Forget the 7.1 million: ObamaCare's real enrollment numbers are still to come

The Affordable Care Act was never going to solve the nation's health care problems in its first big year

Obama and Biden
(Image credit: (CC BY: The White House/Pete Souza))

President Obama confirmed on Tuesday that a last-minute surge has enrollment on the Affordable Care Act's new insurance exchanges topping 7.1 million, just under the deadline to register (or to start the registration process, depending on the state). The president claimed victory in a speech at the White House, having achieved a goal that was in doubt when stumbled badly out of the gate in the fall of 2013.

But if we buy the Congressional Budget Office's projections, hype over hitting the magic "seven million" might be short-sighted — there's a bigger enrollment story on the horizon. The agency expects enrollment though the insurance exchanges to more than triple by the end of 2016, to 22 million. Total enrollment is expected to level out at 24 million to 25 million in 2017.

Yesterday's news demands certain caveats: we don't know how many enrollees have paid, how well the healthy will balance out the sick at the state level, or how many were uninsured before enrollment. But it remains remarkable, considering that seven million was the CBO's enrollment projection for 2014 before the embarrassingly glitch-ridden launch of caused the agency to revise its estimate downward. Even acknowledging uncertainties, meeting the enrollment target is irrefutably good news for supporters of the health law.

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So what's up with that crazy enrollment math expected in the next few years? It takes time for abstract policy levers to become tangible realities. The Affordable Care Act depends on a system of sticks and carrots to encourage people to enroll in coverage: the individual mandate requires people to sign up or else pay a tax penalty, while tax credits used to subsidize premiums bring insurance within financial reach for many lower- and middle-income families. The trouble is that these policy levers have been little more than talking points so far, and not terribly effective ones at that: according to last month's tracking poll from the Kaiser Family Foundation, about one-third of Americans don't know about the penalty and more than 40 percent are unaware of the subsidies.

Those provisions will spur enrollment as they become a routine part of U.S. health policy. The penalty is weak now, but climbs to $695 or 2.5 percent of income above the filing threshold in 2016, whichever's higher. For uninsured Americans, the mandate will take on a new salience as they file taxes in coming years. General familiarity with the tax credits should also grow over time as enrollment spreads; CBO anticipates that a full 80 percent of future exchange enrollees will receive subsidies.

Health reform was never going to remedy the nation's deep health care problems — in which millions are either underinsured or have no insurance at all — in its first big year. Nor is the Affordable Care Act expected to fully do so in the long term. It's still unclear whether reality will match the CBO's estimates that the number of uninsured will fall by 13 million in 2014.

What is clear is that this year is only the beginning of the story. We're talking about a trend, not a solitary event; by the end of 2016 we're supposed to see 25 million fewer uninsured individuals than if the Affordable Care Act had never been enacted.

The CBO is the closest thing policy nerds have to a crystal ball. Its projections aren't perfect — none are — but they're worth our attention, if the last few days are any indication. It's entirely too early to judge the "success" or "failure" of the health insurance exchanges, because according to CBO's numbers, the biggest enrollment stories are yet to come.

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Adrianna McIntyre is a graduate student in health policy at the University of Michigan. She serves as managing editor of The Incidental Economist