The first open-enrollment period under the Affordable Care Act has, for the most part, ended.
So now what?
Analysts say they have plenty of questions as last-minute stragglers who attest to starting the process before enrollment ended finish the job.
The Obama administration says it is on track to meet the original estimate of 7 million enrollees set by the Congressional Budget Office despite the rocky roll-out of Healthcare.gov, the federal health exchange site.
But questions range from who signed up — if they're young-and-healthy or previously uninsured — to how the new pool of people will affect next year's premiums. As insurers gauge just how involved they want to be in the next round, advocacy groups are figuring out what they can do better to sign up groups that missed the call, such as young Hispanic men. And conservatives will continue to ignore the administration's numbers until the insurers release the numbers of people who have paid their first month's premiums.
"It's very unclear how this nets out," said Edmund Haislmaier, senior research fellow for health policy at the Heritage Foundation, a conservative think tank. "We really don't have anything reliable."
But Ezekiel Emanuel, University of Pennsylvania bio-ethicist and one of the architects of the law, said he said insurers have record membership and record profits because of the Medicaid expansion and the 6 million new private-plan enrollees.
"I don't think they've written a letter to President Obama thanking him yet," he joked.
(President Obama is planning to address the nation at 4:15pm Tuesday regarding the ACA.)
Here's what to watch for in the next couple of weeks:
1. Who signed up, and who paid the first month's premium?
It's impossible to know how much the law has reduced the numbers of the uninsured, Haislmaier said. "We don't know how many people have lost their coverage or how many have picked up replacement coverage or how many were previously uninsured," he said.
Republicans and opponents of the law say 6 million people lost their coverage because their insurers canceled their plans because they didn't meet the law's requirements. The law requires a minimum amount of benefits for all policy holders, such as for prescription medications or hospital stays. Some of the old plans didn't meet those requirements.
The Obama administration and insurance companies say the final number was lower than 500,000, because insurers automatically enrolled people in new plans or worked to keep their customers.
More of an issue may be the demographics of those who signed up. The law has provisions that protect insurers if the pool of policy holders leans toward older and sicker people, who tend to cost more. The composition of the insurance pool will determine future premiums.
Enrollment statistics released by the government last month showed that about 27% of the pool was adults younger than 34, and that percentage had risen in recent weeks.
Sam Nussbaum, chief medical officer at health insurer WellPoint, said he has seen an uptick in young people as the numbers continue to come in, and that 80% appear to be previously uninsured.
States with their own exchanges have reported first-month's premium payment rates of up to 85%.
Geography will matter, said Dan Mendelson, CEO of Avalere Health, a health care consulting firm. Even if nation-wide enrollment meets CBO projections, insurers who banked on states that expected high enrollment — and didn't get it — may end up with high premiums, or out of the exchange market completely, for the next go-round.
For example, California has met its goals with more than 1.2 million people enrolled, but in Mississippi, only 25,000 people had enrolled by the end of February.
Cecilia Muñoz, assistant to the president and director of the Domestic Policy Council, said it's important to remember that premiums increase about 15% every year and to put "in context" any talk about increases because of the exchanges.
"We heard a year ago rumblings about rate hikes and rate shock," she said. "That didn't happen. We're starting to hear that again."
2. Do the states, and the feds, revamp the exchanges?
"Once they shut down enrollment, they'll be able to go in and do aggressive changes," Mendelson said. "I know that the engineers are looking forward to that."
While the federal website performed much better by the end of November, some state sites, including Oregon, Hawaii and Maryland, still face significant problems. All three states have had their directors replaced. Maryland announced this week it was starting over immediately after the deadline and modeling its exchange after Connecticut's.
"Some of those states that are still struggling will decide the course or throw in the towel," Mendelson said. "The third route is to just copy the federal exchange page."
Emanuel said he visited the Connecticut exchange recently, which has been ranked in the No. 1 or 2 spot for ease of use. Insurers were involved in the process from the beginning, he said, and the place "operates like a start-up" because everyone involved can offer up ideas.
"They started late," Emanuel said. "The federal government thought they were a basket case when they started working in 2012."
They outsourced everything from the call center to the technology, but they also tightly managed contractors and cut back on bells and whistles to make sure the basics worked, he said. Next year, there will be a smart phone app and an avatar will appear to answer questions.
"The federal exchange was a disaster — I think everyone agrees to that," Emanuel said. "But several of the state exchanges were successful. That shows that the federal exchange was a management issue, not that the exchange itself was a bad idea."
3. What do the enrollment advocates do now?
"I'm a little worried that there's an idea of 'We're all done now,'" said Kavita Patel, managing director for the Engelberg Center for Health Care Reform. "There are still lots of people who don't have coverage."
Anne Filipic, president of Enroll America, said her organization would continue to do outreach and education because some people, such as those who get married or become unemployed, will be eligible to enroll if they have a major life event.
"But we're also going to do a lot of work to educate people who will be eligible for next year," she said. "We learned a lot from this enrollment, but we'll have a real opportunity to see who did enroll and who didn't."
They will look at what worked and what didn't, and they'll share it with other advocacy organizations, she said.
"From within the administration, we've been as aggressive as we can be, but we've also depended on partners," Muñoz said. She said it's been difficult to break through to some communities, such as Hispanic groups. "People don't have insurance; they don't necessarily know the lingo of co-pays and co-insurance."
4. What's next for the plans?
"The plans are almost immediately going to have to set rates for next year," Mendelson said, adding that he's already hearing about double-digit increases from some insurers before the final enrollment numbers have come in. "It needs to be based on the populations they see."
But Mendelson said the plans should also be figuring out how to get more information about what doctors and medications are included in each plan before next year's enrollment period.
Ceci Connolly, managing director of PWC's Health Research Institute, said the plan managers would be looking at the health status of the new enrollees. Nussbaum said that also appears to be evening out after an initial waive of high users and that success for one company might look very different for another company.
"There are big, national insurance companies thaw saw this as an experimental year," Connolly said, "and there are start-ups that hoped this was going to help them get off the ground in a big way."
5. What do people think of their new healthcare?
Researchers will watch to see if people take advantage of preventive pieces, such as free annual exams, that were built into the law to try to cut down on costs; whether they will learn how to shop for prices if they are in high-deductible plans; and whether they will learn to avoid the emergency room in favor of a primary-care doctor's office. But beyond all of that, do people like their insurance?
"I think there will be a lot of people very happy and satisfied with what they have," said Joel Ario, formerly the director of the Office of Health Insurance Exchanges at the Department of Health and Human Services and now a managing director at Manatt Health Solutions."But there may be those who say, 'Nobody told me about the deductible on the bronze plan.' People are going to say the cost-savings measures are too high, particularly around some of the drug plans."
Ario and others who helped create and implement the law said they knew it was a move toward consumers having "more skin in the game," because they will have to weigh the costs and benefits of medical procedures.
"For people who think the ACA takes care of everything for you, you'll find it's more like 20 years ago, where it takes care of the serious things," Ario said. "But they're not going to go bankrupt anymore. It's far better to owe $5,000 in the deductible than have a bill from the hospital saying you owe $100,000 or more."
People will also continue to question the limited networks, he said. Some of the plans keep their costs down by saying consumers may only see certain doctors, or else pay more, and consumers need to understand that better both while shopping for plans and while seeking treatment.
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