One More Post re. the "OMG!! 5M CANCELLED!!" talking point

Yesterday, in response to a partially-reasonable, partially-not critique, I added something to The Graph: A prominent note that no, neither the spreadsheet nor the graph take into account the estimated 4.8 million non-compliant policies which were cancelled last fall (my own included). I concluded my response with the following:

However, you've [the commentor] chosen to completely ignore the single largest missing piece of the puzzle here, which I've discussed many, many times: OFF-EXCHANGE QHP ENROLLMENTS.

I've documented nearly 560,000 of these, and that's from only 2 states (Washington and Wisconsin), plus a half-dozen other companies...out of the 200+ companies throughout the country. Even the WA and WI data for off-exchange enrollments are still out of date, since they only include through the end of January. My guess is that there are easily 4 million or more of these out there (in Washington State, as of the end of January there were about 84,000 exchange-based QHPs and 184,000 OFF-exchange QHPs since October...or 69% of the total! In Wisconsin the numbers were closer to what you'd expect: about 50,000 exchange-based and another 7,900 off-exchange, or around 14% of the total).

So, you're absolutely correct that both unpaid enrollments and previously insured enrollments probably should be subtracted from the total.

HOWEVER, if you're going to do so, you also have to ADD the total number of off-exchange enrollments, SHOP enrollments and Medicaid/CHIP enrollments first.

If you can provide me with the total number of outstanding off-exchange QHP enrollments from the remaining 47 states (Vermont, along with DC, requires all enrollments to be done via their exchanges), then I'll be happy to subtract the 4.8 million canceled policies (which includes my own) from the combined total, and will even subtract the Medicaid "bulk transfers" from the total as well, to get a true picture of people now covered by ACA-compliant policies or Medicaid who were previously uninsured.

My guess is that this would look like the following:

Current: 15.6 Million
ADD at least 4 million more off-exchange enrollments
SUBTRACT about 4.8 million canceled policies
SUBTRACT about 1.5 million "bulk Medicaid transfers"
SUBTRACT about 550 thousand unpaid enrollments

= NET gain of around 12.75 million newly-insured people.

However, until you (or someone) can provide that missing off-exchange QHP data, I'm not going to do so. Instead, I clearly and transparently list all of the possible numbers involved, including fully-linked sources and my rationale explanations for each.

Well, I forgot about one more thing: Not all of those 4.8 million "cancelled" policies were actually cancelled.

Another commentor, danslabyrinth, reminded me that thanks to President Obama and HHS announcing their "grandfathering" policy which extended the deadline for existing non-compliant plans by a year (and, more recently, by another two years, to as far out as the end of 2016), this 4.8 million figure has already been vastly reduced. By how much?

Well, according to this article about the additional 2-year extension, 1.5 million people never had their policies cancelled after all (or at least, they had them reinstated after originally being cancelled, anyway):

It's not clear how many people will actually be affected by the most closely watched provision of the new regulations, the two-year extension on policies that were previously subject to cancellation. The administration cites a congressional estimate of 1.5 million, counting individual plans and small business policies.

About half the states have allowed insurance companies to extend canceled policies for a year under the original White House reprieve. The policies usually provided less financial protection and narrower benefits than the coverage required under the law. Nonetheless, the skimpier insurance was acceptable to many consumers because it generally cost less.

"It's not likely to affect a large number of people but it certainly avoids difficult anecdotes about people having their policies canceled," said Larry Levitt of the nonpartisan Kaiser Family Foundation, an expert on insurance markets. "I think it's a small and dwindling number of people who are affected."

Now, that 1.5 million figure isn't given as solid...but then again, neither is the 5 million figure (I've heard the number claimed being as low as 4.7 million or as high as 6 million, but the 6M sources are, to put it mildly, a bit shakey to say the least).

UPDATE: Thanks to Tim Dickinson for pointing me towards the source of the "1.5 Million UNcancelled Policies" estimate...which is actually the same updated CBO report which lowered the exchange QHP estimate from 7M to 6M:

In November 2013, the Administration announced that state insurance commissioners could give health insurers the option of allowing individuals and small businesses to re-enroll in coverage that did not comply with certain market and benefit rules, such as the prohibition against adjusting premiums based on health status, that were scheduled to take effect in January 2014. CBO and JCT estimate that, as a result, roughly 11⁄2 million people in the individual and small-group markets will renew policies in 2014 that are not compliant with those rules. In addition, because subscribers may renew such coverage between January and October of 2014, CBO and JCT estimate that half a million people will continue to be enrolled in noncompliant policies in 2015. 

So, here's what I'm willing to do: Since 5M is the most-cited figure, I'm willing to use that. And since 1.5 million appears to be the maximum number that have taken the administration up on their extension offer, I'm even willing to knock a couple hundred thousand off of that in the interests of being, shall we say, "conservative".

This means that we can subtract 1.3 million from 5 million, leaving 3.7 million people who genuinely had to replace their existing non-compliant health insurance policy with a fully-compliant one...via either the ACA Exchanges or off-exchange, directly through the insurance companies.

And as I explained yesterday, until I know how many of those 3.7 million replaced their policy off-exchange instead of on the exchanges, I have no way of knowing how many to "subtract" from the graph and therefore can't do so.