Many who initially took advantage of the opportunity to obtain subsidized insurance had pre-existing medical conditions or had been penalized financially by the previous overpriced and underinsured individual insurance market. The millennials who signed up—early estimates pegged the 18-to-34 age demographic as slightly more than a quarter of all new enrollees—were those who responded well to a message that emphasized social insurance works only when everybody is in the pool.
But the first-year results lagged among key demographic groups. Surveys show women, who have greater healthcare needs, represented 54% of those who signed up, even though men represented 55% of the uninsured. The 45-year-old overweight smoker in a low-wage job who doesn't think he needs anyone's help will be far harder to convince—even with an individual penalty—than the college-educated, mountain-hiking invincible who voted for President Barack Obama.
Hispanics, who represented 36% of the uninsured prior to reform, still make up nearly a quarter of the uninsured, according to a July Commonwealth Fund survey. Even in California, which waged a major push to sign up its huge uninsured Latino population (63% of all the uninsured), only 28% of new enrollees were Hispanic. While undocumented residents are not eligible for exchange coverage, the Obama administration's failure to push through immigration reform did not send a positive signal to the broader Latino community about their eligibility for government programs.
On the positive side, the insurance industry has risen to the challenge. HHS Secretary Sylvia Mathews Burwell reported last week that there will be a 25% increase in the number of insurers participating in the exchanges. New Hampshire, for example, which had only one insurer on its exchange last year, will now have five insurers offering plans.
Only California saw reduced insurer participation. But a drop from 12 to 10 carriers on its exchange doesn't suggest disenchantment, but rather that weaker players are dropping out of a very competitive market. UnitedHealthcare, the nation's largest insurer, plans to double its exchange participation in 2015.