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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On the morning of Oct. 1, most of the federal government was shutting down.
But at the Center for Consumer Information and Insurance Oversight — known, among health policy types by its acronym, CCIIO — a newly established "war room" was just starting up.
"This group will meet twice daily," the notes from the first meeting announce. "Group leaders will meet for 15 minutes after the morning meeting to handle other issues."
Notes from a month of the war room meetings, released Tuesday by the House Oversight Committee, reveal a chaotic implementation process that looked just as bad from the inside — if not worse — than it did to the public on the outside.
Each day brought different issues, some of which the administration learned about from reading outside news reports.
"Bloomberg news article says that many 834s are corrupted and HCSC (Blue Cross issuer in OK, IL, MT, TX, and others) is upset," notes from Oct. 8 say. "They are quoting that 200,000 bad enrollments are happening."
Mostly though, the war room notes underscore how significant it was that the federal government ended up running the majority of health law insurance marketplaces, and how that increased the Obama administration's workload.
Thirty-four states decided to either operate an insurance marketplace in partnership with the federal government, or leave the entire task to the Obama administration. That means, that in about two of every three states, its the people in the CCIIO War Room, and their colleagues, who are managing the back end of the exchange.
In the lead up to October, it wasn't clear that this extra workload would be a huge factor. There were arguments about whether the federal government's work could be easily scaled. If you're building one insurance marketplace, the thinking would go, its easy enough to plop that model down in any state where the feds are running the show.
In terms of the Web site's consumer facing design, this worked: Each state on the federal marketplace uses the same homepage for HealthCare.gov. The application process looks the same, whether you're buying coverage in Alaska or Wyoming.
But behind the scenes, the war room notes paint a completely different narrative, where each state's idiosyncratic issues didn't lend themselves to scale. Alaska and Wyoming, in other words, had totally different problems — ones that couldn't be addressed with a singular fix.
On Oct. 4 alone, three separate states reported three completely different issues. New Hampshire had a question about whether it could add elective abortion coverage to its health plans and, if it did, should that increase the premiums.
Wisconsin carriers wanted to change certain rates on the marketplace. Would that be allowed?
And in Utah's marketplace, two insurance plans had disappeared from HealthCare.gov altogether.
"They are saying all of their plans are not available," notes on the Utah-specific issues say. "We don't know enough to know what to do because we don't know if it is an across-the-board problem or a scenario problem."
This happens again and again throughout the war room notes, with issues coming in from across the country. Florida has different problems than Texas; Idaho and New Mexico seem to experience similar issues to one another, but not to other states.
In states running their own marketplaces, there's a whole team of people in that state dedicated addressing issues like these.
The big workload from managing lots of state marketplaces definitely was not the federal government's only problem; throughout the war room notes, there are mentions of challenges with 834 enrollment forms, which tell insurers who has signed up for their plans — and were being sent out with inaccurate information.
At one point in late October, the marketplace didn't send out any of these forms for a few days because of the data problems.
But having lots of state marketplaces on their plate certainly didn't help — nor did a government shutdown right at the moment that HealthCare.gov launched. While the health care law was generally shielded from the shutdown, there are nine mentions of furloughed workers and their impact on exchange operations.
"The two folks running the call are furloughed," notes from an Oct. 1 meeting read, regarding a call with health plans. "The call should go on."
"Casework, team was furloughed yesterday, but called back in today," notes from the next day say, "so they should be up soon."
KLIFF NOTES: Top health policy reads from around the Web.
McAuliffe's win could boost chances of a Virginia Medicaid expansion. "McAuliffe, who mentions his support for the expansion in nearly every speech, has made extending basic health-care coverage to more than 400,000 low-income Virginians a central part of his platform. That’s a stark contrast to his opponent, Attorney General Ken Cuccinelli, who filed a lawsuit against Obamacare the very day it passed in 2010." Jason Millman in Politico.
Obamacare enrollment figures are coming out next week. "Testifying Tuesday on Capitol Hill, Marilyn Tavenner said her agency, the Centers for Medicare and Medicaid Services (CMS), plans to release information next week about who enrolled through the state and federal exchanges. She said the target for the end of November is 800,000 enrollments." Sandhya Somashekhar and Amy Goldstein in The Washington Post.
But don't put too much weight on those numbers. "For starters, the number is sure to be small. Democrats anticipated low take-up in the first month, and they have acknowledged that HealthCare.gov’s technical problems will make October’s numbers even lower than expected. Republicans might be able to crow over a small number of enrollments, but it won’t be a surprise. Moreover, focusing on the total number of enrollees leaves other important questions unanswered. Obamacare’s success will depend not only on how many people enroll, but also on who they are and where they sign up — information a top-line enrollment figure won’t necessarily provide." Sam Baker in National Journal.