Millions of newly insured people are hiding in plain sight.
They are the people who have bought new health insurance since the start of this year but have chosen for one reason or another to bypass the state and federal exchanges that opened last year under the Affordable Care Act. While the exact number is unknown, some health care experts estimate that it may be in the millions.
Politicians and policy makers have focused on the number of people who signed up through the exchanges — at nearly seven million and counting a day after the March 31 deadline — but they have largely overlooked the group that did not use the exchanges, even though it could have a major impact on the program's financial success in the years ahead.
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Because insurers place customers in the same risk pool, regardless of how they enrolled, "these lives count every bit as much as the ones that came in through the exchange," said Gary Claxton, a vice president and health care expert at the Henry J. Kaiser Family Foundation.
Helen Ferguson is one of those people. Ms. Ferguson, a psychologist in Fort Worth, began her search for health insurance last fall, creating an account on the federal marketplace to shop for coverage. But when it came time to select a plan, Ms. Ferguson worried that the malfunctioning website would prevent her from signing up.
So instead, she en rolled directly through Blue Cross and Blue Shield of Texas, selecting a plan that was also offered in the marketplace.
"I needed the insurance so much that I just didn't want to take a chance," said Ms. Ferguson, 63, who had been uninsured since last May. She obtained health insurance just in time. On Jan. 3, two days after her coverage took effect, she fell and fractured her foot. "I think people forget that the law is not a website — the law is so much bigger than that," she said.
All individual health insurance plans offered after Jan. 1 must adhere to several new requirements, regardless of whether they are bought through the marketplaces. Insurers must offer more comprehensive coverage and charge healthy and sick people the same rates. And the y can no longer turn people away if they have existing medical conditions.
It makes little difference to insurers how the new customers arrive at their door: What matters most is that they get there. Insurers must bring in enough new customers, including a significant number of healthy ones, to offset the higher costs of complying with the law.
Aaron Billger, a spokesman for Highmark, an insurer that offers plans in Delaware, Pennsylvania and West Virginia, said about 30 percent of the approximately 133,000 members that Highmark had enrolled as of mid-March had signed up outside the marketplaces. The large insurer WellPoint, which has said it expects to enroll about one million customers nationwide in new plans, has reported that about 20 percent of its sign-up s have occurred off the exchanges.
Although little is officially known about the people who are signing up outside the marketplaces, health care experts said that the customers were likely to be wealthier, because those who qualify for tax-credit subsidies must use the exchanges. Many may also have been people whose plans were terminated at the end of last year and who signed up for new plans through their existing insurer. People who are in grandfathered plans, or who were permitted to extend noncompliant plans for an additional year, do not enter the same risk pool as those buying newly compliant plans.
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Mr. Billger said Highmark's analysis of the customers who signed up outside the marketplace showed that they tended to be older than those who enrolled through the marketplaces. Although older people tend to need more medical care, "it's too early to speculate on whether it's a good risk pool or not because we don't have any claims on them yet," he said.
Ana Gupte, an analyst who covers the health insurance indus try for Leerink Partners, also said she believed that those who had bought plans outside the marketplace might be older, and therefore less healthy, than those who were officially counted as signing up through the exchanges.
But whether that could be bad news for insurers, she said, will be based on what the insurers expected when they set premium prices for this year.
So far, Ms. Gupte said, big insurers like WellPoint have said that their expectations are being met, "and that's what matters at the end of the day."
As the sign-up deadline approached, Ms. Ferguson said she was amused at the not-so-subtle reminders she had been receiving from th e federal health care website.
"I'm getting emails from the marketplace, saying you haven't enrolled," she said. "And I'm like, yeah, I enrolled. It's O.K."
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