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How much ACA enrollment is enough?

Posted by John McDonough  October 16, 2013 10:33 PM

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Now that the shutdown insanity is in a locked ward, we should expect a fevered level of attention to return immediately to the progress of the Affordable Care Act expansions. We can predict a frantic desire to know one thing:

How many have signed up for coverage in the last three minutes?

Two models come to mind for reporting this information. Model A is the New York Stock Exchange and minute-by-minute tallies and updates. Model B is the monthly unemployment statistics, out the first Friday of every month (except when there's a federal government shutdown -- d'oh!).

In Massachusetts, we had intense interest in the progress of enrollment in the early days of health reform in 2006 and 2007, and we followed Model B. Once a month, at the board meeting of the Health Connector, everyone would learn what happened the month before. That makes sense.

To my friends in the media, I have one message: please take a chill pill. You won't see 7 million enrollees for a while, and that's not failure, that's real world.

Here's the actual data on initial enrollment in Commonwealth Choice -- the unsubsidized part of MA health reform:

Choice1 - Monthly Enrollment
Month Members
Jul '07 2,799
Aug '07 5,095
Sep '07 7,241
Oct '07 8,559
Nov '07 10,159
Dec '07 14,698
Jan '08 15,922
Feb '08 17,161
Mar '08 17,490
Apr '08 17,907
May '08 18,122
Jun '08 18,042
Jul '08 18,132

Worth noting -- July 2007 was the first month of actual coverage.  Enrollment in the months leading up to July was a trickle.  You can see the biggest jump in December 2007 because that is the month when the individual mandate penalty became effective -- even though it was only a $95 hit on state taxes for 2007. 

Here's the actual data on initial enrollment in Commonwealth Care -- the subsidized part of MA health reform.  Note, please, the difference in enrollment between the no premium and the premium paying parts of this population:

Care 1 - Monthly Enrollment
Month No premium Premium-paying Total
Nov '06 3,654 0 3,654
Dec '06 18,327 0 18,327
Jan '07 34,343 0 34,343
Feb '07 44,712 226 44,938
Mar '07 47,814 4,186 52,000
Apr '07 52,528 10,451 62,979
May '07 53,768 15,560 69,328
Jun '07  59,816 19,984 79,800
Jul '07 75,473 16,573 92,046
Aug '07 83,962 20,845 104,807
Sep '07 92,881 22,534 115,415
Oct '07 101,257 25,877 127,134
Nov '07 104,570 28,349 132,919
Dec '07 122,027 36,150 158,177
Jan '08 126,810 42,114 168,924
Feb '08 131,203 45,933 177,136
Mar '08 127,337 48,961 176,298
Apr '08 126,038 48,557 174,595
May '08 126,508 50,371 176,879
Jun '08 124,855 50,762 175,617
Jul '08 122,043 52,264 174,307


Inside baseball, though important -- the high rate of initial enrollment in no-premium coverage related to the auto-enrollment of tens of thousands of individuals who were enrolled in the state's uncompensated care pool prior to the passage of the MA health reform law.

Bottom line -- expectations of large-scale, instantaneous enrollment in the ACA are unrealistic and uninformed.

Massachusetts has achieved a level of coverage which is higher than the likely full impact of the ACA ever -- about 97% of all state residents.  The rest of the nation should be so lucky.  AND, it did not happen over night.  It was a slow crawl, not a sprint.

Keep your own, and your readers', and the public's expectations at a realistic level, please.  You'll be doing a service.

This blog is not written or edited by Boston.com or the Boston Globe.
The author is solely responsible for the content.

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About the author

John E. McDonough is a professor of practice at the Harvard School of Public Health. He is the author of the book “Inside National Health Reform”, published in 2011 by More »

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