Insurance shoppers frustrated by this screen have other online options. (Photo by Karen Bleier/Getty Images)

Welcome to Health Reform Watch, Jason Millman's regular look at how the Affordable Care Act is changing the American health-care system — and being changed by it. You can reach Jason with questions, comments and suggestions here. Check back every Tuesday and Thursday afternoon for the latest edition, or sign up here to receive it straight from your inbox. Read previous columns here.

Well, is back in the news again, thanks to a new Government Accountability Office report that blames the Obama administration for pretty poor management leading up to the Web site's launch last fall. It's also clear that the Web site, which has cost $840 million so far, still needs more work.

The next Obamacare sign-up period will show "visible and continuous improvement, but not perfection," Andy Slavitt, the Centers for Medicare and Medicaid Services principal deputy administrator who's overseeing repairs, told a congressional committee on Thursday. Some consumers will still face "a bumpy process" with enrollment, he acknowledged.

Some of the behind-the-scenes functions that consumers don't see, like the systems allowing federal subsidy payments to insurers, still need to be built. But there's another part of the enrollment system that isn't quite ready, and it doesn't sound as if it will be by the time the Affordable Care Act's second enrollment period rolls around.

It's known as "direct enrollment," in which a consumer can go to a private online Web broker who provides a similar function that does — the brokers can sell a range of ACA health plans and offer insurance subsidies to those who qualify. The federal government reached agreements with several such entities last summer, with the idea that they would provide more opportunities for people to enroll in ACA plans.

The Web brokers envisioned a process in which an insurance shopper who comes to one of their Web sites could find an ACA-compliant health plan, find out their eligibility for subsidies and, if eligible, get that subsidy to purchase coverage — all within that same Web site. The subsidy eligibility check, which must be done by the IRS, would happen behind the scenes.

But that's not how things have worked in practice, said Gary Lauer, chief executive of the online broker eHealthInsurance. Instead, customers coming to the private Web brokers are able to shop for health plans, and then they're sent to t0 go through the application process again if they qualify for a subsidy. Then they're sent back to the broker's site to complete enrollment. Not exactly the most seamless process.

"It's really pretty archaic, but that's what we have," Lauer said during an earnings call Wednesday night. And he's not counting on direct enrollment getting any better for the next sign-up period. "We don't expect to see anything but [that] this year. We think that's going to be more stable, but it's not highly efficient."

Despite those complications, eHealth said it has helped about 10,000 people enroll in health plans with subsidies — a skimpy total compared with the 480,000 people who applied for individual and family coverage through eHealth during the ACA's first open enrollment period. Besides the clunky online process for obtaining subsidies, the company can also help people enroll in subsidized coverage over the phone, as other Web brokers have done. The enrollment process is much easier, though, if you earn too much to qualify for an insurance subsidy (more than 400 percent of the federal poverty level, or about $47,000 for an individual).

"We think we could've had the opportunity to have enrolled as many subsidy-eligibles as we did non-subsidy-eligibles in this last open enrollment period," Lauer said. "We certainly believe that the demand was there." was working well enough by the end of the last enrollment period that almost two-thirds of the 8 million who applied for exchange coverage went through the federal Web site. But the second enrollment period will still present some challenges. The Congressional Budget Office has set the unofficial enrollment bar with its projection that 13 million will sign up in exchange coverage during the 2015 enrollment period, which lasts just three months — half as long as the first one. The federal government brought on Web brokers to help boost exchange enrollment, but Lauer's comments raise questions about how much they can help next year.

Top health policy reads from around the Web:

A new fight brews over panel's recommendations for training doctors. "A high-level report recommending sweeping changes in how the government distributes $15 billion annually to subsidize the training of doctors has brought out the sharp scalpels of those who would be most immediately affected. The reaction also raises questions about the sensitive politics involved in redistributing a large pot of money that now goes disproportionately to teaching hospitals in the Northeast U.S. Released Tuesday, the report for the Institute of Medicine ... called for an end to providing the money directly to the teaching hospitals and to dramatically alter the way the funds are paid." Julie Rovner for Kaiser Health News.

Illinois outlines strong limits on Sovaldi access. "Medicaid officials have put in place tight criteria on prescriptions for Sovaldi, a new drug for hepatitis C with potentially game-changing effectiveness but also a budget-breaking price tag. A panel at the Illinois Department of Healthcare and Family Services that included Director Julie Hamos this month implemented a set of 25 criteria for prior authorization before it will pay for the drug, a product of Gilead Sciences Inc. with a wholesale price of $84,000 per 12-week regimen, or $1,000 per daily pill. The aim of the list is to narrow the eligibility for Sovaldi among the state's roughly 3 million Medicaid beneficiaries and limit the state's bill for treating hepatitis C, a potentially fatal liver infection." Andre Wang for Crain Chicago's Business.

Indiana governor meets with HHS on coverage expansion. "Gov. Mike Pence made a personal pitch Wednesday for federal approval of his alternative approach to expanding Medicaid, but acknowledged after a meeting with Health and Human Services Secretary Sylvia Burwell that differences remain. Instead of expanding traditional Medicaid as the law envisioned, Pence wants to use a variation of the Healthy Indiana Plan pilot program that's been in place for some Hoosiers since 2008. Some conservatives have said the proposal is already too much like traditional Medicaid and worry it will be watered down further to gain federal approval." Maureen Groppe in the Indianapolis Star.