There’s been a lot of noise surrounding the early returns on health exchange signups during the first full open enrollment period of the Trump administration. But the early returns might not be indicative of the health exchange’s new reality.

Enrollment across the 39 states using’s platform has run significantly ahead of 2017, with about 300,000 more signups than in the first two weeks of November 2016. This small sample might point to an uptick, but speaks to a grimmer reality - open enrollment through hits the halfway point in its third week.

Cautious optimism? Not here.

Bear in mind that enrollment ends six weeks earlier than in 2017. In four weeks, closes shop for general enrollment. Several state-run exchanges will keep enrollment going into January and could even see enrollment grow. How that will play out is unclear, since state-run exchanges such as Colorado’s have also seen enrollment up noticeably. In Colorado, 86 percent of the enrollments thus far are renewing coverage. People who have coverage and are concerned about the future of the ACA are probably signing up sooner to lock in 2018 coverage.

Despite the lack of competition in many markets, especially rural counties, everyone has at least one carrier and multiple plan options. In many ways, the exchange markets have come to resemble Medicare Advantage, where large metro areas enjoy a plethora of carrier and plan choices, while rural options are few or none (unlike exchanges, many counties have zero MA plans, as well as all of Alaska).

Some states that moved to could have buyer’s remorse. Nevada, which moved to in 2015 after its own exchange platform was riddled with glitches, will look at migrating back to a fully state-run model.

Bear in mind the second week might not be the best comparison. November 2016’s second week included Donald Trump winning the presidency, and most healthcare policy folks, myself included, predicted a swift demise for the Affordable Care Act, not the slow blood-letting forced by legislative inaction.

Now throw in tax reform, which was not expected to touch on healthcare. The Senate tax bill eliminates the individual mandate and associated penalties for not having coverage. That could send healthy people running for the exits, leaving the exchange market demographics older and sick.

At the moment, too many factors work against exchange enrollment exceeding previous years’. If plans to keep up, just running ahead of 2017 enrollment won’t be enough. The federal marketplace will need to drastically exceed enrollment through the next four weeks. Otherwise, those little gains might still amount to big losses.

Follow Bill Melville @BillMelvilleDRG


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