Donald Trump wants Obamacare to implode. That’s not a mischievous inference from his legislative misadventures; that’s a direct quote. “As I said from the beginning, let ObamaCare implode, then deal. Watch!” he tweeted in July.
It’s thus somewhat surprising that on his watch, enrollment currently seems to be on track for its best year ever. In the first four days, 601,462 people signed up for insurance through the federal marketplace, a significantly faster pace than in earlier years. And almost a quarter of them were new to the exchanges.
This is probably not what you expected. It’s not what I expected. Premiums are rising, insurers are pulling out, and the administration seems somewhat uninterested in encouraging people to enroll, having shortened the open enrollment period and defunded the cost-sharing subsidies for low-income enrollees.
Nonetheless, open enrollment seems to be going swimmingly. Four days of data are not enough to draw definitive conclusions, but I can outline some factors that could be contributing to this unexpected spike in enrollment.
The first possibility is that the very failures in the exchange are, perversely, making it more attractive. Briefly: Premium increases have fallen especially heavily on the “benchmark” plans, the second-lowest-cost Silver plan available on a given exchange. Premiums for Bronze, Gold and Platinum plans have also gone up, but not so much. But because the premium subsidies are calculated based on that benchmark plan, this has the odd side effect of making the other plans more attractive, at least to those eligible for a subsidy. For many of them, the cost of a Gold plan, which covers 80 percent of expected health-care expenses, may actually be cheaper this year than it was last year – not because the cost of the plan fell but because the subsidies rose so much. And many young, healthy people can get a Bronze plan, which covers 60 percent of “actuarial value,” for practically peanuts.
We could also be seeing the Streisand effect. In 2003, singer Barbra Streisand noticed that photographs of her Malibu mansion were available on the internet, but her failed quest to get them removed notified a previously unsuspecting public that they existed. Many, many more people looked at images of that house than would have if she’d kept her mouth shut.
Similarly, the last year of high-profile attempts to repeal Obamacare may have reminded folks that Obamacare exists. That may seem crazy to anyone who follows politics closely, but most people don’t. They may have been too wrapped up in their daily lives to pay much attention to open enrollment but, having seen “Obamacare!” splashed across the news for six months, finally decided to check it out when the exchanges opened for business.
A related theory is the “#Resist” factor. Trump’s opposition has been operating at a high emotional frenzy for almost a full year, flooding social media with ways to undermine the president’s agenda. That includes reminders about open enrollment, which, anecdotally, have been much more prominent in my newsfeed than they had been in earlier years. All those reminders floating around might finally have gotten health care stragglers to log in to Healthcare.gov.
To this we may add a phenomenon known as the endowment effect. Psychologists have noticed that once people have something, they value keeping it more than they valued getting it in the first place. This is demonstrated by experiments in which, for example, people say they would be willing to pay only a modest sum to buy a coffee mug on offer – but demand a much larger amount to sell a coffee mug they have just been given.
The threat to take Obamacare away may have triggered the endowment effect. This would explain why the public’s opinion of the program dramatically improved once Republicans took office and promised to make good on their vow to repeal it. And that “strange new respect” may also have made people more interested in actually signing up.
On the other hand, perhaps they’re afraid that Obamacare will go away next year so they’re making darn sure to sign up and get as many treatments as possible, in case the exchanges die. We’ve seen signs of similar strategic gaming in earlier years: people who signed up, used a lot of services and then canceled their policies, leaving insurers on the hook for bills that were far in excess of any premiums collected. If this is a factor, expect to see that insurers are, once again, losing bunches of money in 2018 and that even fewer of them are willing to come back for the 2019 season, leading to even higher premiums and fewer coverage options next year.
Then there is the most prosaic possibility: Sign-ups have gone up in the first week of enrollment because the enrollment period is shorter this year. Conscious of the looming deadline, people perhaps didn’t want to risk missing the window.
These theories aren’t mutually exclusive, so they all may be playing into the higher enrollment numbers. Around Christmas we’ll have a better idea whether this represents a new high for the exchanges, or just slightly condensed business as usual.
Washington Post/Bloomberg View