Amidst all the political posturing and spin it is difficult to get a clear and unbiased picture of the impact of the reform law, especially in regard to its primary goal of reducing the insured. The Rand organization has issued a report which attempts to give a better sense of changes in enrollment. (Rand Report) The report is based on an ongoing survey that Rand collects from the same pool of about 2400 individuals, aged 18 to 64, at regular intervals, giving a longitudinal look at their insurance status. The report tracks changes from September 2013 to March 2014. The researchers estimate that 9.3 million people have gained coverage over that time period, lowering the uninsured percent of the population from 20.5% to 15.8%. The net gain is comprised of 14.5 million who gained coverage, while 5.2 million were losing it. Enrollment in employer-sponsored insurance increased by a net 8.2 million, while Medicaid enrollment went up by 5.9 million. Around 3.9 million people had coverage through the exchanges. Eighty percent of adults have the same form of coverage in March 2014 as they had in September 2013. For those who were uninsured in September but are covered now, 7.2 million got their coverage through employer-sponsored insurance; 3.6 million got their coverage through Medicaid and only 1.4 million got coverage in the insurance exchanges. So about 1 million people went into employer-sponsored insurance who previously had some other form of coverage and about 2.3 million people went into Medicaid who had another form of coverage before. And about 2.5 million people who enrolled on the exchanges already had some form of coverage. About a million people who had individual market insurance became uninsured. So the exchanges, which offer individual coverage, at best got an additional 400,000 people coverage. The most puzzling thing about the Rand report is the large drop in people who had “other” insurance, over 7 million. The report doesn’t clarify what the breakdown of that “other” is, other than to say military coverage, Medicare and retiree insurance. While employers are eliminating retiree insurance, and the military is shrinking, that 7 million reduction seems way too large for that group. And the number of 18-64s who are “disabled’ and therefore eligible for Medicare coverage has been growing rapidly, not shrinking. More detail is needed to understand this significant change.
What needs to be kept in mind with almost all the data flying around right now is that it is often based on estimates and preliminary numbers. Until we see specific enrollment details from Medicaid programs and insurers and until someone looks very carefully at the movement of specific individuals out of, into and between specific coverages, we won’t know the real impact of the reform law and other factors impinging upon the health care coverage marketplace. But early indications are that the exchanges have had a very minor impact on reducing the number of uninsured, in fact when the impacts on the prior individual market are considered, it is essentially nonexistent. The Medicaid expansion has added a fairly large net number of newly insured. But the Rand report indicates that the largest force reducing the uninsured population is likely the recovery from the recession which has added to payrolls and given employer-based coverage to a large number of employees and dependents, and the individual mandate, which may have incented employees who had not enrolled in a health plan available through their employer, to do so.