What do we know about Obamacare's enrollees?

Based on Obamacare's year 1 enrollment numbers, the law has been very successful in bringing down the numbers and percentages of people without health insurance. But these data also show why it struggles to win support among the broader public.

The Affordable Care Act, a.k.a. Obamacare, will officially turn 5 at the end of March (measured from the date it was signed into law). But when it comes to the law's most important provisions to expand coverage, the ACA is just a year old, since its premium subsidies, health insurance marketplaces/exchanges, Medicaid expansion, mandated benefits, individual insurance requirement, and ban on discriminating against people with preexisting conditions only became effective on Jan. 1, 2014. Until recently, we knew little about who actually signed up in the first enrollment year.

Now, based on a large set of data from Enroll America (the non-profit group that is coordinating efforts to sign people up) and the Civis Analytics firm, we know much more about the characteristics of those who enrolled, according to the New York Times:

  • About 10 million previously uninsured persons signed up for Obamacare coverage, and the national uninsured rate fell to 11% from 16%.
  • Whether a state expanded Medicaid is the single greatest indicator of how much its uninsured rate fell. The uninsured rate dropped from 14.9% to 9.2% in states that expanded Medicaid, compared to a drop from 18.2% to 13.8% in states that did not.
  • Although blacks and Hispanics started with—and continue to have—higher uninsured rates than whites and Asians, they also showed larger gains. The uninsured rate for Hispanics nationwide dropped from 26.2% to 16.5%. For blacks, it was a drop from 24.1% to 16.1%; for whites, 14.1% to 10%, and for Asians, 13.6% to 9.7%.
  • Younger people showed the largest reductions in being uninsured of any age group, with their uninsured rate falling to 14.2% from 21.6%. (This doesn't count the young adults under age 26 who stayed on their parents' plans.) These younger adults saw a 7.4% reduction in being uninsured compared to 5.2% for people ages 35 to 44, 4.4% for persons ages 45 to 54, and 3.6% for ages 55 to 64. The higher rate of enrollment by young people is particularly important to ensuring the ACA's overall success, because they are needed to help offset the higher costs of insuring older and sicker people.
  • The poorest 20% of neighborhoods saw the greatest reductions in persons being uninsured, falling from 26.4% to 17.5%. By comparison, the richest 20% of neighborhoods saw their uninsured rate drop from 13.4% to 9.4%.
  • The coverage gains were higher in rural areas than in urban ones, and more women signed up for coverage than men.

Perhaps the most counterintuitive finding is that the uninsured rate dropped more in counties that are solidly Republican (according to 2012 election results) than in solidly Democratic ones. The New York Times explains that many of the more liberal-leaning states already made insurance more available to their residents, leaving less room to improve, and many of the poorest people who gained coverage from the ACA live in states that tend to vote Republican.

But do the people who signed up for Obamacare like their coverage? The Gallup organization says yes. Politico reported in November that a Gallup survey of a representative sample of people who signed up for ACA marketplace coverage found that 71% said their coverage is “good or excellent,” 19% said it was “fair,” and only 9% said it was “poor.” Seventy-five percent of newly insured in the exchanges are satisfied with the cost of care compared to the 61% of all insured persons nationwide who said they are satisfied with their costs.

Based on Obamacare's year 1 enrollment numbers, then, we can now say with a high degree of confidence that the law has been very successful (so far) in bringing down the numbers and percentages of people without health insurance—the law's main purpose, after all, and the principal reason that ACP supports it. Lower-income people, Hispanics, African-Americans, and rural people benefited the most, no real surprise, because they started with higher rates of being uninsured, and the ACA's subsidies and Medicaid expansion (in the states that have agreed to it) are directed mostly at helping uninsured people afford coverage. And despite concerns about high-deductible plans and narrow networks, most Obamacare enrollees like their coverage and are satisfied with the cost of care.

But these data also show why Obamacare still struggles to win support among the broader public, and especially among certain parts of the population that may not see much benefit. If you are older and wealthier, live in a metropolitan area, and are white or Asian, you were less likely to be uninsured in the first place and less likely to see the direct benefits of a decline in the uninsured rate that disproportionately benefits other people. This would be especially true if you are paying higher taxes or premiums yourself to help pay for their coverage. And you are less likely to know someone who was uninsured and benefited from the law. (This, of course, is a generalization. There are many people who are well-off and insured themselves, in 1 of the categories of people who generally are less likely to directly benefit from ACA coverage, who strongly support the law's goals. And there are many less well-off people, in the categories of people who are more likely to benefit, who oppose Obamacare.)

The ACA's first-year enrollment numbers, like historical stock market returns that are not guarantees of future success, do not tell us how many more people will enroll this year, how many who enrolled in 2014 will renew, or the characteristics of those who will sign up. It is reasonable to assume that the greatest coverage gains will continue to be in the subgroups that are most likely to be uninsured because they are poor and live in a state that has not made coverage generally available, with the greatest gains being in poorer states that expand Medicaid. Even so, the question remains: Will we get to the point where the general public, including insured persons who do not see as direct a benefit to them, support the ACA because it extends coverage to those most in need of it?