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The JAMA Forum
November 12, 2014

A To-Do List for the New CEO of the Federal Health Insurance Marketplace

Author Affiliations
  • 1Senior Vice President for Special Initiatives at the Kaiser Family Foundation and Senior Advisor to the President of the Foundation.

Copyright 2014 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA. 2014;312(18):1847-1848. doi:10.1001/jama.2014.14527

Recently, the Obama Administration announced the appointment of a new chief executive officer (CEO) for the federal health insurance marketplace under the Affordable Care Act (ACA). Kevin Counihan—who headed up Connecticut’s health insurance exchange, which worked quite well—will fill the newly created position.

Larry Levitt, MPP

Calling this position a CEO represents semantic gymnastics of a sort. That’s because CEOs generally have near-total autonomy to manage an organization, reporting only to a board of directors. Nothing like that really exists in government, short of the president. In this case, the new CEO reports to the administrator of the Centers for Medicare and Medicaid Services, so he is firmly ensconced in the normal federal agency bureaucracy. That may be a positive, because it respects the traditional lines of authority and accountability that help the government function.

But there is a sense in which the CEO title sends an important signal: there is now one person who goes to sleep every night and gets up every morning thinking about how to make the health insurance marketplaces work well. That was not the case in the first year of full implementation of the ACA, which likely contributed to the website meltdown and generally rocky start.

This new position, in fact, goes well beyond simply making function (although that, in itself, is a tough and important job). The new CEO will oversee all aspects of the federal marketplace, including the technology, application and enrollment process, and outreach and assistance to consumers. He will also oversee the states running their own exchanges—some of which worked well, others of which did not—and regulation of the insurance market. These are all pieces of a whole in making the ACA work, so it’s appropriate to have someone with the full playing field in his view.

The new CEO’s to-do list will no doubt fill up quickly, and he won’t have complete control over it as unforeseen developments intervene. But here are few items that will hopefully be on the priority list to get done by the next open enrollment period, which starts November 15:

  1. Make sure the lights turn on. It would create enormous perception problems if there are technical glitches during open enrollment like those that plagued the program last fall, not to mention leaving consumers in the lurch. The top priority should be making sure that the website functions. That is even more important this year, because open enrollment runs for only 3 months (rather than the 6 months during the first year). There’s little margin for error.

  2. Focus on getting people enrolled. More than 8 million people signed up for plans in the new marketplaces by the end of the open enrollment period this year (although the actual number of enrollees is likely slightly less than that because not everyone paid their first month’s premium). The Congressional Budget Office (CBO) projects that enrollment will ramp up to 13 million in 2015. Although the CBO develops projections for budgetary purposes, its enrollment figure will no doubt be treated as a target for next year, as was the case this year. Getting that many people enrolled will be a challenge. It means retaining as many current enrollees as possible. The federal government has sought to foster retention through an automatic renewal process (though that will require careful communication because many people will be better off shopping around rather than sticking with their current plan). Ramping up enrollment also means signing up millions of new people. In some ways, signing up new people gets more difficult, because those who have not yet purchased insurance are by definition the harder-to-reach. One thing that will help push enrollment is the substantial increase in the penalty for not being insured.

  3. Streamline the process for consumers. This year, 2 million enrollees ended up with discrepancies on their applications that have to be reconciled through a lengthy and cumbersome process. Several hundred thousand immigrants have to provide documentation of their legal immigration status by this week or lose their insurance. Helping people navigate the enrollment process could avoid such problems, but it’s not yet clear if as many (let alone more) consumer assistance resources will be available for the next open enrollment period. Improving the call center will also be key, avoiding the long hold times and inconsistent information that sometimes occurred in the first year.

  4. Provide greater transparency around provider networks. There was controversy this year around the emergence of plans with narrower networks of physicians and hospitals. It is appropriate to offer consumers the opportunity to get lower premiums in exchange for a narrower choice of providers, so long as they have assurances that they can access promised benefits and go in with their eyes open. This year, consumers were not always able to easily obtain information about insurers’ networks.

One can hope that this year’s open enrollment season will go more smoothly than last year’s problematic rollout. However, we should not expect perfection.

The ACA is still a very young program, and assuming the law stands—which seems increasingly likely—it will take years to iron out the kinks. And uncertainty abounds about how people will behave as the law enters its second year of full operation. Enrollment will undoubtedly ramp up as the law matures, but we should be careful not to treat the expectation that 13 million people will be covered in the health insurance marketplaces in 2015 as anything other than a good guess at this point.

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Article Information

Corresponding Author: Larry Levitt, MPP (

Published online September 3, 2014, at

Disclaimer: Each entry in The JAMA Forum expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association.

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