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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
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With a Bumpier Rollout Than Expected, Better Transparency Needed on Health Insurance Exchanges

As we all now know, the start-up of the federally run insurance exchange websites and the first few weeks that the exchanges have been operating have been extremely bumpy—certainly bumpier than anyone (including me) had been predicting.

Gail Wilensky, PhD

The experience of the District of Columbia and the 14 states that are running their own exchange websites has been mixed but generally better than that of the federal exchanges. Jeffrey Zients, the former senior person for management at the Office of Management and Budget who has been brought on to oversee the Obama Administration’s clean-up efforts, has publicly promised that the federal exchanges will be running smoothly for “most users” by the end of November.

A variety of reasons have been offered as to why the federal exchange website has been so dysfunctional—frequently crashing, sending repeat error messages partway through enrollment sequences, and so on. The administration initially attributed the problems to higher-than-anticipated volumes of users accessing the sites. Unfortunately, volume was, at most, only a contributing factor among many other problems. A statistic reported by Phil Galewitz of Kaiser Health News clearly characterized the early experiences: it took Galewitz 17 days and 63 attempts to enroll.

Avoiding Sticker Shock

The administration’s requirement that individuals create an online account before being able to see the options available to them is widely believed to have been a major factor contributing to the surge in online visitors and to have increased the likelihood of error messages along the way to creating the accounts. The rationale was that by having people enroll and then establishing their income, it would be possible to calculate the subsidy available to each individual and thus prevent potential “sticker shock” from seeing the gross cost of a premium rather than the after-subsidy cost.

In contrast, Medicare and most commercial websites allow people to see the options in their geographic area before they establish accounts or provide detailed personal information. The administration has now provided a way for people to consider plan options before going through the enrollment process, although I have found it is still much harder to access and use than either Medicare or commercial websites.

Other reasons have been cited to explain the problems with the rollout. The government kept making changes to the specifications that the various vendors had to include in their programming, delaying their ability to effectively test the programs. Additionally, the government chose to be its own “general contractor” rather than make one of the vendors responsible for the integration of all of the sections. This placed a critical burden on individuals who typically had little experience managing comparable complex information technology operations. It also provided a compelling excuse for the private vendors to claim they had done their pieces accurately and couldn’t be held responsible for the failure of the integration of the component pieces.

The experiences reported by the states have been mixed, but there have been surprises here as well. I had anticipated that Maryland would have an easy launch because the governor and legislature had embraced the Affordable Care Act (ACA) immediately after its passage and the state did not wait for the Supreme Court ruling on the law last June to begin its work on its state exchange. But Maryland stumbled badly early on, having to resort to paper applications for at least some time in October.

Kentucky, on the other hand, seemed to have an easy launch and reported enrolling sizeable numbers of individuals in private insurance during the first few weeks of October. The irony with Kentucky’s success is that, unlike Maryland, the exchange was created without the consent of the legislature, and lawsuits challenging its legitimacy have been filed—an issue that will probably be decided by Kentucky’s state supreme court.

Addressing the Problems

The administration recently announced that one of the vendors responsible for part of the initial programming in the federal exchange will be the coordinator for revising all federal exchange protocols and will also integrate the fixes currently being undertaken by various other vendors. This will mean one point of contact and one focus of responsibility for the functioning of the exchange going forward.

President Obama and Jeffrey Zients have promised a quick turnaround for the problems that have been plaguing the federal exchange websites. The importance of the timing is straightforward. To have coverage when new benefits become available on January 1, people must enroll by December 15, including people whose insurance will have been canceled because it no longer meets the ACA’s requirements. That means the insurance exchange website needs to be fully functioning between mid- and late November so that people will have time to consider the options available to them and complete the enrollment process by December 15. That’s not much time to fix an unspecified number of problems rumored to be in the hundreds.

The administration also recently announced that individuals now have until the end of March 2014 to enroll in a qualified insurance plan; previously, the expectation was that a person’s coverage must in effect by that date (which would have required enrolling weeks earlier). After that time, those without coverage will be subject to a penalty, whether or not they were eligible to receive a subsidy.

The concern is that with the difficulties encountered to date, the people most likely to doggedly persist through the process are the ones who need insurance the most—those who used to be in high-risk pools and others who know they need medical insurance because of their health needs. The worry is that the expected “low users” of health care—the “young immortals” or others who are otherwise healthy and likely low users—also need to sign up for insurance to get the risk pool at a manageable level. Whether they will be as persistent in making it through the enrollment process is unclear.

In the meantime, the federal government should take a lesson from the states and their willingness to share information about enrollees’ experiences in their exchanges. On the state exchange websites, it is easy to see how many people have visited, viewed options, set up accounts, and enrolled in private insurance or in Medicaid.

For reasons known only to the administration, the federal government has adamantly insisted it will not share information on actual private plan enrollment until at least mid-November. This type of continued stonewalling is a really dumb idea—not the least because it makes people wonder what else the government isn’t telling them.

 About the author: Gail Wilensky, PhD, is an economist and Senior Fellow at Project HOPE, an international health foundation. She directed the Medicare and Medicaid programs, served as a senior adviser on health and welfare issues to President George H. W. Bush, and was the first chair of the Medicare Payment Advisory Commission.  She is an elected member of the Institute of Medicine.
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