How Many Million Will Enroll on Day One?

By Guest Blogger

A report released by the Government Accountability Office (GAO) last month comparing early enrollment in the Pre-Existing Condition Insurance Plan (PCIP) with that of the Children’s Health Insurance Program (CHIP) didn’t make many headlines. But it did offer important insights into what we can expect in the initial open enrollment period for exchanges in 2013, and the Medicaid expansion that will follow close on its heels in 2014.

  • Enrollment takes time to ramp up. Both the PCIP and CHIP suffered from early enrollment numbers that were far below projections from the Congressional Budget Office (CBO). PCIP enrollment was only 27,000 people after its first year of operation (less than 10 percent of CBO’s enrollment projection), and CHIP enrollment was 705,000  people (only about 30 percent of CBO’s enrollment projection; plus, only 31 states had programs up and running by the end of the first year). However, with time, enrollment in both programs has grown and continues to grow as we learn more about the barriers to enrollment and how we can help eligible individuals overcome these barriers.

Enrollment may start slow, but it will likely pick up as word spreads.

  • The past matters. States that already operated high risk pools before the PCIPs were created were able to get their PCIPs up and running more quickly than states that never had a similar program. Having the expertise on program design and the infrastructure to support a high-risk pool made it easier for these states to move quickly to implement their PCIP. Similarly, states that already operated state programs to cover uninsured children who are ineligible for Medicaid before CHIP was created were able to establish CHIP more quickly—and saw higher initial enrollment—than states that had to start from scratch.

States that already have health insurance exchanges, Basic Health Plans, and expanded adult Medicaid eligibility are poised to make early enrollment gains.

  • But demand matters, too. Unlike the CHIP example, states that didn’t have high risk pools actually saw PCIP enrollment increase more quickly than states that did. This could be because there was more pent-up demand for a plan that serves people with pre-existing conditions in those states. Public confusion about the different rules for the state’s high-risk pool and the PCIP might also have had a cooling effect on enrollment in states with both programs.

States with large concentrations of uninsured people can expect big enrollment numbers from the start.

It’s important to continue setting our sights on getting 30 million or more Americans enrolled in coverage starting in 2013, but we’re bound to be disappointed if we expect every last one of them to enroll as soon as open enrollment begins. That said, there are some key things we can start doing ahead of time to help increase the numbers early on.

First, a clear and early outreach campaign that prepares the public for the steps they’ll need to take to enroll and what they can expect out of the application and enrollment process will be absolutely crucial. This is especially important because, unlike the PCIP and most CHIP programs, enrollment won’t be open all the time; there’s a finite window to get people in the door. There were no national outreach campaigns for either PCIP or CHIP when they launched. 

Second, online applications and streamlining the enrollment process will help people enroll more quickly. States like Oklahoma are getting impressive enrollment results from online Medicaid applications that verify eligibility using electronic data-matching. States should be thinking outside the box and taking advantage of new verification rules as they’re designing their eligibility and verification process.

The bottom line? Previous experience suggests that some patience and realistic expectations are in order, but that shouldn’t stop us from putting the pieces together now to ensure strong enrollment from the start in 2013.


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