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 or sign up here to receive it straight from your inbox. Read previous columns here.

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Jane Good hasn't finished her Christmas shopping yet -- in fact, she hasn't even started. Unlike the rest of us, Good has an excellent excuse: She is the point person at one of the country's largest health insurance plans for making Obamacare enrollments work.

"We're in the trenches," Good, program director for service operations and technical solutions at health insurer Aetna, told a packed ballroom at America's Health Insurance Plan conference in D.C. on Thursday. "Please tell my family they're not getting Christmas presents this year."

We all now know that the rollout of HealthCare.gov went terribly, and was nowhere near what the Obama administration had hoped. For the past few months, Good has had a front-row seat to the behind-the-scenes dysfunction. That made her perspective on how badly things went -- and how that's changing now -- especially interesting to hear.

Back in September, Good says her team at Aetna was worried about smaller problems. They were nervous, for example, that the invoice they sent to consumers wouldn't match the premium quote given on the federal Web site. They prepared for those types of situations -- and not one where some subscribers wouldn't even know if they were enrolled. Her team devoured various handbooks and guides put out by the federal government, memorizing the rules and regulations.

When Good was asked to speak at this mid-December conference back on Oct. 7, she imagined the Web site's initial bumps would be largely smoothed out.

"I thought I would bring an easy set of 'lessons learned' slides and maybe even a big 'mission accomplished' banner," she says.

The first few weeks were incredibly rough. Problems that Aetna expected to be limited to a handful of cases were widespread. Aetna is part of a small group of insurers that the Centers for Medicare & Medicaid Services calls "the Alpha Team," who the administration works most closely with in sharing information and understanding problems.

"In some situations, what we thought might be an exception, like multiple transactions by the same member in the same day, turned out to be more the standard," Good says. "The early lack of information made processing those transactions a challenge."

By mid-October, HealthCare.gov's back-end problems were coming into focus; insurers were realizing that the files they get when someone signs up, known as 834 transmissions, had problems. Lots of problems. They started seeing something that's come to be known as "orphan" files: Situations where someone clicked "enroll" but a transmission was never fired off to the insurance plan.

Problems with a wrong address or incorrectly spelled name are troublesome but, in a way, manageable: There's at least some clue that a person tried to buy health insurance coverage. The orphan files are pretty much as sad as they sound, situations where the insurer has no clue that someone wants to sign up.

Good recalls suggesting, in mid-October, that the federal government provide health insurers with some type of list of who they thought had signed up. That would at least give insurance plans a sense of who was left out in the cold.

"We've been very persistent and outspoken in many meetings we attend," Good says. "In mid-October, we started suggesting to CMS and others that they extract that information."

That information went out to health insurance plans...nearly two months later, earlier this week. Good, and other insurance officials I've spoken with, say they're still looking over those files to get a sense of how many orphans actually exist. The good news here, she says, is this problem seems to be a bit lower than expected. Good also says that enrollment has picked up.

"All issuers received these pre-audit files, and now we're able to tackle orphan records and any other data disconnects we might find," she says. A lot of the focus now is moving to the actual nuts-and-bolts of getting people enrolled in insurance, like sending out insurance cards and making sure that doctors are ready to accept them.

The orphans, in other words, may get their insurance coverage for Christmas. Although Good warns that her family, on the other hand, might not quite get their presents on time.

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

The federal exchange has a backlog of about 50,000 paper applications.  "Even though HealthCare.gov has been working better since the start of the month, there are still reasons why people may be having trouble getting coverage. One significant reason is that the federal marketplace has accumulated a backlog of 50,000 to 60,000 paper applications as cracks have appeared in that low-tech method offered this fall as a backup plan, according to government officials." Amy Goldstein in The Washington Post.

Obamacare is getting blamed for pretty much everything. "Just because something is happening and Obamacare exists doesn't mean it's happening because Obamacare exists—even in health care. Don't tell that to the law's critics: The Affordable Care Act has become the go-to scapegoat for just about everything people don't like about health care, if not in the economy overall. The law is being blamed for trends, economic incentives, and basic realities that it did not create and that were part of the health care system long before President Obama was even elected." Sam Baker in National Journal.

Some New Yorkers are turning against Obamacare. "Many in New York’s professional and cultural elite have long supported President Obama’s health care plan. But now, to their surprise, thousands of writers, opera singers, music teachers, photographers, doctors, lawyers and others are learning that their health insurance plans are being canceled and they may have to pay more to get comparable coverage, if they can find it." Anemona Hartocollis in The New York Times.