"Continuing to build enrollment is job number one," said Joel Ario, a managing director at Manatt Health Care Solutions and a former Pennsylvania insurance commissioner. "I'm not sure we're going to get to the 7 million (estimated by the government) but we need to get substantially beyond" the 2.1 million now insured under ACA.
Reaching a sustainable number means adding more than 50,000 people a day, Ario said. That means the number of enrollees each month for January, February and March must match December's total.
"And there still will have to be a big push in March," he said.
The focal point of the push will be young people. According to the numbers released by the Department of Health and Human Services last week, only 24 percent of 18- to 34-year-olds have jumped into the risk pool. That's 14 percentage points below the administration's original estimate.
That wasn't a surprise. Officials and insurers said from the get-go that older, sicker people would dominate the marketplace after it opened on October 1st. Also, if Massachusetts' experience with a similar program is any indication, young people would tend to wait until the end before joining.
"What we saw in the first quarter are people who understand the value of insurance, who have insurance, or who may be replacing an existing plan," said Paula Sunshine, Independence Blue Cross' vice president for consumer affairs. "We will continue to see demand all the way up to March 31st. But it will be a different part of the population. It will be people who may not have had coverage but will be accessing coverage for the first time."
If ACA clears the numbers hurdle, expect to start hearing about other issues, such as will 2015 premium rates rise and is the Affordable Care Act living up its name?
Premium rates are locked in for the rest of this year. But next year's rates will rely in part on the size and breadth of this year's enrollment.
"If the risk pool ends up not nearly as good as the actuaries predicted, then 2015 premiums will be higher," said Joel Cantor, director of the Center for State Health Policy at Rutgers University. So "there is a risk of a premium bump in 2015 raising more affordability problems."
Even with most people receiving a government subsidy to buy health insurance, gold and platinum plans are still out of reach for most. Two-thirds of the plans chosen are in the silver tier. But some of those plans contain cost-sharing and coinsurance that raise the affordability issue.
Cost-sharing was included, Ario said, to give consumers "skin in the game" and make people sensitive to price.
The question is, when does the cost of skin in the game become too much?
The new plans also have new, tighter hospital and doctor networks, which insurers included to keep prices down, promote competition, and improve the quality of care. But that too raises questions: will patients accept the networks?
Cantor said the law, for all its complexities and controversy, is delivering what it promised - so far.
"There are going to be tens of thousands, hundreds of thousands of people who are getting coverage for whom it was out of reach before the reform," Cantor said. "People of modest means are eligible for government help in buying private insurance. That was the plan. And that is happening."
For more information:
Resources for Human Development 855-668-9536
The Health Federation of Philadelphia 215-567-8001
Mental Health Association of Southeastern Pennsylvania 267-507-3894
Center for Family Services 1-877-9ACCESS (1-877-922-2377)
Robert Calandra can be reached at 215-836-0101 or R.Calandra@comcast.net.
This article was produced in partnership with Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health-policy research and communication organization not affiliated with Kaiser Permanente.