HealthCare.gov is busted. These four state exchanges aren’t.

October 25, 2013

Welcome to Health Reform Watch, Sarah Kliff’s regular look at how the Affordable Care Act is changing the American health-care system — and being changed by it. You can reach Sarah with questions, comments and suggestions here. Check back every Monday, Wednesday and Friday afternoon for the latest edition, and read previous columns here.

There's a lot of focus right now on what isn't working with HealthCare.gov, the Web site where shoppers are still having trouble signing up for coverage. As one reader in Indiana wrote to me Friday morning, "At Day 25, we're still not registered."

This is what the health-care law looks like in most states -- but not every state. A handful of states that built their own insurance marketplaces are actually having a pretty decent time signing people up for health insurance coverage. They are the exception, rather than the rule. But they are worth looking at to get a sense of how HealthCare.gov could work -- and what the states did right to get there.

Kentucky Kynect

Kentucky

The Kentucky Kynect likely takes the award for most written-about Obamacare marketplace -- and for good reason. It had one of the most flawless launches of any state marketplace, posting robust application numbers on Oct. 1. So far, the state reports that 26,174 people have enrolled in private insurance or Medicaid.

Kentucky is the only Southern state operating its own insurance marketplace and has had the strong backing of Gov. Steve Beshear, a Democrat.

"State officials and outside experts attribute the smoother rollout to a variety of factors, including intensive testing of the system, a less-flashy but more-efficient website and strong coordination among state agencies involved in the effort," The Wall Street Journal's Arian Campo-Flores wrote in one article on Kynect.

Another possible factor in the Kynect's success: The state hasn't exactly publicized the fact that it's part of the president's health-care law. The Huffington Post's Jason Cherkis has a great anecdote about this from the Kentucky State Fair, when a gentleman visiting the Kynect's booth muttered "This beats Obamacare I hope."

A worker there decided against letting him know it was, indeed, a part of Obamacare.

Access Health CT

Connecticut

Connecticut doesn't have the highest enrollment numbers, with just under 4,000 people signing up for private plans and the state Medicaid program, know as HUSKY. They have, however, had one of the smoothest launches -- and are putting out the most detailed statistics about who is signing up for coverage.

Only in Connecticut, for example, do we know that about one-third of the new enrollees are under 35. We know that about half are purchasing mid-level silver plans, with the rest divided between the bronze and gold offerings. We know which carriers they are buying from, too. This data is important to how well the marketplace works: Keeping premiums low depends in no small part in getting young people to sign up. In Connecticut we know that, at least right now, that's happening.

Washington HealthPlanFinder

Washington

Washington State's marketplace had a pretty rocky start: Within hours of its Oct. 1 launch, it had to be taken down for two days of maintenance. While other states' consumers were getting a first peak at their premiums, Washingtonians just saw a message telling them to come back later.

"We decided within the first few hours of that day to take it down," spokesman Michael Marchand said. "It would have been a lot easier to try to see if we could make it through the first day. But we didn't want thousands of people to have bad experiences."

Keeping the Web site up would have been something like "driving down a highway with a tire that's slowly losing pressure," Marchand says. "It was better to pull over to the side of the rode, change the tire, and then take the trip."

Software engineers in Washington spent two days pouring over the system's code, looking for bottlenecks and then rebooting the entire system. This meant a two day delay for Washington's shoppers -- but, since then, a pretty smooth shopping experience. The state has enrolled about 4,500 people in private coverage, and another 20,000 in Medicaid plans through its exchange.

"The end result was a better experience," Marchand says of taking the system down for two days. "We're continuing to monitor the system. We want to make sure it's the best for the consumer, so we keep tweaking the system. I'm sure we'll be doing this for a while."

Covered California

Covered California

California was the very first state to commit to building a marketplace. That extra time gave them a bit of a leg-up in building the country's largest Affordable Care Act marketplace. At the same time, California also faced challenges: Most notably, budget woes made it difficult for Gov. Jerry Brown to focus on implementing the health law.

The staff of Covered California though seem to have pulled off a successful launch. And that might have a bit to do with their experience: Some of the staff working on the marketplace also were at the helm when former governor Arnold Schwarzenegger made a 2007 push for universal insurance coverage.

KLIFF NOTES: Top health policy reads from around the Web. 

Obamacare contractors say HealthCare.gov testing started too late. "Private contractors in charge of building the federal online health insurance marketplace testified Thursday that the administration went ahead with the Oct. 1 launch of HealthCare.gov despite insufficient testing. In their first public remarks since the debut of the problem-ridden insurance exchange, executives of the main IT companies told members of the House Energy and Commerce Committee that full tests of the Web site that should have been carried out months in advance, but began just two weeks before its rollout." Sandhya Somashekhar and Amy Goldstein in The Washington Post.

This graphic explains how HealthCare.gov is broken. 

Before launch, the White House painted a rosy Obamacare picture. " Just days before HealthCare.gov went live with disastrous results, top White House officials were excitedly briefing lawmakers, reporters, Capitol Hill staff members and Washington pundits on their expectations for the government’s new health care Web site. Led by David Simas, a senior communications adviser in the West Wing, and sometimes joined by Denis McDonough, the White House chief of staff, and others, the fast-paced PowerPoint briefings showed images of a shiny new Web site that was elegantly designed, simple to use and ready for what officials hoped would eventually be a flood of customers on Oct. 1. One lawmaker recalled comparisons to Travelocity, the travel booking site." Michael D. Shear and Sheryl Gay Stolberg in The New York Times.

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Neil Irwin | October 25, 2013