“Within a month, only about a hundred people had signed up — a hundred. But then 2,000 had signed up, and then a few more thousand after that. And by the end of the year, 36,000 people had signed up.”
– President Obama, remarks in Boston, Oct. 30, 2013
The president traveled to Boston this week to tout his troubled health-care law, to the very spot where his erstwhile rival, former governor Mitt Romney (R), had signed into law his own universal health-care law with an individual mandate. He cited the experience in Massachusetts to point out that enrollment there started off slowly and increased substantially just before key deadlines.
The administration has not released enrollment numbers, but presumably it is preparing Americans for relatively low numbers at first.
But is this really a case of apples and apples — or apples and oranges?
There are many similarities — and differences — between what are popularly known as Obamacare and Romneycare. In this case, we will focus just on enrollment, not on issues such as the fact that Massachusetts already had a relatively small population of uninsured people.
Under the Affordable Care Act, enrollment for everyone seeking insurance on the exchanges began on Oct. 1, and open enrollment ends on March 31. If a person does not sign up for minimal health coverage by then, he or she may be liable for a “shared responsibility” payment due with tax returns. That will equal 1 percent of annual income or $95 per person in 2014, but will reach 2.5 percent of income or $695 per person by 2016.
The Massachusetts plan, by contrast, had three distinct phases. The first part, which began on Oct. 1, 2006, began automatically enrolling people who were at or below 100 percent of the federal poverty level, or FPL, in a type of Medicaid program. Within a month, 3,659 people had been enrolled, according to state documents.
So what is Obama referring to? He is talking about Phase 2, which began in January 2007. That was the phase for subsidized health care, covering people between 100 percent and 300 percent of FPL (between about $21,000 and $62,000 in income), who had to pay at least part of their premium.
The final phase, which began in May 2007, was for unsubsidized coverage. The deadline for enrollment for everyone was the end of the year, after which point the individual mandate would take effect. But because of the slow rollout, many health-insurance plans for the final phase were not even available in the early part of the year, according to news reports at the time.
Jason Lefferts, a spokesman for the Massachusetts Health Connector, the state agency that helps residents find health-care plans, said that at the end of the first month for enrollment in the subsidized plan, 123 people had signed up, though by Feb. 8 the number was 226, according to meeting minutes that day. After the end of the second month, 2,089 had signed up. By the third month, more than 5,000 people had enrolled, he said.
In other words, Obama is citing just Phase 2 enrollment. Jon Gruber, an MIT economist who advised on both plans, said that was the appropriate place to start, with the first phase “irrelevant to the debate” because these are people automatically transferring to a type of Medicaid program. Some might differ, but we were convinced on this point.
But there is another wrinkle. Before the Romney law, Massachusetts had what was called an Uncompensated Care Pool, which essentially was a system in which hospitals were reimbursed for covering people who had no health insurance. According to a 2006 memo for the Board of the Connector, there were 62,000 people who were in the Uncompensated Care Pool with incomes between 100 and 300 percent of FPL. The memo, noting that because these individuals would have to pay a premium and thus could not be automatically enrolled, said:
“Staff recommends that we notify in January 2007 all of the UCP members between 100 and 300% of FPL that they are eligible for Commonwealth Care, and that we change their system status from ‘UCP’ to ‘Commonwealth Care.’ We would let them know that they can now enroll in Commonwealth Care if they’d like to, but we would not automatically assign them to a health plan, if they do not choose one on their own. Under current UCP rules, until such time as they actually enroll and reach their effective date in a Commonwealth Care plan, they will remain eligible for UCP ‘coverage’ and their providers may continue to bill the UCP.”
In other words, there was not much urgency. People still would be treated for free in emergency rooms, and thus they could take time to evaluate their options. Gruber acknowledged this was a valid point but also noted that Massachusetts had an extensive outreach to these people — notices and phones calls — and yet enrollment still took time to take off.
In the final month of enrollment, about 8,000 people signed up for insurance, nearly one-quarter of the final enrollment.
“Insurance is a tough sale,” said Jon Kingsdale, founding executive director of the Connector in a phone briefing arranged by the White House. “I mean, nobody goes down to their broker on a Saturday morning to smell the leather and test-drive this baby. It’s a grudge buy, and so there’s going to be a lot of browsing.”
Interestingly, as far as we can tell from looking at news clips, there was no coverage of these enrollment figures at the time.
The Pinocchio Test
By citing the 100 figure, the president is highlighting a not very relevant figure.
Even if you ignore Phase 1, the Massachusetts sign-up period was twice as long as the enrollment period for the Affordable Care Act. Moreover, only people receiving premium subsidies could sign up in the first six months, compared to everyone now in the national health plan.
The president would have been on firmer ground if he had said that in the first quarter of the Massachusetts plan enrollment, only about one-sixth of the total enrollees had signed up for the plan. That would have placed the numbers in proper context. But at least he did not mention only the first month’s figure.
We wavered on whether this was worthy of One or Two Pinocchios, but ultimately decided this fit the definition of One: “Some shading of the facts…. Some omissions and exaggerations, but no outright falsehoods.”
Check out our candidate Pinocchio Tracker