Thirty-one things we learned in HealthCare.gov’s first 31 days

November 1, 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.

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1. HealthCare.gov was not ready to launch.

error message h

It is, at this point, a statement of the obvious: The Web site that rolled out on Oct. 1 was not one ready to support the millions of visitors it received right off the bat. This was despite repeated promises from administration officials, including Health and Human Services Secretary Kathleen Sebelius, that consumers would be able to purchase coverage on day one.

2. Building a successful insurance marketplace is not impossible.

Washington

We know that, because we have seen a handful of states launch insurance marketplaces where many people have had a smooth experience shopping for insurance coverage. This includes places like Washington state and Kentucky (a bit more on Kentucky later), where they’re seeing tens of thousands of people enroll in coverage.

3. HealthCare.gov was stymied by a lack of direction.


Marilyn Tavenner, the administrator of the Centers for Medicare and Medicaid Services, pauses while testifying on Capitol Hill. (J. Scott Applewhite/AP)

This story from The Wall Street Journal’s Christopher Weaver and Louise Radnofsky should be required reading for anyone trying to understand what went wrong with the health-care law. “The accounts of more than a dozen current and former officials show how a disjointed bureaucracy lead to the site’s disastrous launch,” they write in an account of the months leading up to the marketplace’s launch.

4. The portal tallied six enrollments the morning of Oct. 2.

war room october 2

Notes from a morning meeting of the Center for Consumer Information and Insurance Oversight total exactly “6 enrollments” after the marketplace’s first day. It turns out that, behind the scenes, the launch looked just as bad as it did for the general public.

5. Overwhelming traffic is not HealthCare.gov’s big problem.


A different sort of traffic. (Photo by Justin Sullivan/Getty Images)

The Web site did get a lot of traffic in its first day, and even the first week. But what we’ve learned over the past few months is that, even as traffic has died down, the problems have persisted.

wObamaCare_g1

6. There are problems determining who qualifies for which program, and with submitting applications. The easiest way to understand all of that is with this graphic.

7. The New Yorker has been handed most excellent source material for its cover.


8. HealthCare.gov also launched with a glaring security error, which was only fixed a few days ago.

(Photo by Andrew Harrer/Bloomberg)
(Photo by Andrew Harrer/Bloomberg)

More on this from my colleague Brian Fung, over at The Switch: Administration officials knew that the Obamacare Web site posed a danger to online security days before it actually went live, according to an internal memo obtained by the AP and The Washington Post. The memo warned that in the days leading up to the launch, the system hadn't been sufficiently tested, "exposing a level of uncertainty that can be deemed high risk."

9. The Web site is still sending inaccurate data to health insurance plans.


This is an 834 transmission. Exciting, right?!

"The system isn't functioning, so we're not getting that reliable data," Sebelius told lawmakers, answering a question about why the administration will not release enrollment data. She was referring to “834 files,” which are what the Web site sends to health insurance companies when someone signs up for their plans. Insurers say these forms are coming out in duplicate or with information missing, forcing them to hand check each one.

10. HealthCare.gov didn’t have enough testing before going live.

This became clear in a series of Congressional hearings, where federal contractors testified that end-to-end testing only began in the final weeks of September, right before the Oct. 1 launch. When pressed on how much time would have been ideal for testing, one contractor told lawmakers that “months would have been nice.”

11. Government contractors are having their 15 minutes of fame.


I swear, this is the most attention contractors will see in awhile. (Michael Reynolds/EPA)

About a dozen television cameras and many more reporters showed up last week, to hear government contractors talk about computer systems for 4.5 hours. That is...weird. My favorite moment though, was right after the hearing, when a dozen cameras chased one of the contractors out of the room; the pack of cameramen nearly tumbled over a set of marble stairs, being so intent on their chase.

12. Have you gotten a third of the way through this list and realized you kind of forgot how, exactly, Obamacare works? It’s okay! Watch this video, and rejoin us at 13.

13. The Obama administration says that contractors messed up.

(Photo by J. Scott Applewhite/AP)
(Photo by J. Scott Applewhite/AP)

“Contracts for HealthCare.gov have not met expectations,” Sebelius testified on Wednesday.

14. Contractors say that the Obama administration messed up.


Cheryl Campbell, vice president at CGI Federal, throwing some shade. (Jahi Chikwendiu/The Washington Post)

“It was not our decision to go live,” Cheryl Campbell, a vice president at contractor CGI Federal, testified last week.

15. Okay, pretty much everyone thinks everyone else messed up.

national journal

Thanks to Brian Resnick for this chart.

16. Red Solo Cups come up at surprising frequencies in discussions of health policy.


What about your bros?! (Melina Mara/The Washington Post)

Who thought that keg stands would be a subject of discussion for Sec. Sebelius? Probably the same people who foresaw the former Kansas governor getting pressed on her tricycle riding habits.

17. The administration has a plan in place to fix this whole thing.


Jeffrey Zients to the rescue! (J. Scott Applewhite/AP, File)

Health and Human Services has brought on former administration official Jeff Zients to manage the repairs efforts. He told reporters last week that the administration has come up with a “punch list” of items that need to be fixed. QSSI, one of the contractors already working on the Web site, will manage the fix project.

18. That punch list? It has over 100 items.


Not that kind of punch, silly. (Julie Jacobson/AP)

And at the top, Sebelius says, is a fix for that faulty data that insurance plans are receiving. The administration sees this as crucial to the health law’s success and with good reason: Insurers need to know who they’re covering for the coverage expansion to work.

19. If they hit their targets, HealthCare.gov will start running smoothly one-third of the way through open enrollment.


"It's a marathon, not a sprint" says pretty much every health law supporter. And the people pictured here, albeit for different reasons. (Cliff Owen/AP)

The White House and its allies like to say that open enrollment is a marathon, not a sprint, noting that Massachusetts only got a handful of sign-ups in its first month. At the same time, we’re no longer talking about a few weeks or days of a delay. Two months of the six-month open enrollment period will have gone by before the marketplace functions as it's supposed to.

20. The administration isn’t talking about extending open enrollment, or delaying the individual mandate.

(Photo by Jonathan Bachman/Reuters)
Let's be honest, I'm running out of pictures. (Jonathan Bachman/Reuters)

Some Democrats, however, have raised this option, and, if the Web site isn’t fixed on schedule, you can expect to see more calls for delays to different parts of the law.

21. Kentucky knows how to build an insurance marketplace.

Kentucky

Apparently there’s some sort of correlation between bourbon production and health law marketplace building? Kentucky has had one of the most successful launches of any state, with many signing up in the past few weeks.

22. Oregon knows how to make fun ads -- but not how to sign people up for coverage.

A simpler time for Obamacare. (YouTube)
A simpler time for Obamacare. (YouTube)

The state got a lot of attention for its early ads and was among those that really wanted to make the Affordable Care Act work. But so far, technology issues have blocked the state from signing people up for coverage through its exchange, Cover Oregon. The state announced Thursday it would begin processing applications manually as it works on a technology fix.

23. Washington state knows how to do both.

The state has had some of the most robust sign-ups of any state -- and a pretty rocking advertising campaign. There were some initial hiccups; the Web site had to come offline for 48 hours right after launch, when officials saw it wasn’t working. Since then though, the experience in the Pacific Northwest has been pretty smooth.

24. And the Onion knows how to make the most funny Obamacare photograph.


It still gets me every time.

25. The botched rollout hasn't changed public opinion.

views-of-aca-largely-unchanged-this-year-polling

Lots of people weren’t using the Web site, or paying close attention to its launch.

26. About half of people who currently buy their own insurance will receive cancellation notices.


Experts have estimated that somewhere between half and three-quarters of those who currently buy their own policies will not have the option to renew coverage, which works out to around 7 to 12 million people. This is due to some changes in the health-care law that require insurance plans to cover a set of 10 essential health-care benefits.

27. Some people are happy about their cancellation notices. Others are furious.

It all depends a lot on what exactly you think insurance coverage ought to look like. Some people want to have a really bare-bones plan, perhaps one that only covers hospital trips. That mostly won’t be allowed under the Affordable Care Act. Others want access to a more robust policy that covers lots of things and accepts every consumer. The New York Times talked to people on both sides of this issue, which is worth a read.

28. Most of the people gaining coverage through the law this month have come in through the Medicaid program.


This is only in the first month and subject to change, but, in month one, the Medicaid program has had much more robust sign-ups than private insurance.

29. We have no clue at all how the health law's first year will go. That's because there are a lot of people who want to sign up for coverage right now, but can't. There are still five months left in the enrollment period, and those will likely tell us a lot more about shoppers' interest in purchasing coverage. Keep in mind, a mere 123 people signed up for coverage during Massachsuetts's first month of open enrollment.

30. The key date is no longer Oct. 1. It's Nov. 30. This is the third night of Hannukah, but, more relevant here, the day that the administration expects the Web site to be up and running. If it's not, health law supporters say, it will be difficult for some people to sign up by Dec. 15, the last day to get coverage beginning January.


If the menorah is all that is lit before HealthCare.gov is up and running, that is...problematic. (Lubavitch Youth Organization/AP)

31. It is possible in the modern era to have your face plastered on a national Web site for three weeks, and still have no one track you down.

HCG screenshot

Who are you, mysterious HealthCare.gov lady?!

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

The health law's slow launch has Democrats worried. "Already under fierce attack from Republicans over the new health care law, President Obama now faces broad and mounting Democratic concerns that the troubled start of the insurance program will cut into the political benefit the party received from the government shutdown and cost Democratic candidates in next year’s midterm elections." Jonathan Weisman in The New York Times.

Google is involved in efforts to fix the Web site. "Google Inc., Red Hat Inc., Oracle Corp. and other technology companies are contributing dozens of computer engineers and programmers to help the Obama administration fix the U.S. health-insurance exchange website. The help is arriving as the government’s main site for medical coverage remains plagued by repeated outages a month after its Oct. 1 debut. Michael Dickerson, a site reliability engineer on leave from Google, and Greg Gershman, innovation director for smartphone application maker Mobomo, are among those helping, the Obama administration said yesterday." Alex Wayne in Bloomberg. 

Navigators are becoming human versions of HealthCare.gov. "Ms. Kaufmann, the 61-year-old director of a navigator program for Montana Primary Care Association in Helena, has been bombarded with phone calls from consumers who can't access the site. People want to know how much their health care will cost and if they are eligible for government subsidies. 'I come in every day to more phone calls than I can handle,' said Ms. Kaufmann, who is also a part-time state legislator." Timothy W. Martin in The Wall Street Journal.

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