Only 106000 Pick Health Insurance Plans in First Month

WASHINGTON - Just over 106,000 people picked health plans in the first month of open enrollment through the state and federal insurance marketplaces established by the Affordable Care Act, President Obama's health secretary said Wednesday, a fraction of the administration's initial estimate for enrollment during that period.

Only about a fourth of the new enrollees - 26,794 - signed up through the problem-plagued federal exchange, HealthCare.gov, according to figures released by the Centers for Medicare and Medicaid Services. A much larger number, 76,319, signed up through the 14 state-run marketplaces.

The long-awaited figures, released by Kathleen Sebelius, the secretary of health and human services, became instant fodder for the continuing political battle over Mr. Obama's signature legislative initiative. As nervous Democrats on Capitol Hill threatened to introduce legislation altering the law, Republicans called the new numbers dismal and embarrassing and cited them as further proof that the program was a 'train wreck.'

The White House has spent weeks trying to lower expectations about the numbers - even as questions emerged about the way it counts who is enrolled. On Wednesday, Ms. Sebelius and congressional Democrats were upbeat, saying people were clearly shopping for coverage.

'The marketplace is working,' Ms. Sebelius said. 'People are enrolling.'

The nonpartisan Congressional Budget Office has predicted seven million people will enroll by the time the initial six-month sign-up window, and administration officials insist they can meet that goal. But the numbers released Wednesday fall far short of the administration's early projections, contained in an internal memo in September, which said 464,920 would sign up in the first month.

In a method that Senator Mitch McConnell, the Republican leader, called 'Enron-like accounting,' the administration defines enrollees as those who have 'selected a marketplace plan.'

They are people like Hung Trang, 60, a nail salon owner in Tampa, Fla., who has been trying for weeks to sign up. With help from a counselor, called a 'navigator,' he has picked a plan for himself and family, but has not yet committed to buy it.

The industry, though, says people like Mr. Trang do not count until they have agreed to pay.

'Paying the first month's premium is what needs to happen before coverage actually begins,' said Robert Zirkelbach, a spokesman for America's Health Insurance Plans, the industry trade association. 'Until a consumer makes their first-month premium, they can make a different coverage decision - including whether they want to buy coverage or not.'

A total of 106,185 consumers went through the enrollment process and picked plans, the administration said. Many more people - 846,184 - applied in the state and federal marketplaces without adding plans to their shopping carts for purchase. Those applications would cover a total of 1,509,883 Americans.

A peek into state data reveals vast disparities. Florida, the state with the second-highest number of uninsured (behind Texas), had the most enrollees in the federal-run exchange, 3,571. Texas was second, with 2,991. There were just 42 in North Dakota.

In explaining the relatively low figures, administration officials cite problems with the federal website that have prevented people from signing up. But they also say experience shows people wait until the last minute.

When Massachusetts expanded health coverage in 2007, only 123 of the 36,167 people who ultimately signed up did so during the first month of enrollment. But more than 7,000 signed up in the final month. (Massachusetts counted only people who had already paid their premiums as enrollees, according to Jon Kingsdale, who ran that state's health insurance exchange for the first four years.)

There is still one month to go until the Dec. 15 deadline for signing up for coverage that begins Jan. 1; the initial enrollment period does not close until March 31. So administration officials, and some outside experts, say these early figures do not reveal much.

'These numbers are interesting,' David Simas, a top White House adviser on health care, said in an interview, 'but in terms of any kind of insight into the success of the program, they're not the central indicator.'

In political terms, though, the numbers are yet another problem for the White House, which is one reason Ms. Sebelius - and not the president - announced them. Republicans insist that, at this rate, there is no way the administration can reach its goal.

'By the time we reach the critical month of December, actual enrollment could lag projections by over one million people,' Representative Dave Camp, Republican of Michigan and chairman of the House Ways and Means Committee, wrote in a letter this month, accompanying a subpoena for detailed enrollment data.

In an interview, he said enrollment figures were only a part of the story. 'It's not just about the top-line number,' he said. 'What I want to know is the mix of these people. What kind of insurance are they getting? What age are they?'

Ms. Sebelius said Wednesday that her agency would release that kind of data at some point; she did not say when. But experts on all sides of the debate agree that the 'mix' may be far more important than the actual enrollment numbers. If not enough young, healthy people enroll, premiums will skyrocket, and the law's promise of 'affordable care' will not be realized.

'The mix is valuable for insurers, because it will result in more stable premiums; if all the people who enroll are very sick, they will have to raise premiums next year, and that is a problem,' said Dan Mendelson, who was a health policy adviser to President Bill Clinton and is now chief executive of Avalere Health, a consulting firm.

'But,' Mr. Mendelson said, 'the numbers are important; enrollment is important. I do think this administration is going to be benchmarked on how much enrollment materializes.'

Mr. Mendelson's firm recently looked at 12 of the 14 state exchanges and found a far lower rate of enrollment than for other programs, including the expansion of prescription drug coverage under Medicare under President George W. Bush. He said problems with the federal website had created a 'negative communications climate' that was depressing enrollment.

'Their problem is more than technology,' he said, referring to the administration. 'It's that because of technology, they can't be beating the drum, and they can't be sending the president out to advocate for enrollment.'

If Massachusetts is any guide, signing up people is difficult even under the best of circumstances, Mr. Kingsdale said. In the first three months of operation, he said, the state found that for each 100 hits on its website, 44 were 'unique hits' from Massachusetts residents. Of those, 18 shopped for plans, and one bought coverage.

Sheryl Gay Stolberg reported from Washington, and Susanne Craig from New York.