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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If you have spent anytime talking to health-reform supporters in recent days and weeks, there's a certain six-word phrase that seems to come up in nearly every conversation.
"It's a marathon, not a sprint," Families USA president Ron Pollack, among others, has been fond of saying. This is meant to emphasize that an initial stumble out of the blocks doesn't doom the health law's entire open enrollment period.
President Obama offered a slightly different version of that analysis in his Rose Garden Speech Monday morning.
"We’re only three weeks into a six-month open enrollment period, when you can buy these new plans," he said. "Keep in mind the insurance doesn’t start until January 1st; that’s the earliest that the insurance can kick in."
As Obama made clear, there's no opening day special when it comes to shopping on HealthCare.gov; a health insurance policy purchased Oct. 1 is identical to one bought on Dec. 1.
At some point though in the future, a certain day or week, we get out of the sprint phase and are smack in the middle of the Affordable Care Act marathon. We're not in week three, but maybe week four, five or 16. There's a point where not having a functional Web portal actually does interfere with consumers' ability to gain coverage through the marketplace.
I've spent most of Monday talking to experts about when, exactly, that happens and, perhaps more importantly, why it matters. Most of them point to sometime around mid-November, or even Thanksgiving, as the crucial moment where the health insurance marketplace needs to be working.
"It seems to me if you don't have a Web site that is close to fully functional by sometime in the latter half of November, that's problematic," says Joel Ario, a consultant who previously oversaw exchanges at the Center for Consumer Information and Insurance Oversight.
"What I have been saying is that getting this fixed by mid-November gives people plenty of time to enroll," Caroline Pearson, vice president at Avalere Health, says. "You really have no meaningful impact on January 1 if you're up and running by November."
A lot of these people also have another nearby date circled on their calendars: Dec. 15. That's the very last day that shoppers can purchase a plan that starts on Jan. 1. The fact that there are two weeks of wiggle room might reflect some lessons learned during the Medicare Part D roll out. Back then, enrollment went up to Dec. 31 for Jan. 1. Seniors showed up at pharmacies looking to fill prescriptions, only to find that insurers' still did not have their enrollment data.
"December 15 is obviously a critical date because it's when people have to buy coverage if they want it to be effective on January 1," Kaiser Family Foundation President Drew Altman says.
If the Web site isn't fixed by time Thanksgiving hits, there are three potential problems that experts can foresee. First, fewer people would sign up for the program, shrinking the reach of the health law's insurance expansion.
Second, the people who do sign up might be a bit sicker and older than the general population -- and that would drive up the cost of health insurance in Affordable Care Act's second year. Pearson at Avalere says this wouldn't be a giant rate increase; certain policies like the temporary reinsurance program are meant to allay such challenges.
"It would mean that rates probably go up a bit," she says. "That's why you've got the reinsurance and risk corridors. And I think all the plans assume that, in year one, there will be some degree of adverse selection."
Third, if HealthCare.gov doesn't work by mid-November, and it is difficult to sign up for coverage before Jan. 1, then you're looking at some left-out shoppers who are in violation of the mandate to carry insurance coverage. It's important to note that they won't get penalized right away; the health-care law does allow for a two-month gap in insurance coverage before the mandate's tax penalties kick in.
Ario, the former administration official, also makes the case that not everything hinges on the Web site working perfectly. If it doesn't work well by mid-November, the administration could take more aggressive steps to direct shoppers to in-person assistance options or the call center, much like Obama did Monday.
"The truth is that's the way most of the system operates today," he says of applying for government programs. "It's not ideal, but it would probably be the way that things would go forward."
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Experts see weeks worth of work left on the exchanges. "Federal contractors have identified most of the main problems crippling President Obama’s online health insurance marketplace, but the administration has been slow to issue orders for fixing those flaws, and some contractors worry that the system may be weeks away from operating smoothly, people close to the project say." Sharon LaFraniere, Ian Austen and Robert Pear in The New York Times.
In the Northwest, Oregon and Washington are having hugely different experiences. "The Washington state-run exchange, called Washington Healthplanfinder, is widely perceived to be off to a strong start. Nearly 25,000 residents have enrolled in health-care coverage through Healthplanfinder over the exchange’s first two weeks, according to figures released Monday by the Washington Health Benefit Exchange, which operates the exchange. Compare that to Oregon, where state officials acknowledge not a single resident has been able to enroll through the website of that state’s exchange, called Cover Oregon, because the site still is not fully functioning." Amy Snow Landa in The Seattle Times.
And between New Mexico and Texas, a widening gap with the Medicaid expansion. "April Gomez-Rodriguez hopes Obamacare changes her life. Daniel Hughes says it’s like the health law never happened. Gomez-Rodriguez and Hughes are both uninsured. They don’t get coverage through their low-wage jobs, but they don’t qualify for traditional Medicaid. There’s no way they can afford to purchase health insurance on their own. But Gomez-Rodriguez, 32, who works with kids at a behavioral health center, lives in New Mexico, where Gov. Susana Martinez was among the first in the GOP to embrace the Medicaid expansion under the Affordable Care Act. On Jan. 1, Gomez-Rodriguez and her husband will have health coverage for the first time in years." Jennifer Haberkorn in Politico.