The exchanges set up by the health reform law have rebounded, largely thanks to the efforts of UnitedHealth Group’s Optum Insights unit, which has made using the federal exchange websites much easier.  A number of state exchanges are still struggling.   (WSJ Article)  Enrollment, the Administration claims, is over 4 million, but the reality is many of those people have not actually paid for coverage yet.  The actual number is probably 3.5 million at most.  This is far below the Administration’s and the Congressional Budget Office’s projections.   Another reality is that younger, healthier people are not enrolling in the numbers needed to create a sound actuarial pool for participating insurers.  UnitedHealth, the savior of the federal exchange functionality, also looks pretty smart for not participating as a plan on those exchanges.  And it has become apparent that the administration has eviscerated its own individual mandate through a broad and ambiguous “hardship” definition and other loopholes.  Young people are smart and word gets around quickly in the age of social media, so don’t expect them to feel pressured to sign up.  Many of the people who did sign up will get subsidies and Medicaid enrollment has boomed, so the federal and ultimately the states’ deficits will also be growing more rapidly.  It is not an exaggeration to describe reform, as many predicted, as a disaster, a very expensive disaster which has upended many lives.  And the worst may be yet to come when the plans offered on the exchanges have to set premiums for the second year of coverage.  And of course, we still don’t have the employer mandate in place.