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Recent news of 600,000 sign ups into the federal health exchange in the first week provides a small glimmer of hope for the ACA. Nothing more motivating then scarcity — think Black Friday for health insurance. However, the effort to maintain or grow enrollment for 2018 is unlikely, especially when the enrollment period has been cut in half, enrollers have been eliminated and HealthCare.gov is down on Sundays. Despite the focus on the post-election state of affairs, the real story regarding the uninsured population is not what has happened over the last year, but what has occurred over the last two enrollment cycles. Since 2015, we have not seen a significant reduction in the number of uninsured individuals across the U.S. and that number has held steady at around 10 percent of the population.  

The underlying premise is we need an infusion of healthy uninsured individuals to spread the risk and sustain cost. And, the goal of the ACA was to mostly eliminate our uninsured population, so this 10 percent remains a thorn in the side of the legislation.  Why has this elusive group of uninsured not selected a plan on the federal exchange? And why do they choose not to, despite being required to pay penalties (2.5 percent or $695 per individual and up to $2,085 for a family)? 

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