clock menu more-arrow no yes mobile

Filed under:

This is the best-case scenario for Obamacare enrollment this year

“It is very unlikely that we will hit the same number of enrollees as last year.”

Woman holds up a cast with words "I 'heart' Obamacare" Jewel Samad/Getty
Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

This is the web version of VoxCare, a daily newsletter from Vox on the latest twists and turns in America’s health care debate. Like what you’re reading? Sign up to get VoxCare in your inbox here.

It’s crunch time for Obamacare. Because the Trump administration slashed open enrollment in half this year, the last day for people to sign up for 2018 health coverage is next Friday.

A lot of ink has been spilled trying to assess whether Obamacare is running ahead of or way behind previous years, given the shorter enrollment period and the Trump administration's deliberate sabotage of the health care law.

This seems to be the proper assessment, with one week to go: More Americans are signing up on a daily basis, but, because of the truncated window for sign-ups, 2018 has fallen behind if you look at it as a share of the enrollment period.

This chart from Avalere makes it clear, I think:

The people who are working to sign people up for Obamacare this year are acutely aware of their closing window. Sarah spent some time in Wisconsin recently talking with those folks.

This is what Adam VanSpankeren, the lead health care navigator at Covering Wisconsin, a nonprofit that signs people up for the Affordable Care Act programs, told her:

In Wisconsin, VanSpankeren is energized by the high sign-ups but nervous about the next two weeks. The sign-up period ends on December 15. There isn’t much time left.

“It can be stressful because I worry we won’t be able to do enough,” he says. “If I have stress, it’s because there are people we’re not reaching. When I’m at home in the evenings, I feel like I should be doing more. The window is closing.”

This all got me wondering: What exactly would it take for Obamacare to match last year's sign-ups? I talked to Avalere's Caroline Pearson and we played with the numbers to try to figure it out.

(For simplicity, we're sticking with, which serves nearly 40 states. Some of the dozen state-based marketplaces are having longer enrollment periods, which could help them mitigate any falloff from last year or even expand their enrollment. Charles Gaba at has been tracking both federal and state marketplaces.)

The last update from the Trump administration gave us enrollment numbers through December 2, leaving about two weeks to go until the December 15 deadline. had 3.6 million sign-ups at that point.

Last year, the federal marketplaces had 9.2 million enrollments. So that is a lot of ground to make up.

But there are two big X-factors over the final two weeks, Pearson said:

  1. Auto-enrollment. Current Obamacare enrollees who do not actively select a new plan for 2018 are auto-enrolled into one. Over the last two years, about 1.6 million people have been automatically signed up.
  2. The deadline surge. Every single year, we see sign-ups spike when the deadline comes. The biggest two-week surge, according to Pearson, was in 2016: 3.7 million people signed up before that year's deadline to have coverage starting on Jan. 1.

So let's add those bolded numbers up: 3.6 million + 1.6 million + 3.7 million = 8.9 million. That looks like the best-case scenario at this point.

Pearson and I ended up with some existential questions. For example, could we see even more of a surge this year because of the shorter open enrollment? Or is that 3.7 million the absolute most we can expect for the last two weeks?

"Does the surge itself also surge because of truncation?" Pearson said. "Or is the surge finite?"

Her bet has been that Obamacare enrollment for 2018 will ultimately fall short of the 2017 numbers.

"I think it is very unlikely that we will hit the same number of enrollees as last year," she told me. "I can't see a scenario where I can reasonably say we're gonna get to 9.2 million."

It would require, after all, a record number of sign-ups over two weeks, under an administration that has been actively working to make it harder for people to enroll in Obamacare coverage.

That left me with one more question: How should we interpret these numbers? Let's say we get 8.9 million customers, under the math above, down from 9.2 million.

Is that good or bad, considering Obamacare transitioned from an administration deeply invested in its success to one transparently trying to make it fail?

Pearson said it was a matter of a perspective.

"We expect enrollment to grow every year, not to shrink. This market is likely to shrink," she said. "It is a big deal, for a market that's already too small and unstable."

But on the other hand, she added, "there will still be a market that's mostly the same as last year."

So Trump hasn't killed Obamacare, at least not yet. But he certainly appears to have prevented it from getting any better.

Chart of the Day

Javier Zarracina/Vox

Medicine’s best obesity treatment is also its most misunderstood. Vox's Julia Belluz has a great piece for you on the misunderstood bariatric surgery:

The medical case for bariatric surgery has grown much stronger in recent years. High-quality studies on the long-term health outcomes of people with obesity who got surgery show, on average, that they’re able to lose dramatic amounts of weight, and even reverse their obesity-related health conditions, like diabetes and high cholesterol.

Yet out of the 20 million people who are eligible in the US, fewer than 1 percent get bariatric surgery for weight loss, according to the Obesity Society.

Why? Polling data shows that many Americans still think it’s dangerous and ineffective.

Kliff’s Notes

With research help from Caitlin Davis

Today's top news

Analysis and longer reads

  • “Hospitals are making a fortune on Wall Street”: “Hospitals say they're having trouble staying afloat because insurance programs, namely Medicare and Medicaid, aren't paying them enough. But while their margins on patient care are slim, they've more than made up for it on Wall Street.” —Bob Herman, Axios
  • “Churning, Confusion And Disruption — The Dark Side Of Marketplace Coverage”: “The task of finding new insurance annually often undermines the continuity of care for people with ongoing medical needs or chronic conditions. That challenge is immeasurably harder this year as policies change under the Trump administration, spurring unstable networks and turmoil in many state and local markets.” —Jay Hancock, Kaiser Health News
  • “Hospitals and patients feel the pain from Anthem's ED policy”: “Under the controversial policy, which nabbed plenty of headlines when it was rolled out in some states in mid-2017, Anthem won't cover ED visits for conditions that the insurer decides were not emergent after a review.” —Shelby Livingston, Modern Healthcare

Join the conversation

Are you an Obamacare enrollee interested in what happens next? Join our Facebook community for conversation and updates.

Sign up for the newsletter Sign up for Vox Recommends

Get curated picks of the best Vox journalism to read, watch, and listen to every week, from our editors.