kids on their parent’s plan, elimination of pre-ex on children and removal of lifetime limits. As the author states, current enrollees counts are likely from the long-uninsured and underinsured. Yes, it’s still early, human nature is to procrastinate and a turnaround might occur. But given the above, the overall low number of enrollees these first 6 weeks, and the challenge getting the “young invincibles” to enroll, the belief that the Obamacare death spiral may have officially begun may not be the fantasy the author thinks it is. We’ll all know in the next couple months.

  3. says

    This is no easy ride. Unfortunately it is just the tip of an iceberg. The machinations of whoever devised the plan ignored the complexities of health insurance. Actuarial information is an ‘estimate’ at best. The early failure of enrollments will doom the remainder of the plan(s)

    Those who devised, planned, and are still promoting Obamacare already have egg on their face. They are only interested in saving face, not the welfare of patients, or providers.

    A lot is being made about patient-centric medicine…It should carry over to hospitals, and the government. Government seems to be lacking common rules of etiquette and caring for those who pay their salaries. …

  4. says

    The Massachusetts plan was well-publicized as well, yet the late signups occurred.

    A couple of interesting items were released this week suggesting that reports of the death spiral may have been exaggerated …


    The Affordable Care Act Can Survive Low Enrollment and Adverse Selection in the First Year, Blumberg & Holahan, RWJF, link to

    The Numbers Behind “Young Invincibles” and the Affordable Care Act, Levitt, Claxton & Damico, KFF, link to