Image source: White House on Flickr.

It may be hard to believe, but a third year of open enrollment under the Affordable Care Act, commonly known as Obamacare, is officially over.

The Centers for Medicare and Medicaid Services released its final snapshot for the 13 weeks of open enrollment on Thursday, Feb. 4. The results, which included approximately 3.1 million enrollees from the one dozen states operating their own exchanges, showed that about 12.7 million people had selected plans in 2016. By comparison, some 11.4 million people had selected plans by the end of the enrollment period in 2015, and the Congressional Budget Office forecast just 10 million paying enrollees by the end of 2016. Considering that insurer-initiated cancellations are already factored into this year's 12.7 million figure, it's looking likely that the CBO's conservative estimate will prove low.

As expected, some states performed very well, such as California, which netted close to 1.6 million enrollees (and we're still waiting for a final number that accounts for overtime enrollees), Florida, which tallied more than 1.7 million enrollees, and Texas, with a hair over 1.3 million enrollees.

Three states where Obamacare enrollment grew the most
While these were impressive numbers, it was the percentage gains in select states that really stood out. More than four out of five states saw enrollment rise in 2016 on a year-over-year basis, while three states saw enrollment rise by anywhere from 34% to 43% from the previous year. Best of all, in some instances the number of enrollees still hasn't been finalized, so these figures could rise even more. 

Let's briefly take a look at the states where Obamacare enrollment grew the quickest in 2016, as well as note the one state of these three that's a genuine surprise.

Boston, Massachusetts. Image source: Pixabay.

Massachusetts: +34%
Ultimately, Massachusetts might wind up demonstrating the best year-over-year growth of any state, but for now it sits in third with an improvement of 34%. But here's the catch with Massachusetts' state enrollment figures: we haven't received an update since the end of December. In other words, we have a full month's worth of enrollment still to be accounted for.

Through the end of December 2015, Massachusetts Health Connector had enrolled 189,700 people. The goal for the entire three-month enrollment period was just 190,000, so the state looked to be well on its way to surpassing that.

Why is Massachusetts suddenly succeeding? A lot of it has to do with putting technical glitches in the rearview mirror. Prior to the launch of ACA, Massachusetts ran its own private health insurance platform which was somewhat similar to Obamacare. When the ACA became the law of the land, Massachusetts struggled to align its program with Obamacare, causing numerous enrollment and reenrollment glitches. However, following $285 million in investments into the exchange, those problems appear to be in the past.

Massachusetts has also done a good job of limiting the number of plans offered within its state. Whereas Obamacare is designed to promote competition, Massachusetts' regulators actively negotiate with insurers on price and only allow a certain number of plans on the exchanges each year. The number of plans in 2016 was about 35% fewer than in 2015, for instance, because regulators felt there was too much confusion being created by essentially overlapping plans in 2015.

Regardless of how you look at it, Massachusetts' 3% uninsured rate suggests its efforts have worked.

Baltimore, Maryland. Image source: Pixabay.

Maryland: +37%
The state of Maryland was a true shining star in terms of enrollment performance in 2016. According to data released by Maryland Health Connection, total qualified health plan selections hit 165,123, including more than 49,000 new enrollees. By comparison, just 120,145 Maryland residents enrolled in 2015.

It would appear that some minor approach changes seem to have paid off in a big way for Maryland in 2016. As reported by The Baltimore Sun in November, state regulators focused on website improvements, simplicity, and easier access to information as their formula for success. For example, the Maryland Health Connection website was redesigned prior to the Nov. 1, 2015 start of open enrollment to include icons that helped explain terms that may have confused consumers in prior years.

Additionally, focus groups noted that they would prefer more in-person help. Despite pushing things toward a self-sustaining online marketplace, the key in Maryland wound up being that personal touch. Events set up in storefronts, libraries, and churches served as a starting point to get Maryland residents enrolled. These events helped walk residents through the process, but also explained terms that consumers may not have been familiar with.

Finally, Maryland regulators worked to alert those individuals who may qualify for financial assistance and weren't already aware of it. A whopping nine out of 10 enrollees received some form of financial subsidy in 2015, but Maryland regulators still pointed out that there were people left who were unaware of the aid they could be receiving.

Like that of Massachusetts, Maryland's plan of action seems to have succeeded.

Minneapolis, Minnesota. Image source: Pixabay.

Minnesota: +43%
Remember that surprise I mentioned? Here it is: Minnesota wound up enrolling 85,390 people via MNsure, a 43% increase over the 59,704 people enrolled via MNsure in 2015. Furthermore, Minnesota led the nation with 45% of its enrollees being new to the system, per its own admission.

Why is Minnesota's success so surprising? A recent analysis conducted by Freedom Partners found that the average premium increase in 2016 was higher in Minnesota (up 47.7%) than in any other state in the country. In all fairness, Minnesota's premiums for calendar year 2014 were the lowest in the nation, so seeing them rise closer to the national average over the past two enrollment periods isn't all too surprising. However, seeing this increase coincide in the year when Minnesota led the nation in enrollment percentage growth on a year-over-year basis is really shocking.

How'd Minnesota do it? MNsure attributes its success to its nearly 2,000 navigators and assistors for setting up more than 2,000 enrollment events across the state. These events worked to educate consumers, and, more importantly, made a specific effort to get those who could qualify for financial assistance enrolled. This financial assistance was key with rates rising at the fastest clip in the nation.

Image source: Flickr user COD Newsroom.

Two big questions for insurers
Although these states performed very well in 2016, and Obamacare enrollment looks as if it'll handily top the CBO's estimates by year's end, there's still no guarantee that Obamacare is itself sustainable.

First we have the elections in November, which will determine who winds up in the oval office. Whereas someone like Hillary Clinton might retain and build upon Obamacare, pretty much any Republican taking office would look to repeal and replace the law as it exists now. It's tough for insurers to look into next year when there's no certainty that a next year really exists for the program.

Secondly, there are still questions of sustainability. UnitedHealth Group (UNH 2.15%), the nation's largest health-benefits provider, expects to lose nearly $1 billion on its individual marketplace plans between 2015 and 2016, and it's threatened to pull its plans from the exchange by as early as 2017. UnitedHealth has cited patients' ease in changing plans and higher insurance usage as reasons why the plans are losing money.

For its part, Anthem, the nation's number two insurer, remains profitable on its individual market plans, but it's noted on occasion that the margins associated with Obamacare plans are lower than expected. If giants like Anthem and UnitedHealth Group are having potential problems adapting to Obamacare, it makes one wonder how sustainable the program is over the long run.

So, while it was a solid year for Obamacare based on plan selections, keep in mind that for insurers it's generally been a struggle.