It Was the Best Exchange, It Was the Worst Exchange

In the first three months of Obamacare enrollment, the insurance exchanges have been a very mixed bag.

National Journal
Sophie Novack
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Sophie Novack
Dec. 26, 2013, 1 a.m.

Con­sumers’ ex­per­i­ence with Obama­care has var­ied a great deal de­pend­ing on where they live. At the Oct. 1 launch, state-run ex­changes claimed most of the in­sur­ance suc­cess stor­ies, while con­sumers try­ing to sign up through Health­ found it largely non­func­tion­al. Among those 15 state-based ex­changes (in­clud­ing the Dis­trict of Columbia), the ex­per­i­ence ranged from easy to lit­er­ally im­possible. 

Now past the ini­tial en­roll­ment dead­line of Dec. 24 for most states, the in­sur­ance ex­changes have come a long way since the be­gin­ning of Oc­to­ber. As the next phase of en­roll­ment be­gins, ex­changes can learn from those that suc­ceeded and those that went very wrong. 

The Best


A state with nearly 7 mil­lion un­in­sured res­id­ents, Cali­for­nia is boast­ing the highest en­roll­ment num­bers dur­ing the first three months of Obama­care im­ple­ment­a­tion.

As of early this week, about 400,000 people had en­rolled in private plans through the state’s ex­change, Covered Cali­for­nia. Cali­for­nia saw a huge surge in en­roll­ments in Decem­ber, par­tic­u­larly ahead of the dead­line for Jan. 1 cov­er­age. Between this past Fri­day and Sunday, 77,000 people chose a private in­sur­ance plan on the ex­change, with a re­cord 29,000 en­roll­ments on Fri­day alone.

“We’re all in the first in­ning of a nine-in­ning game,” Peter Lee, ex­ec­ut­ive dir­ect­or of Covered Cali­for­nia, said on a press call last week. “But we’re start­ing to see data in­dic­at­ive of where we’re go­ing, and data to learn from.” Lee poin­ted out that the en­roll­ments do not in­clude those buy­ing dir­ectly from in­sur­ance com­pan­ies.

Lee says Covered Cali­for­nia has not ex­per­i­enced the back-end prob­lems that have plagued Health­, which were caus­ing in­surers to re­ceive in­ac­cur­ate con­sumer in­form­a­tion. Plans are billing con­sumers between one and three days after re­ceipt of their ap­plic­a­tion.

The dead­line to pay premi­ums for cov­er­age be­gin­ning Jan. 1 is Jan. 6 in Cali­for­nia.


Ken­tucky is un­usu­al as a red state that is ag­gress­ively im­ple­ment­ing Obama­care — both ex­pand­ing Medi­caid and set­ting up its own ex­change — thanks to Demo­crat­ic Gov. Steve Be­s­hear’s no-par­tis­an-non­sense ap­proach to im­ple­ment­a­tion.

As of Dec. 21, more than 100,000 Ken­tucki­ans had en­rolled through the state’s ex­change, Kynect, with about a 75 per­cent to 25 per­cent split between Medi­caid and private-plan en­roll­ment. Over 640,000 Ken­tucky res­id­ents — about 15 per­cent of the state’s pop­u­la­tion — are un­in­sured, with a great deal to gain from ex­pan­ded cov­er­age.

Kynect has been op­er­at­ing smoothly, and the back-end has not been an is­sue, ac­cord­ing to Car­rie Ba­na­han, ex­ec­ut­ive dir­ect­or of the Ken­tucky Health Be­ne­fit Ex­change. Once ap­plic­a­tions are ap­proved, the forms are trans­mit­ted to in­surers nightly, and ap­plic­ants can be billed as early as the next day.

Con­sumer in­terest and en­roll­ment has been high in the state since Oct. 1, with a re­cent surge ahead of the first dead­line. Since Thanks­giv­ing, pur­chases of private ex­change plans have in­creased by 121 per­cent. The ex­change is ap­prov­ing around 3,000 people for Medi­caid or private cov­er­age each day, up from 1,000 and 2,000 in pre­vi­ous es­tim­ates.

Ken­tucki­ans must pay their premi­ums by Jan. 1 for cov­er­age to be­gin on that date.

Run­ners-up: New York, Wash­ing­ton

The Worst


The Ore­gon health ex­change, Cov­er Ore­gon, has con­sist­ently per­formed worse than the much-ma­ligned Health­ Three months in­to open en­roll­ment, the web­site is still a fail­ure, and the ex­change has been the slow­est to en­roll people in private cov­er­age.

Ore­gon has re­lied on pa­per ap­plic­a­tions, which are slow to pro­cess, and the prob­lems will leave many Ore­go­ni­ans without cov­er­age at the be­gin­ning of the year. The state set a Dec. 4 dead­line to sub­mit pa­per ap­plic­a­tions. Once an ap­plic­a­tion is ap­proved, the in­di­vidu­al re­ceives an en­roll­ment pack­et in the mail, and must then se­lect a plan through the Cov­er Ore­gon web­site.

Of­fi­cials say they have only just got­ten through most of the on-time ap­plic­a­tions, fol­low­ing a back­log of over 30,000 un­pro­cessed ap­plic­a­tions two weeks ago.

Around 70,000 Ore­go­ni­ans have been deemed eli­gible for cov­er­age through private plans or the state Medi­caid pro­gram. About 36,000 con­sumers en­rolled as of Tues­day — 12,000 in private plans and 24,000 through Medi­caid. In Oc­to­ber and Novem­ber, a total of only 44 in­di­vidu­als se­lec­ted private plans on the ex­change.

Of­fi­cials are still work­ing to no­ti­fy those who have been deemed eli­gible in time for them to en­roll in cov­er­age by this Fri­day. Most con­sumers whose ap­plic­a­tions were on time but in­com­plete have not been con­tac­ted, and they will likely face a cov­er­age gap un­til they com­plete their ap­plic­a­tions for cov­er­age be­gin­ning Feb­ru­ary. 

Eli­gible ap­plic­ants must choose a plan by 5 p.m. on Dec. 27 and pay their premi­um by Jan. 15 to re­ceive cov­er­age be­gin­ning Jan. 1.


The prob­lems with the fed­er­al ex­change have been well-known, be­cause the web­site serves all 36 states us­ing the fed­er­al mar­ket­place. For­tu­nately, the spot­light forced re­pairs, and the web­site has been run­ning smoothly for the most part since the ad­min­is­tra­tion’s self-im­posed fix date of Dec. 1. However, tech­nic­al prob­lems dur­ing the first couple of months pre­ven­ted many who ini­tially flooded the site from en­rolling, and this set cov­er­age goals back severely.

En­roll­ment dur­ing the first month was dis­mal, hampered by high er­ror rates, long wait times, and web­site crashes. The fed­er­al mar­ket­place ac­coun­ted for only 25 per­cent of the 106,000 total en­roll­ments in the fed­er­al and state ex­changes in Oc­to­ber, des­pite serving 36 states.

The num­ber of en­roll­ments through Health­ jumped in Novem­ber, and dra­mat­ic­ally in Decem­ber. Around 29,000 people en­rolled in the fed­er­al ex­change in the first two days in Decem­ber — more than in the en­tire month of Oc­to­ber. Over 500,000 people en­rolled in cov­er­age through the fed­er­al ex­change this month, Pres­id­ent Obama said at a news con­fer­ence Fri­day.

The Health and Hu­man Ser­vices De­part­ment ini­tially ex­pec­ted 3.3 mil­lion people to en­roll in cov­er­age by the end of Decem­ber, and 7 mil­lion by March 31. The ad­min­is­tra­tion will surely miss its end-of-year goal, but the ac­cel­er­a­tion of en­roll­ment in Decem­ber is a good sign for the next three months.

Back-end prob­lems with Health­ were still cre­at­ing ser­i­ous prob­lems for in­surers in Decem­ber, al­though er­ror rates in trans­mis­sion forms dropped dra­mat­ic­ally from 25 per­cent in Oc­to­ber and Novem­ber. It re­mains to be seen wheth­er prob­lems will oc­cur when con­sumers be­gin us­ing their in­sur­ance in Janu­ary.

In­di­vidu­als on the fed­er­al ex­change must pay their premi­ums by Jan. 10 for cov­er­age be­gin­ning Jan. 1.

Run­ner-up: Mary­land 

Obama­care open en­roll­ment in all states runs through March 31, 2014. Con­sumers must en­roll by Jan. 15 for cov­er­age be­gin­ning Feb. 1. 

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