Maryland looks to Connecticut for health exchange answers


Gov. Martin O’Malley holds up a phone number for people to call to get help enrolling in health insurance in the state’s health care exchange in March. (Brian Witte/AP)

The Access Health CT Web site is everything that the Maryland Health Connection site had hoped to be.

The format is simple and easy to navigate, allowing Connecticut residents to browse health insurance plans before creating an account. More importantly, the system properly relays enrollment information to insurance companies and the federal government, making real the Affordable Care Act’s vision of quickly insuring tens of thousands of previously uninsured people.

Both Web sites were constructed on a tight deadline at the enthusiastic behest of Democratic Govs. Martin O’Malley and Dan Malloy. Connecticut’s site thrived, while Maryland’s barely functioned.

Now, Maryland is racing through a rebuild of its site, using a free copy of Connecticut’s creation. Federal officials are closely watching and want Maryland to provide evidence that the site will work when the next enrollment period opens Nov. 15. The next major check-in must happen by June 15.

What went right in Connecticut provides a window into what might have gone wrong in Maryland, where officials have declined to formally investigate and continue to make major decisions behind closed doors.

O’Malley has repeatedly said that the reason his state’s exchange struggled is that it hired the wrong companies to build the system. Connecticut officials say their exchange was a success because they fostered an environment that’s more like a tech start-up than a government agency — having a realistic plan for what they could build on such a tight deadline.

“We wanted to build a Ford Focus — something that will get you to the grocery store and back, and not much more,” said Kevin Counihan, chief executive of Access Health CT. “We figured that later we could add the power windows and automatic locks. This is not a Cadillac.”

Landmark opportunity

The two deeply blue states started in nearly the same place, with O’Malley and Malloy rushing to implement President Obama’s health-care vision. This was not just an opportunity to help constituents; it was a chance to partner with the White House on a landmark initiative and perhaps set themselves apart on the national stage. O’Malley pledged that Maryland’s exchange would be the best in the country.

Both governors pushed their lawmakers to establish quasi-governmental exchanges to operate Web sites tailored to the states’ needs rather than joining the federal marketplace, HealthCare.gov.

Both put their lieutenant governors in a position of responsibility: In Connecticut, Lt. Gov. Nancy Wyman chairs the exchange board. In Maryland, Lt. Gov. Anthony G. Brown oversaw implementation of the health-care overhaul, while Joshua M. Scharfstein, the state’s top health official, was put in charge of the board.

Brown is the frontrunner in the race to succeed O’Malley. He has touted health-care overhaul as one of his accomplishments, even though the state’s exchange was one of the worst-performing in the country.

The board appointees indicate each state’s approach to the project: Maryland chose mostly academics, many of whom previously worked in state government. Connecticut’s board is packed with people who have worked for private insurance companies.

In Connecticut, staff members call their federal grants “venture capital” and their sign-up centers “retail store fronts.” They designed their site to function like travel-booking sites and set up enrollment fairs modeled after Apple stores. Most managers came from the corporate world, drawn by the opportunity to participate in a historic project that could disrupt the marketplace.

They brought their private-
sector values with them.

“If you miss too many target dates, you lose your job,” said James Michel, operations manager for Access Health CT. “We were determined we would make it happen, come hell or high water. We didn’t want to fail.”

The states had to periodically check in with the federal officials who were funding the massive projects. In early 2013, the federal government warned Connecticut that it might not be allowed to go live Oct. 1 because it was so far behind.

Meanwhile, federal officials gushed about the progress Maryland was making, Counihan said.

Connecticut doubled down, putting off the building of any non-vital features — a third of its to-do list — and pushing its hired contractors even harder. By the next test a few months later, the state was off the watch list.

“You know what they told us? ‘Maybe you guys will catch up with Maryland,’ ” Counihan said.

Connecticut’s site went live Sept. 27, giving workers time to fix bugs before enrollment opened Oct. 1.

Maryland’s early promise dissolved, however, as contractors and subcontractors fought over work and money. The system was so unstable that officials debated delaying the launch.

O’Malley made the final decision. He told the exchange managers to flip the switch.

On the morning of Oct. 1, Connecticut’s staff gathered around large monitors in their office. As they watched traffic to their site steadily build, and the number of residents enrolled in health insurance plans grow, some became emotional.

That same morning, Maryland’s site crashed and remained down. It took two months to fix the biggest problems, and the site never worked as expected, making it difficult for thousands to get coverage.

When enrollment closed March 31, Connecticut had one of the highest sign-up rates in the country, with more than 79,000 people enrolled in private plans.

Maryland, which has 40 percent more people than Connecticut and more than twice as many uninsured residents, had one of the lowest enrollment rates in the country with more than 67,750.

Connecticut became the rock star that Maryland had hoped to be. Obama visited. The exchange staff worked the conference circuit. And other states asked for help.

“We have lots of people calling up and saying, ‘Gee, how can we do business with you?’ ” said Steven J. Sigal, chief financial officer for Access Health CT.

If the exchange could cash in on its expertise, officials said, it could rely less on fees from insurance companies, which would help keep rates low. As other states and the federal government struggled to get their sites working, Counihan was making sales pitches.

He traveled to Baltimore in January to meet with Maryland officials, explaining that Connecticut could provide anything from an all-inclusive “exchange-in-a-box” to behind-the-scenes technical support or targeted advice and training.

Maryland was only interested in Connecticut’s software, which would be free since it was created with federal funds. Counihan cautioned that technology is only one part of building a successful exchange — the right staff and proper management is also needed.

Maryland hired Deloitte Consulting, which built Connecticut’s exchange, to revamp its system.

Maryland’s rebuild could cost as much as $60 million, but it does not have to pay Connecticut anything. Connecticut officials have provided free support and guidance, including two days of presentations for about 20 Maryland exchange staff members last month.

Sharfstein, chairman of Maryland’s exchange board, said he gave Access Health CT a gift basket of Old Bay-flavored products to show his appreciation.

Other states with struggling exchanges have chosen different paths: Oregon is abandoning its exchange and joining the federal marketplace. Massachusetts is also rebuilding and has the option of joining the federal exchange for one year.

Sharfstein said he is confident that Maryland’s site will succeed.

And Connecticut officials remain hopeful that Maryland will find the need for something it sells. Access Health CT recently unveiled a smartphone and tablet application that will allow residents to sign up for insurance and take photos of documents to upload.

This time, the exchange owns the code.

Jenna Johnson writes about Maryland politics, including the General Assembly, the administration of Gov. Martin O'Malley and the 2014 election.
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