WASHINGTON — In April 2014, President Barack Obama declared victory in the government’s aggressive push to enroll people in private health insurance plans under the Affordable Care Act, announcing that 8 million people had signed up for coverage.
“This thing is working,” he said.
By the end of the year, enrollment was down to 6.3 million, but administration officials confidently predicted a 44 percent increase for 2015.
So it was surprising this week when Sylvia Mathews Burwell, the secretary of health and human services, predicted only slim gains in the coming year, millions below earlier projections. Burwell suggested that a huge campaign with thousands of field workers would be needed to keep enrollment at recent levels.
Why did the Obama administration set such a modest goal? It was part of an elaborate numbers game played for several years by proponents and opponents of the health law.
On the one hand, administration officials want to manage expectations in a presidential election year, when surpassing the goal will be better for Democrats than falling short. In this respect, federal officials are like corporate executives who smooth out earnings to meet or exceed projections given to investors.
On the other hand, health policy experts said, the enrollment goal for 2016 may be realistic. The White House aims to have 10 million people insured through the new marketplaces at the end of 2016, an increase of just 100,000 over the number enrolled in June of this year, and experts said it would not be easy to find and enroll people who have refused to sign up for the past two years.
Stan Dorn, a health lawyer at the Urban Institute, a nonprofit research group, said the enrollment goal was sensible. “I am not optimistic that we will see more than that,” Dorn said. “The easiest people to reach have already signed up.”
Judith Solomon, a vice president at the Center on Budget and Policy Priorities, a liberal-leaning research and advocacy group, said the administration’s target was “realistic but disappointing.”
The tax penalty for people who go without insurance will be higher next year: $695 for each adult or nearly 2.5 percent of household income, whichever is greater. That may encourage some people to enroll, Dorn said, but the cost of insurance is “still an obstacle” for some.
Hillary Clinton is the latest prominent politician to suggest that the Affordable Care Act is not so affordable for some people. A significant number fail to pay their monthly premiums or struggle with high out-of-pocket costs for medical services and prescription drugs.
The cautious calculus by the White House, as the administration gears up for the third open-enrollment period, from Nov. 1 to Jan. 31, tends to confirm perceptions of the health law that have been taking shape in the past two years. The expansion of Medicaid appears to be a more durable source of coverage than private insurance bought through the marketplaces.
Consumers with the lowest incomes receive the largest subsidies in the exchanges, and many have concluded that subsidized insurance is a good value. More than 80 percent of people using the federal exchange have incomes less than 250 percent of the poverty level (less than $29,425 a year for an individual). But marketplace coverage has been less attractive to people with higher incomes who receive less financial assistance.
One of the big questions raised by the new target is whether enrollment is reaching a point where it will remain stable.
“We’re not seeing evidence of having plateaued,” said Richard Frank, an assistant secretary of health and human services. But, he added, “we are seeing a much longer path to long-term equilibrium in the market.”
The Congressional Budget Office predicted in June that enrollment through the exchanges would reach 20 million in 2016 and then level off around 22 million through 2025. The White House accepted the budget office estimate for 2014 as a goal, but now administration officials do their own analysis and projections, and they take issue with the budget office numbers.
If the administration’s prediction disappointed supporters of the health law, it was, in part, because the administration had pumped up expectations with several years of optimistic reports on enrollment trends and market dynamics.