1.5M Young Adults Must Still Sign Up for ACA To Hit Projections. Don't Count on It.

by Dan Diamond, California Healthline Contributing Editor

Back on Nov. 13, the Obama administration released its first monthly report on enrollment through the Affordable Care Act's exchanges. That issue brief, and three subsequent ones, have followed a consistent pattern: Page after page of data and anecdotes about sign-up patterns, plan metal levels, and broader trend lines.

But for a Cliffs Notes version of the report -- for the White House's attempt to control the message on health reform, in just one chart -- just look for "Figure 1."

In December's report, Figure 1 was devoted to the rising number of sign-ups through the federal exchanges. Ditto for January's report, too.

And in the report released last week? Figure 1 mapped trends in age distribution -- specifically among young adults.

"The proportion of young adults (ages 18-34) selecting a Marketplace plan increased by 3 percentage points during the fourth month of the initial open enrollment period (from 24% to 27%)," the chart's description reads. "Figure 1 [is] consistent with expectations," according to accompanying text.

Translation: Stop worrying about whether young adults are signing up for Obamacare. The White House thinks -- or at least wants you to think -- they're on the way.

Low Numbers Miss Expectations

According to the Obama administration's original estimates, almost 40% of enrollees by March 31 were projected to be between ages 18 and 34. And about 1.6 million of these young adults were expected to have signed up by now.

Instead, the total number of 18- to 34-year-olds who had signed up by Feb. 1 was roughly half of that -- 807,515.

And critics have noticed. Republicans have mocked Obamacare's "young adult problem." Several front-page stories in the Wall Street Journal and the New York Times have worried over whether premium costs will spiral up if young enrollment doesn't go up.

That's why the White House is making such a big fuss over a relatively small increase.

(To put that three-percentage point jump in January in context, it represents a swing of about 30,000 young adults -- basically equivalent to signing up every attendee at a single live concert for One Direction.)

There are a handful of arguments for why the number of 18- to 34-year-olds has lagged. 

  • The ground game hasn't worked out. Attempts to repurpose the Obama campaign's vote-getting tactics have been stymied by scarce volunteers and non-working websites, Evan McMorris-Santoro writes at BuzzFeed. And many people approached by canvassers just aren't interested in signing up, Michael Shear suggests in the New York Times.
  • The cost of premiums still outpaces small tax penalties. The personal-finance website NerdWallet crunched the numbers and found that the average young adult will likely save about $1,000 by opting not to purchase health insurance in 2014. "It isn't just a 'young and reckless' mentality keeping so-called 'young invincibles' from signing up," writes NerdWallet's Napala Pratini. "Many young adults will follow a logical financial rationale for remaining uninsured in 2014."
  • There wasn't enough of a tailored effort: Nearly half of all millennials do most of their online browsing from cell phones, tech entrepreneur Alex Bratton writes, but Healthcare.gov wasn't optimized for those devices. "One webpage covering 'how to sign up with your mobile phone' instructs the user to call for more information to enroll," he notes.

Perhaps the most pervasive argument centers around personal responsibility; namely, young adults are procrastinators, President Obama and others have suggested. Pointing to evidence from Massachusetts -- specifically, noting that "young people slacked in signing up" for RomneyCare -- The New Republic's Jonathan Cohn has consistently predicted a surge in sign-ups from young adults later in the ACA's own enrollment period.

But based on new CBO numbers, the White House is about 1.5 million young adults away from its goal of enrolling 2.34 million young adults by the end of March. And it will take much more than a Massachusetts-like surge to hit that mark.

Under RomneyCare, the percentage of 18- to 34-year-olds did inch up as the enrollment period dragged along ... but in any given month those young adults never represented more than about one-third of all enrollees in the program's private plans.

Under the ACA thus far, 18- to 34-year-olds account for about one-quarter of all enrollees ... and to get to the White House's stated goal, young adults would have to account for about one-half of all new sign-ups that CBO expects to see in February and March.

What It Means

That sign-up pattern is almost certainly not going to happen, which may spark a new round of critical headlines. But it may not matter all that much, a growing group of experts say.

Their consensus is summed up by the title of a recent Urban Institute report: "The Affordable Care Act Can Survive Low Enrollment and Adverse Selection in the First Year." According to authors Linda Blumberg and John Holahan, even if insurers don't get the mix of enrollees that they were expecting, they probably can't hike prices drastically.

"Insurers cannot recoup losses without achieving significant market share, and achieving market share requires that they price their products competitively for expected enrollees in the coming year," they write.

A similar report from the Kaiser Family Foundation debunks fears of a "death spiral," or a situation where too few young enrollees leaves the market filled with too many older, sicker patients, driving up premium costs by staggering levels next year.

But even in a "worst-case scenario" where young adults represent 25% of all enrollees -- or essentially, where the numbers are now -- premiums for 2015 will go up just 2.4%, Kaiser's Larry Levitt, Gary Claxton and Anthony Damico write.

That's not to understate the concern, the experts acknowledge. But it's important not to overstate the problem using crisis rhetoric.

"It's a problem if it goes on forever," Holahan told The New Republic's Cohn, "but it's not a problem if it's just year one and if enrollment is improving over time ... The system can handle it." 

How To Boost Enrollment

Meanwhile, advocates and officials are still thinking creatively about how to tap into the young adult market. A new slate of commercials will run during NBA games and "March Madness" college basketball games. HHS is reaching out to moms, Joanne Kenen writes at Politico. The state of Illinois will run ads on The Onion's website.

"It's all about meeting young people where they are," says Tamika Butler, the California director for Young Invincibles. "You have to reach us where we are, online, on our cell phones."

Young Invincibles was among several groups, led by Enroll America, that organized last weekend's National Youth Enrollment Day. Modeled on National Voter Registration Day, advocacy organizations hosted dozens of events around the nation. (The timing was unfortunate; the ACA's own site was down for maintenance for part of the day, so advocates spent a good portion of the day focused on education rather than enrollment.)

Butler of Young Invincibles told California Healthline that the focus on young adult enrollment tends to overlook one key factor.

"I think people forget that young adults can sign up after March 31 if they have a qualifying life event," she said, "like getting married, having a kid, moving somewhere else."

"On March 31, we're not going to slow down."

Around the nation

Here's a quick review at what else is making news on the road to reform.

Sink vs. Jolly: David Lauter of the Los Angeles Times looks at a congressional race in Florida that may end up being a test of Obamacare.

Which insurance markets are the cheapest? At Kaiser Health News, Jordan Rau reviews the 10 least costly places to buy a health plan through the ACA's exchanges.

Arkansas Medicaid plan in peril: Legislators failed to pass a bill renewing the 'private option,' and David Ramsey of the Arkansas Times explains what that would mean for Arkansas' health insurance marketplace. (Here's a closer look at the private option fight from "Road to Reform.")


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