On the Public Health Insurance Marketplaces: October 2013


Federal officials, state representatives, nonprofit organizers, and uninsured individuals alike waited with baited breath for the October 1st rollout of public health insurance exchanges under the Affordable Care Act. Now that we’ve let out that collective breath, let’s look back on the first month and learn what it meant for the states.

All 34 states with exchanges run by the federal government faced challenges as the website, Healthcare.gov, was plagued by technical issues relating to higher traffic than anticipated. States running their own exchanges, on the whole, had more success in enrolling people in plans. Enrollment numbers continue to creep upwards as technical issues are resolved and more Americans enroll online, over the phone or in person.

Latest Developments:

State Run Exchanges and Partnerships -

California: As of October 8th, 28,000 people had enrolled through Covered California, the state’s health insurance exchange, via the online portal, over the phone, and in person. Program executive director Peter Leepredicts that 500,000 to 700,000 Californians will enroll with subsidies by the March 31 end of open enrollment.

Covered California has removed a much-hyped online tool that would have allowed people to search by zip code for doctors available through plans in their area. Program representatives cited technical glitches as the reason for removing the tool.

Outreach efforts continue with state officials stating they plan to train and certify 20,000 enrollment counselors and 12,000 insurance agents. Only a small fraction of those already trained have received official approval, often leaving healthcare consumers to navigate the system alone or be subject to long wait times for over-the-phone assistance.

The diversity of the state has made bilingual outreach the focal point of education campaign efforts. Bilingual ads and door-to-door education campaigns aim to reach hard to access populations. Health clinics are another popular location for outreach. To aid in this effort, Covered California has awarded millions of dollars in grants to organizations helping Latinos and other ethnic groups enroll.

While support is available online and via over the phone helplines, state officials report that 80% of consumers will want in-person help and this has been problematic due to the shortage of enrollment assisters authorized to handle applicants. Of the 16,000 assisters envisioned by the state, only 20% have been trained and authorized.

As many as 700,000 Californians have been informed that their previous coverage plan does not conform with ACA standards and will be cancelled. While approximately a third of these will receive subsidies from the federal government, others will be faced with new plans and in some cases, higher premiums.

The Covered California website has faced some technical issues, but has had considerably more success than the federal site, Healthcare.gov. The state site received 987,000 visitors in the first five days, with high traffic volumes causing pages to load slowly at times.

Covered California chief Peter Lee defended continuing to withhold enrollment data for the state exchange, citing a need to “make sure the numbers are right.” A lack of transparency has been a continuing criticism of both state and federal exchanges. The state has also not released quality ratings on eight of the twelve insurers offered on the exchanges. Exchange officials stated that ratings would be available in October 2015, after examining patient reviews and other data.

Covered California gets help from cities and counties across the state in the form of volunteer outreach efforts. The state exchange has money to authorize community organizations as enrollment assisters, but does not have similar funds for cities or counties.

The Children’s Partnership launched a campaign specifically targeted at reaching uninsured children and their families and enrolling them in health insurance through Covered California.  The ALL IN campaign focuses on outreach and education at schools, afterschool programs, and child care centers.

Colorado: Colorado released its metrics for the first week of its exchange, Connect For Health Colorado, reporting 162,941 unique visitors. Of those visitors, 18,174 created accounts, but only 226 bought plans. State officials attribute this lack of enrollments to technical issues and expect higher numbers by the time open enrollment ends in March 2014.

Exchange CEO Patty Fontneau considers the first week a success, citing visitor numbers as an indication of how much interest there is in the program and insisting that the low enrollment is only a temporary setback. The health exchange board, in the meantime, expressed frustration at the slow enrollment and many wondered how much higher the enrollment numbers would be without all the delays.

USA Today interviewed uninsured Coloradans, in a piece titled “Microcosm of Confusion on Health Law.” While interviewees did mention feeling underinformed about the options available to them, many also expressed hope that the new health care system would help alleviate the stress of being uninsured and save them money.

The Colorado exchange has embraced a new character in encouraging Coloradans to enroll  – the college bro. Ads featuring beer kegs and red cups have one bro asking, “Yo, mom, do I got insurance?” Whether these humorous ads will be successful in encouraging enrollment is yet to be seen.

Connecticut: Almost a third of enrollees in Connecticut’s health exchange are under 35, according to program CEO Kevin Counihan. This is good news since insurance providers depend on high enrollment from younger, healthier people to support more costly care for older enrollees. The state-run exchange, Access Health CT, received 1,157 applications its first week, with the majority split between the silver and gold plan options.

According to state officials, 4,065 individuals have enrolled in private insurance plans on the exchange since October 1st. The state aims to enroll 100,000 people by the end of open enrollment on March 31st.

Many Connecticut residents are having to change plans, as many of their current plans will not be offered under the new system. Major carriers such as Anthem Blue Cross, Cigna, and Aetna are discontinuing existing plans, some for non-compliance with federal standards, and are working to migrate their customers onto new plans with similar benefits.

The state exchange site has been hit with at least five unsuccessful hacker attacks in recent weeks. Security of consumers’ personal health information remains safe and data security remains a major concern for state officials running the exchange. The site faced another setback on October 27th when the federal hub, which verifies individual’s identity to determine eligibility for subsidies, went down for a time.

District of Columbia: District officials announced that despite earlier issues with a “high error rate” being reported, DC Health Link, the district’s health insurance exchange, would launch on time. The district reportedthat the site received 15,000 unique visits on the first day and 4,000 applications were created in the first week.

Hawaii: As other states resolved their technical issues and started enrolling people in health insurance, as of October 11th Hawaii residents were still unable to buy plans on the state-run exchange, Hawai’i Health Connector. Site visitors could log on, create an account, and begin filling it out, but could not view prices or purchase plans.

Idaho: Idaho’s state-run exchange, Your Health Idaho, may raise its per-policy fee from 1.5% to 2.6% by 2016 to make the program sustainable in the long run. The state was originally praised for only charging a 1.5% assessment on plans as compared to 3% for the federal exchange. While this rate hike may still occur, exchange finance chief Pat Kelly’s planned announcement to this effect was cancelled because the calculations were deemed “too preliminary to make public.”

Illinois: Illinois rolled out a long-delayed $33 million advertising campaign for the state’s health insurance exchange on October 1st. Called “Get Covered Illinois,” the campaign began with full- color newspaper ads in 50 cities and will continue from there.

Illinois residents faced challenges when attempting to enroll in health insurance via the federal website,Healthcare.gov. Illinois, which operates its health insurance exchange as a partnership with the federal government, directs its residents to enroll via the federal site but plans to transition to a state-run exchange next year.

Iowa: Iowa’s federally-run health insurance exchange got off to a “buggy” start, with high site visit volume and technical issues on Healthcare.gov frustrating Iowans attempting to enroll.  Trained navigators from Planned Parenthood of the Heartland, Visiting Nurses Services of Iowa, and Genesis Health System fielded calls from state residents and will continue to provide enrollment support going forward.

Kentucky: Kentucky has trained more than 5,000 people to aid in enrollment for its health insurance exchange, Kynect. This number includes state employees, insurance agents, social service workers and volunteers. Commonly called “navigators,” in reference to the navigator grant provided by the federal government to states to train people to assist in enrollment efforts, Kentucky has dubbed theirs “Kynectors.”

President Obama highlighted Kentucky as evidence of the healthcare roll out’s success in a statement to the press on October 3rd despite some technical issues. According to the president’s remarks, almost 11,000 people applied for new insurance plans in the first two days.

Quality web design is being credited with much of the praise garnered for Kynect and consumers experienced easy enrollment, with an expert at the Kaiser Family Foundation calling the site the easiest to navigate of those she’d examined, due to its simple design and lack of distracting “bells and whistles.”

Maryland: Despite optimistic projections from the state’s governor, Martin O’Malley, the Maryland health insurance exchange site faced numerous technical issues, causing a four-hour delay in launching on October 1st and blocking people from creating accounts and enrolling.  The issue has been identified as a bottleneck caused by users making personal accounts before starting enrollment.

As of October 7th, state officials reported just 326 people had successfully enrolled, despite thousands of recorded site visits.  Approximately 13,532 distinct accounts were created as of October 6th and officials are hopeful that a greater percentage of that number will successfully enroll going forward.

Patients at Maryland community clinics are among those most eager to enroll, according to a recent article by the Washington Post. Navigators are reaching out to moderate- to low-income communities to reach those poised to benefit the most from the new exchanges.

Maryland continues to struggle with implementation of the small business portion of its exchange, missing the deadline to launch its small business exchange and now shelving plans for small business insurance educational workshops. Cancelling these workshops fueled speculation that the small business exchange will not be ready in time for January 1st.

Massachusetts: A week into enrollment, a reported 1,134 individuals had successfully submitted applications for health insurance on the state-run exchange. The exchange website had approximately 1.6 million views in the first week of enrollment and aced some technical issues.

The state still had a sizeable advantage because of prior experience running the state’s online marketplace, The Connector, which has been in operation since 2007. This is evidenced by the fact that 97 percent of the state’s 6.6 million residents are insured – the highest coverage rate in America. Of those currently covered, about 150,000 will have to re-enroll to comply with new requirements under Obamacare.

Michigan: Michiganders faced delays when attempting to enroll on the federally-run Healthcare.gov website, with continued error messages and long wait times plaguing site visitors. An estimated 7 million people visited the federal site, although numbers of visitors from individual states is currently unavailable.

Minnesota: MNsure chairman Brian Beutner was pleased with the state-run site’s rollout despite continuing problems such as site freezes and automatic logouts, which prevented many Minnesotans from successful enrollment. State officials believe there is still time for the enrollment in the exchange to take off, as consumers have until 2014 to have enrolled in a plan.

State officials have attempted to alleviate some of the frustration with the exchange website by increasing the number of login attempts before a user is locked out. Previously, users had three attempts to log on before being locked out for a week. Now, the number of attempts has been upped to six and the lockout period reduced to 24 hours. This was an issue because users were being redirected to the federal site to verify their identity and the wait time on the federal site was causing users to be repeatedly logged out of the state site.

A Minneapolis resident reported being able to successfully enroll in 2 hours on the state’s exchange, describing the process as simple and straightforward.  This is consistent with a national trend that uninsured people have been significantly more successful with state-run exchanges than with the federal exchange, due to continued issues with the Healthcare.gov website. Approximately 3,700 individuals have started applications as of October 17th, but number of completed applications remains low.

Minnesota officials will continue outreach efforts for the state’s health insurance exchange, MNSure, using the more than 5,000 individuals certified to help consumers navigate the site and enroll in plans. Certified individuals include a mix of insurance brokers, tax preparers, human resources staff, among others.

To address limited plan options in the southeastern part of the state, MNSure has added seven new insurance options from insurer Medica to cover that area and provide less expensive options for residents.

MNSure received a new $41 million grant from the Department of Health and Human Services for implementation of its exchange.  According to a statement, the funding will go towards IT infrastructure, security training and system improvements, and ongoing operations through 2014.

Nevada: As of Tuesday, October 8th 2,000 Nevadans had submitted applications for health insurance on the state-run exchange.  In the first week the exchange was open, the site received an estimated 90,000 unique visitors.

New York: A new interactive map allows New Yorkers to see who will be covered as the various provisions of the ACA are fully implemented. This includes individuals to be covered by Medicaid expansion, as well as those previously uninsured that will be covered under private insurance plans provided by eligible insurers on the state exchange.

As of October 23rd, state officials reported that 174,000 people had applied for insurance on the state’s exchange, NY State of Health. State officials say that 37,030 individuals have completed applications and are now fully enrolled in plans.

Oregon: As many as 80,000 individuals visited the Cover Oregon site on opening day, evidence of high interest among Oregon residents. The site was almost immediately plagued with technical issues, caused in part by high traffic.

Oregon residents remained unable to enroll on the state exchange, Cover Oregon, as of October 7th – 1,300 applications for eligibility for federal tax credits remained unprocessed due to continued technical glitches with the site.

In response to the continuing issues with processing applications, the site now has a feature that allows people tobrowse plans before starting an application. Health exchange workers can also manually review eligibility for individuals looking to get insured on the state exchange.

Rhode Island: As of October 17th, 5,700 Rhode Island residents had created accounts and around 800 had completed their applications for insurance using the exchange. Exchange officials stopped reporting enrollment figures in the latter half of the month, reporting instead a “completed and processed” number, which refers to the applications submitted but with premiums not yet paid. Premiums are not due until December 15th.

Washington: Compared to the glitch-ridden federal website, state insurance websites have seen more successin enrolling their residents, with Washington being one of the success stories. After experiencing bottlenecks at the outset, the site made adjustments to resolve the issues quickly. The site allows visitors to browse plans without creating an account, which avoided the issue of a glut of incomplete applications plaguing other websites.

Nearly 35,500 people signed up for health insurance (this includes Medicaid) in the first three weeks of enrollment on the state-run exchange, Washington Health Benefit Exchange. Of those 35,500, 31,000 have enrolled in Medicaid coverage and 4,500 have enrolled in private health plans.

The state exchange call centers have plans to expand their staff as they have been inundated with calls – as many as 6,000 calls a day. This dwarfs the number of calls predicted before the launch of the exchange, which was about 2,500 a day.

Federally Facilitated Exchange-

Arizona: Blue Cross Blue Shield of Arizona joined forces with Chicanos Por La Causa, one of Arizona’s largest social services organizations focused on outreach to Spanish-speaking communities, to educate the public about options under the new federally-run exchange. The two groups will coordinate media outreach and provide access to bilingual counselors for Arizona’s uninsured residents.

Florida: Health secretary Kathleen Sebelius visited Florida on October 8th to address the continuing issues with the beleaguered Healthcare.gov website. Sebelius got status updates on enrollment in the state from navigators at the University of Southern Florida.

Blue Cross Blue Shield has set up 18 storefronts to inform Florida residents about their enrollment options on the exchange, despite resistance from state officials to the program. In addition to these “Florida Blue” storefronts, community health centers, social service groups and other nonprofits are working on outreach efforts as well.

Administrators of the health insurance exchange in Florida expressed concern that uninsured Floridians are running out of patience and time with the site’s enrollment issues. Many people took time off work or spent time on hold with helplines, only to have their applications accidentally deleted or processed incorrectly due to technical issues.

Georgia: Enrollment numbers for Georgia remain unknown as the federal site continues to withhold numbers for individual states operating on the federal exchange. Enrollment has been slow in the state in general, with assisters at local community centers only able to enroll their first consumer on October 16th, according to somereports.

Kansas: The Kansas City Star released a table detailing the premiums by county available to residents on the state exchange. Kansas will be able to choose from plans offered by two insurers, Blue Cross and Blue Shield of Kansas City or Coventry Health and Life.

Mississippi: Mississippi residents struggle to enroll in health insurance as as the federal site, Healthcare.gov, continues to have issues. In the first three weeks, just 35 people successfully enrolled in insurance, according to insurance commissioner Mike Chaney. For the state’s 275,000 uninsured, the website is expected to be the main way to enroll, although residents can also enroll in person or over the phone with one of the state’s 50 trained navigators.

North Carolina: North Carolina, along with many other states, faces a sizeable knowledge gap as health insurance enrollment begins, according to representatives from Enroll America, a non-profit committed to enrolling individuals and families in plans. People have heard of the penalty for not having insurance, but few know what they qualify for as far as federal subsidies under the federally-run exchange.

North Dakota: Community organizations and insurance providers spread the word on the federally-run exchange and are fighting rampant misinformation as state officials take a hands-off approach to informing North Dakotans about their options for health insurance.

Ohio: Ohio recipients of the federal Navigator grant have been slow to get approval for their trained navigators, with no navigators receiving final approval in time for the October 1st launch. This leaves uninsured Ohioans with little support as they begin the process of enrolling in plans on the federal exchange. Going forward, the Ohio Association of Foodbanks, which received the largest portion of the federal grant money (nearly $2 million), plans to hire and train 30 to 40 navigators to aid with enrollment.

Pennsylvania: Enroll America, a non-partisan, nonprofit organization is working to reach the nearly 1.3 million Pennsylvania residents who are currently uninsured and inform them about their options under the ACA. Volunteers for the organization go door to door with informational materials and also try to connect people with navigators – volunteers trained to advise and help with enrollment.

South Dakota: As of October 17th, just 23 people have signed up using the federally-run exchange. The three insurance providers offering plans on the exchange, Avera, Sanford, and DakotaCare, reported “mixed results” as enrollment fell far short of projected numbers.

Texas: According to a recent statement by Senator Rodney Ellis (D-Houston), the biggest challenge for health insurance enrollment in the state is “to get the word out” as the state remains divided over the program. Texas has the largest uninsured population in the country, with approximately 25% of its residents uninsured, and received the largest percentage of the federal Navigator grant funds (~$11 million) to train people to walk Texans through the enrollment process.

Texas physicians remain uncertain as to whether or not they are included in provider networks offered by health plans on the exchange, according to reports by the Texas Medical Association, Texas Hospital Association and Texas Academy of Family Physicians. This is largely because many insurance providers created provider networks based on previous relationships with doctors and hospitals, but did not contact them to confirm this.

Health care advocates have continued outreach efforts to uninsured Latinos, a population that makes up two thirds of the uninsured in the state. As part of the education effort, “promotoras,” bilingual health care counselors are being deployed to inform and aid with enrollment.

Utah: Utah residents faced the same challenges as many other states – struggling with long waits and site glitches on the Healthcare.gov site – but some residents had their persistence rewarded with comprehensive plans and federal subsidies to help with the cost. The Sherburne family in Salt Lake City, for example,successfully enrolled in a silver plan with a $123 monthly premium (after the federal subsidy). Rates vary depending on region, income, and which of the 96 plans available to Utahns residents select.

Virginia: Local site lists resources available for Virginia residents navigating the new health insurance exchange, including phone numbers for enrollment assistance hotlines, contact info for trained navigators and enrollment counselors, and locations for in-person support.

A recent story from Kaiser Health News explains why some Virginia health insurance plans will cost upwards of $1,800 a month. These plans are slated to include coverage for gastric-bypass surgery – a popular treatment for obesity that can cost between $15,000 and $25,000. Virginia is among a handful of states that require the surgery to be covered under individual insurance plans and this has been problematic in that it makes monthly premiums for these plans prohibitively expensive for consumers.

Wisconsin: Only one of six organizations receiving federal funding to train navigators is up and running in the state. Obstacles include the time consuming process of training and authorizing navigators, which requires volunteers to undergo 16 hours of training, a written examination, background check, submitting to fingerprinting and paying a fee.

Wyoming: Only about 30 Wyoming residents have successfully enrolled in plans available through the state’s two providers – WINHealth and Blue Cross Blue Shield of Wyoming. The low number of enrollments is attributed to issues with the federally-run website, Healthcare.gov.

[Photo Credit: Daniel Rehn on Flickr via Creative Commons 2.0]

This post appeared on the OneExchange blog on November 14th, 2013 and can be viewed there by clicking here.
Towers Watson is a leading global professional services company and operator of the nation's largest private Medicare exchange. Towers Watson OneExchange is the industry’s only holistic private exchange solution, offering exchange options for U.S. employers and their active, part-time and retired workers.