Ten years later, the ACA has actually exceeded CBO enrollment projections...just not quite the way it expected to

For ten years now, I've had Google Alerts set up to send me links to stories about the Affordable Care Act using various commonly-used phrases like "health exchanges" and such. Normally these bring up the most recent articles about the law, but last night one of them included a surprising link to a Reuters article from...March 2013:

Washington could wind up running more health exchanges - official

March 14, 2013

...The Obama administration has given 17 of the 50 states conditional approval to set up online exchanges where working families would purchase private plans at subsidized rates. The remaining 33 states will all have federally run markets, at least in the early years of the coming reform era.

But Gary Cohen, who spearheads exchange implementation for the U.S. Department of Health and Human Services, said some of the approved states face hurdles that could require Washington to step in with federal exchanges before open enrollment starts on Oct. 1.

"I'm absolutely confident that every state will have an exchange that will be functioning and ready," said Cohen, who declined to elaborate on the number or identity of states that could be in for difficulties.

Needless to say, "every state" did not, in fact, end up having an exchange that was "functioning and ready" by the time the first Open Enrollment Period (OEP) launched on October 1st, just 6 1/2 months after this story was published. The launch of both Healthcare.Gov (the federal exchange) as well as many of the original state-based exchanges were infamously disastrous, and it would be several years before all of the technical kinks would be worked out.

However, it was the next paragraph which caught my attention:

The exchange initiative is expected to insure 26 million Americans, many of whom currently have no coverage, according to the nonpartisan Congressional Budget Office. A planned expansion of the Medicaid program for the poor is likely to cover another 12 million people.

Both the exchanges and the Medicaid expansion are due to begin providing coverage on Jan. 1, 2014.

This reminded me of the original "7 Million or Bust!" mantra which both Democrats and Republicans alike (as well as the national media) became obsessed with throughout the first OEP. Due to some unfortunate phrasing then-HHS Secretary Kathleen Sebelius used in a radio interview the fall of 2013 to promote the upcoming launch, the entire nation suddenly became fixated on the idea that if the ACA exchanges didn't enroll at least 7 million people in that first crazy period, it meant that the new healthcare law was an abject failure for some reason.

In a nutshell, Sebelius was asked how she would define success, and her response was basically "I see 7 million people signing up for affordable healthcare coverage by March 31st" and this somehow ended up becoming the singular make/break point for whether Obamacare would work or not. Hell, that mystical 7 million figure was even the impetus for me to launch ACA Signups in the first place.

As it happens, in the end, over 7 million people did end up "signing up" that first OEP...in fact it actually totaled just over 8 million by the time the dust settled on April 19th, 2014.

Seeing the Reuters story reminded me of where that 7 million figure came from in the first place: A report which had been released earlier that year by the Congressional Budget Office (CBO) which projected that 7 million people would have effectuated healthcare coverage for the full calendar year of 2014, which would gradually increase to 24 million people by 2023. At the same time, the CBO only expected Medicaid expansion to cover around 9 million Americans in 2014 and that this would gradually increase to only around 13 million people this year.

Had the CBO's projections been accurate, that would have meant roughly 37 million Americans with healthcare coverage directly provided by the ACA.

Instead, of course, the situation is the reverse of this: When the 2024 OEP wraps up in all 50 states at the end of January, the odds are that between 18 - 19 million people will have enrolled in ACA exchange plans (including BHP plans in MN/NY), while Medicaid expansion enrollment will likely be somewhere between 20 - 24 million (depending on where the ongoing Unwinding process stands). Combined, that's 38 - 43 million people, surpassing the CBO's 10-year coverage projection.

In other words, the exchanges have been less successful than originally hoped, but Medicaid expansion has been far more successful. There's a ton of reasons for both of these, but at the end of the day, the ACA is providing more Americans with comprehensive, affordable healthcare coverage than originally expected.

Oh yeah, there's one other tidbit in the 2013 Reuters article:

New Mexico and Idaho, two of the few Republican-led states to move toward establishing their own marketplace, are still awaiting final approval from their respective legislatures.

I had completely forgotten that New Mexico, which had a Republican governor at the time, was originally supposed to move to their own state-based exchange back in 2015 (they didn't end up actually doing so until 2021), but this ended up falling apart due in large part to Gov. Martinez being unnecessarily rude & sarcastic to the Centers for Medicare & Medicaid Services (CMS):

The second phase build out is a 20-month process that was supposed to start in January 2015 and run through September 2017, when New Mexico’s system would be run entirely in-state. There’s even a nifty timeline of all the things to be done:

(Timeline for implementation of NMHIX, fr. NMHIX board presentation, Jan, 2015)

But when the state submitted its application to the federal government for funding, it included letters from state leaders, including Governor Martinez and then-Secretary of Human Services, Sidone Squier.

NMHIX staff told their board in January that the feds specifically cited those letters in their denial.

“Letters attached to the application indicated [the] state was questioning the benefit of the changes that were required,” staff wrote in a January presentation to the board.

...“I am concerned, however,” Governor Martinez wrote, “that New Mexico’s need to apply for this additional grant funding is due to your department’s decision to require changes in our state’s exchange design.” “The amount of funding represented in the application greatly exceeds that necessary to produce our vision for an exchange,” she continued. She went on to blame the federal agency, saying it had “exacerbated” problems by requiring New Mexico follow federal guidelines in building a one-stop-shop system for all New Mexicans.

As the Progress Now NM story continues:

...There is no word from NMHIX where the $122 million that was already granted to build phase 1 was spent and how far off the mark it is from goals set for states.

“Most grantwriters I know will tell you that you don’t start asking for money by criticizing the grantor,” says Patrick Davis of ProgressNowNM. “That’s fundraising 101.”

“The governor and Squier could have taken a page from Chairman Damron’s book,” Davis adds. “He has been an outspoken opponent of Obamacare, but he bit his tongue and said ‘here’s our application, please give us the money.’ Apparently the governor couldn’t do that and that just cost us one hundred million dollars.”

Again, New Mexico did eventually end up moving to their own exchange six years later...under a new Democratic Governor, Michelle Lujan Grisham.