One-point-two million enrollments -- and counting.
Obamacare's first open enrollment period is over, and if raw volumes are a proxy for state-by-state success, the Golden State wins in a landslide. Covered California had planned for fewer than 700,000 sign-ups, and the Congressional Budget Office forecast was just shy of 800,000. The state blew past both targets more than a month ago.
All told, California represents about one-fifth of national enrollment in the Affordable Care Act's insurance exchanges.
Supporters are ebullient. Topping out above 1 million sign-ups shows the "unprecedented" demand for the exchanges, Covered California Executive Director Peter Lee said on Monday.
But critics point to another seven-digit number: One million plan cancellations -- or more.
Does that take the steam out of Covered California's performance, or are fears over canceled plans just hot air? "Road to Reform" does the math on four key questions.
1. How should we judge Covered California's performance?
The initial enrollment figures are definitely "impressive," says Dylan Roby, who directs UCLA's Health Economics and Evaluation Research Program, which developed the CalSIM predictive model that regulators used to set expectations.
"In our base scenario, we estimated 840,000 people getting tax credits and signing up through [Covered California] by 2014, and our enhanced scenario was at 1.2 million," Roby tells California Healthline.
To judge the first-year numbers, Roby walked through some of his back-of-the-envelope math -- Covered California has reported 1.2 million enrollees, and nearly 90% likely will receive subsidies. As a result, "more than 1 million people are signing up with tax credits to help them purchase coverage, which benchmarks well with our original estimates," Roby concludes.
Keep in mind that the number isn't final, given all the likely churn both on and off the exchange this year. But Roby thinks that the exchange will be "very close" to CalSIM's enhanced scenario throughout 2014, he adds.
2. Why was there such a last-minute surge of sign-ups?
Exchange enrollment dramatically ramped up across the nation last month, but no other state saw more of a total uptick. At least 340,000 Californians signed up through Covered California in March, according to initial estimates released by the exchange on Monday.
To put that in perspective, that's more -- a lot more -- than the number of people who signed up for private plans in all other 49 states and Washington, D.C., between October and November.
And in one five-day window last week, California reported more sign-ups than Oregon and Maryland had reported in five months.
Covered California's last-minute outreach efforts included radio and TV spots, and perhaps those campaigns played a role in driving sign-ups, observers tell "Road to Reform."
But a good deal of that last-minute surge is, frankly, because of human behavior, suggests Micah Weinberg of the Bay Area Council.
"I think that we can chalk a lot of this up to procrastination, particularly on the part of the young and newly insured," Weinberg tells California Healthline.
"Also remember that [these enrollees] could avoid paying three months of premiums and still avoid the individual mandate."
3. Why was the target so off?
Unlike many other states, California may end up doubling its internal projections for enrollment in the exchanges.
"I think Covered California's initial target [of less than 700,000 sign-ups] was set conservatively," UCLA's Roby tells California Healthline. Officials wanted to be sure that "they could raise enough money to sustain the exchange in the long-term with insurer fees," he adds. (A level of sign-ups that Roby thinks they've now hit.)
Given all the uncertainties with launching the exchange, "I'd have been cautious too," says Daniel Zingale of the California Endowment.
Could the many uncertainties once the exchanges were up and running -- for example, the national problems with HealthCare.gov and the local stories about Covered California's website difficulties -- have played a role in driving traffic? Several experts say it's a possibility: The technical issues might have kept Covered California in the news and helped boost awareness.
"If we hadn't that terrible dark period in October and November, then the story that the website was fixed" wouldn't have generated so much interest and remained topical for so many months, Zingale suggests.
"Everything about Obamacare is newsworthy" now, he adds. "We do a lot of great stuff [at the Endowment], but a lot of the press calls I get are about Obamacare, for better or worse."
4. How many people are really 'newly insured'?
Experts pointed out that many media reports are focusing only on Covered California while overlooking Californians who didn't use the exchange to get covered. The wave of new Medi-Cal enrollees, for instance, which include more than 600,000 residents who got covered through the Low Income Health Plan.
Observers also took issue with reports that more than 1 million Californians saw their plans get canceled under new ACA requirements.
"My hunch is that it's been overestimated," Zingale says.
And the frightening terminology around "cancellations" also overplays the actual transitions that unfolded in the market.
"The insurers didn't cancel anybody," Anthony Wright of Health Access told California Healthline. "They basically told all those people 'we are transitioning you to another policy,'" and some of these individuals did choose to shop around instead.
Weinberg cites CalSIM estimates that about 70% of all new enrollments in Covered California would come by virtue of such transitions.
Assume that 85% of Covered California's 1.2 million enrollees have paid, he adds. "That's just over a million actual enrollments." And accounting for those individuals who transitioned from now-canceled plans would leave about 300,000 "new" privately insured through the marketplace, Weinberg suggests.
UCLA's Roby has a slightly different way of looking at the question.
He notes that according to several surveys -- conducted during an earlier part of the open enrollment period -- about one-third of folks were previously uninsured. “I don't buy the argument that the plan cancellations actually resulted in a net loss of insurance," Roby adds.
"I would guess that our individual market for insurance grew by about one million people," he concludes, "with 1.2 million or so signing up through Covered California and another 1.8 million ... buying coverage off-exchange."
Prior to the ACA, surveys had suggested that about 5 million to 6 million state residents were uninsured at any given time. So wherever the numbers end up, observers credit California for making a real dent in its uninsurance rate.
"This is a real cause for celebration," Weinberg says, "but it's just the beginning of a five-year minimum process of creating a culture of coverage and reducing the uninsured in the state to much lower levels."
Battle Over Enrollment Isn't the Real War
Several experts who spoke with California Healthline noted that sign-ups in the exchanges, while important, are just one element of reform implementation. And yet, the constant focus on the exchanges elevated the enrollment count to a political fight, observers concluded -- which ultimately benefited the law's backers, given that the total number of sign-ups ended up exceeding expectations.
It wasn't a battle that supporters of the law sought out, according to Wright.
Opponents of the ACA "picked that fight and I always wondered why," he says.
"At the end of the day ... [an enrollment] is not a vote. This is not a symbol of political support," Wright adds.
"This is people signing up to get a basic necessity of modern life."
Around the nation
Here's a look at what else is making news on the road to reform.
Do medical homes work? At Project Millennial, Tom Liu examines a pair of conflicting studies about medical homes, an initiative tied to the ACA's quality reforms, and Allen Joseph goes deeper into the data to determine whether they save money. (For a broader look at medical homes and Obamacare payment pilots, see this March 5 column from "Road to Reform.")
What's the future of Obamacare? Jonathan Cohn and Avik Roy debate the law's promise and drawbacks on NBC's "Meet the Press." In a video posted by The Atlantic, Adrianna McIntyre and Yevgeniy Feyman also address some of the law's practical questions.
40% of Covered California enrollees may leave the program: At KQED's "State of Health" blog, Lisa Aliferis reports on a new UC-Berkeley study that explores the issue of "churning" on the exchanges.