More than 7 Million People Sign Up for Coverage on Health Insurance Exchanges

Washington, DC—Despite technical glitches that marred the rollout of the health insurance marketplaces last fall, President Barack Obama announced on April 1 that 7.1 million people signed up for insurance coverage in 2014 through the federal and state-based exchanges. Thanks to millions of enrollees in the last few weeks amidst an influx of marketing and advertising, the numbers exceeded the estimated 7 million people that the Congressional Budget Office had projected would sign up.

Still, it was unclear how many people have paid their premiums and how many did not have insurance before obtaining it on the exchanges. Although the Patient Protection and Affordable Act (ACA) was intended to provide healthcare for millions more Americans, the Obama administration is not collecting data on the number of previously uninsured people who enrolled on the exchanges, according to former Department of Health and Human Services (HHS) official Gary Cohen.

Mr. Cohen, who spoke at an AHIP conference, oversaw the implementation of the exchanges for 18 months until departing his position as director of the Center for Consumer Information and Insurance Oversight at the end of March. Mr. Cohen also said the administration is not keeping track of how many individuals bought coverage away from the exchanges.

According to an April 3 report from the Urban Institute’s Health Policy Center, approximately 5.4 million more adults from 18 to 64 years of age had health insurance through early March compared with a year earlier. The study’s authors noted that their estimate on the effects of the ACA on the insurance rate was likely low because 80% of the survey responses were completed before March 6 and did not include people who signed up on the exchanges during the rest of the month. It also did not reflect other ACA provisions that took place before 2013, including early state Medicaid expansions and people <26 years of age being able to remain on their parents’ health plans.

The Obama administration invested tens of millions of dollars and countless hours working on the exchanges, particularly following the problems soon after the October 1, 2013, launch when people had trouble logging onto Healthcare.gov, the Web site for the federal exchange. Since the early struggles, federal officials have changed the way they communicate and operate. 

“We have learned how important it is to be as transparent as we can be as early as we can be about both the policy rules and the system and operational issues so that we can learn from [insurers and consumers] what works and what does not work and how we can improve things,” Mr. Cohen said. “We are changing a lot, and we are asking a lot of [insurers] and consumers, many of whom this is new for them. I think we have to continue to be willing to learn lessons from what has worked and what has not worked, be flexible and adapt.”

More than 26,000 people were trained to assist consumers with any questions they had about enrollment, according to Mr. Cohen. There were also 12,000 call center workers helping customers and case workers at 10 regional offices to deal with more complex issues in person. Nearly 50,000 agents and brokers were registered to sell policies in the individual market, while 19,000 were trained to sell policies to small businesses.

In the days and weeks before the March 31 deadline, President Obama, HHS secretary Kathleen Sebelius, and other top officials traveled across the country promoting the benefits of coverage and the consequences of not signing up. The administration also increased its television, radio, print, and digital advertising. The messaging focused on informing people about the deadline and that they would be penalized for failing to obtain insurance coverage for 2014 unless they were available for an exemption. For this year, there is a tax of $95 per adult and $47.50 per child for a maximum of $285 per family, or 1% of household income. The penalties will increase in 2015.

As part of an appeal to convince younger people to purchase insurance, the Obama administration started a #GetCovered campaign on Twitter and featured online testimonials from people in their 20s who signed up for coverage. President Obama even appeared on “The Ellen DeGeneres Show” and the popular “Between Two Ferns” online show hosted by comedian and actor Zach Galifianakis in early March. Within a month, the 6-minute video with Mr. Galifianakis had been viewed more than 4 million times on YouTube.

From October 2013 through January, young adults accounted for 25% of total enrollees on the exchanges, according to Mr. Cohen. The final percentage was not known as of early April. It was important to attract younger, healthier people to the exchanges to keep premiums and prices low.

Throughout March, there was also an emphasis on advertising in sports-related programming. Television commercials ran during the popular National Collegiate Athletic Association men’s basketball tournament and featured current and former star athletes, such as basketball players LeBron James, Magic Johnson, and Alonzo Mourning. White House chief of staff Denis McDonough went on sports radio stations throughout the United States to promote a Web site (www.gameplan4me.com) that includes information on the importance of health insurance and how to obtain coverage as well as video games and videos from basketball players Kobe Bryant and Jamal Crawford and baseball player C.C. Sabathia.

The marketing push helped President Obama meet his stated goal of 7 million enrollees. With the federal Web site not running properly for several weeks, only 360,000 people had enrolled in the exchanges by the end of November 2013, according to data from Avalere Health. The cumulative number increased to 2.15 million by the end of December 2013, 3.3 million by the end of January, and 4.2 million by the end of February. In March, nearly 3 million people signed up for coverage.

“While our long-broken healthcare system may not be completely fixed, it is without question a lot better,” President Obama wrote in a blog post on the White House’s Web site on April 1. “That is something to be proud of—and there is no good reason to go back. Regardless of your politics, or your feelings about the [ACA], millions more Americans with health coverage is something that is good for our economy and our country. At the end of the day, that is what this law—and the other reforms we are fighting for, from a 21st-century immigration system to a fairer wage for every American who is willing to work for it—are all about: Making sure our country lives up to our highest ideals.”

The federal government, states, and health plans are now preparing for coverage that begins next January. This year, 15 states and Washington, DC, operated their own exchanges, while the remaining 35 states relied on the federal government to run their exchanges. The numbers may change next year because states can choose whether they run their exchanges.

In early March, the Obama administration announced that insurers can continue offering “grandfathered” plans through 2016 that were in place before the ACA was passed but do not meet the minimum coverage requirements of new plans. The “grandfathered” plans were supposed to expire this year, but they will now be in place at least until President Obama’s second term ends. 

“We wanted to give people as many options as they could to make sure that they stay in coverage,” Mr. Cohen said. “There has been a lot of discussion about the fact that there were people who had health insurance who were feeling that the cost of moving into a new plan was going to be prohibitive for them. We are trying to provide the transition. We are making a lot of changes in the market all at once. The last thing we want is to have anybody who had health insurance coverage to not have it.”

Mr. Cohen was unsure if people who enrolled for insurance this year will have to go through the same process next year. Federal officials are also working on the timeline and requirements for insurers that want to offer plans on the exchanges. Mr. Cohen said the government recently hired Accenture to work on an automated computer system for issuing the payments of tax credits and cost sharing reductions to people who qualify. For 2015 coverage on the exchanges, enrollment begins on November 15, 2014, and ends on February 15, 2015.

“The number 1 thing that we have all learned from 2014 is that this is hard work and it is complicated,” Mr. Cohen said. “It is going to take us all some time. It is not a 1-year project. It is a multiyear project. As long as we all continue to keep our focus on the goal that we all share, which is to make sure that people have coverage and are able to get healthcare, then I think we will continue to be more and more successful as time goes by.”