Affordable Care Act Exchanges and Rollout

As a benefits consultant and former manager of benefits for a multi-state corporation, let me state the obvious, the rollout of the www.healthcare.gov website could definitely have been handled better and needs to further improve. On Friday, I browsed the website which is handling enrollment for 36 states and found it to be very informative and helpful. Yet, I did not attempt to set up an account, which is where the rubber needs to hit the road. My ability to browse on Friday was not permitted when it launched on October 1, as a late decision was made to require the set up of an account first to activate the subsidies engine when looking at premium rate information. The administrators have since changed that decision which will allow people like me to look around before we set up an account to purchase coverage.

Let me make three major points as we look forward and backwards. First, the enrollment process is only one of five key pressure points in the execution of coverage. Once you have enrolled, the next pressure point is for the system to pass your information to the insurance carrier you have selected for coverage. That will likely occur in multiple feeds, so it is incumbent on the carrier not to process duplicate records. Plus, for late enrollees who want coverage January 1, there is only fifteen days for a final true up file between the system and carriers.

This enrollment file is vital to making sure coverage begins. So, the third key pressure point is getting enrollment ID cards to verify coverage. When I think of this process, I recall the time one healthcare vendor for my company sent some enrollees six ID cards, some three and some zero. Apparently, the ID printer kept stalling and the system started printing from the start.

The fourth pressure point is when the billing process starts, which actually will occur after the effective date of coverage for many. Will the subsidies be properly applied and will the premiums be properly invoiced each month? In the corporate world, the first pay period when premium deductions are made in January is when people realize they may have signed up for the wrong plan.

The fifth and major pressure point is when a person goes to the doctor in early January. Do they have coverage? This is what is known as the point of reckoning. In my job as manager of benefits, you did not want to get a call from an employee or spouse of an employee whose doctor is seeing coverage denied on the system. So, fixing the website is important, but the administrators and insurance carriers need to make sure they get these other parts right as well.

Second, I want to state the obvious that Obamacare is designed to get insurance coverage to people who did not have access. In the finger-pointing and misinformation campaign, we lose sight of the fact that almost fifty million people do not have access to health coverage. Those with coverage pay for these uninsured now through pass through costs and taxes to support county and federal subsidies. Yet, those without insurance are using the system at the worst time and place – when a medical issue is critical and at the emergency room which is a very expensive place. Getting people access to coverage beforehand will permit a better cost and utilization model for all concerned. And, preventive care will be introduced to help avoid medical issues to worsen.

Already through the earlier implemented items under Obamacare, adult children under 26 not in college can stay on a parent’s plan (this has added over 3 million enrollees), pre-existing condition restrictions are waived for children (and will be waived for all January 1), lifetime limits on medical costs have been lifted, the Medicare prescription drug benefits have been improved and insurance company profits are limited on premiums (which has caused refunds to some premium payers the last two summers). These features are well received and the further elimination of the pre-existing condition restrictions and better mental health benefits are significant changes coming January 1.

Third and final, looking backwards two major stakeholders could have done better. The President’s team should have started earlier and involved more quarterbacking of various efforts. Plus, decisions on the design of the website and supporting call center should have been put to bed months before to permit detailed User Acceptance Testing. If you ask AonHewitt, Mercer, TowersWatson, etc., they each want their clients to put to bed plan design changes and premium rates by early August when they go into the October enrollment cycle for their clients – and this is with a fully designed system. So, the fact someone made decisions late to the design of a very complicated system was a poor move and should have been disallowed.

The other group which should not be overlooked is the role Republicans played in this whole process to make a hard thing harder. They should not be too smug, as when you do the following:

– fight the constitutionality of a law designed to help people (using a structure that is largely a GOP idea no less) through the spring, 2012;

– this fight delayed efforts by many states to set up their own exchanges, which would have made the process less complicated as exhibited by some states having few glitches thus far;

– the Republican led states who decided not to expand Medicaid to defeat Obamacare, which is and was a win-win decision for the people in need, hospitals and the state economies, made it a mixed bag of offerings to administer and communicate; and

– the constant fight to defund, disinform, and dissuade people from using and understanding the new law has done a law designed to help people a huge disservice;

the implementation is made harder. So, to sit back and point fingers as to why did you allow this to happen and see I told you so, does not sit very well with this Independent voter. To me constructive questions on how to make it better and get people enrolled are fair game. I go back to a comment I made in an earlier post – in his twenty-one hours of filibustering, Senator Ted Cruz failed to mention that his state of Texas was dead last out of fifty states and Puerto Rico, by having the most uninsured people in the US. So, my question to him and others is why don’t you support Obamacare and why doesn’t your state expand Medicaid to help those in need? Those uninsureds are citizens of Texas, too.

So, I hope this can get fixed. I think it will get fixed, but the question is when. If it does not or if it takes too long, then it is truly unfortunate as people will get hurt. The political chess game may turn against the new law and the real losers will be those pawns I keep fighting for who need healthcare coverage. They cannot get coverage because of access, cost and pre-existing conditions. There are almost 50 million of these pawns and include Republicans, Libertarians, Democrats and Independents. They will be helped by the Affordable Care Act. Let’s see it through.

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8 thoughts on “Affordable Care Act Exchanges and Rollout

  1. This, too shall pass. Every major government program since Social Security in the ’30’s has had start-up problems, including the last, most recent, Medicare, Part D, under the Bush administration. I can see extending the sign-up period or other work-arounds possible, but it won’t be delayed, and it certainly won’t be cancelled, as our RepubliCANT friends would like.

    • I hope you are right. I agree about the past hiccups as well, but I don’t think we had the “kill the beast” zeal toward those, so every problem is highlighted more.

  2. I would have been shocked if there hadn’t been at least one noticeable bug/glitch/issue. I am equally not surprised by the finger pointing going on between everyone involved. They all have a share of the responsibility for what happened.

    The system is a giant database with information going in and out. The passing of information from one database system to another is typically done through EDI Exchanges that are set up to avoid duplication of information. An EDI exchange takes the information entered into the fields on one database breaks it down into a text document following strict programmed for guidelines and ships it to the other database. The other database reads it, takes the info and puts it into the form on the other side.

    I would not be shocked if the architecture isn’t a maze wrapped in a black-hole with a hub at the center that if modified would end up crashing a portion of the system, or the entire thing. That is on the programming companies and the programmers.

    • Many thanks for your thoughts. This is definitely complex. It would have been easier, but still complex, if separate state exchanges were more involved and every state expanded Medicaid. The finger pointing for its own sake rubs me wrong.

  3. I was one of those who did not have access to health insurance. Uninsured from November 2003 to July 2012. After the lifetime cap was lifted in January 2012 because of the ACA, I had insurance companies calling me, texting me, emailing me, snail mailing me. One even knocked on my door. I now have insurance at an affordable $287 a month with affordable copays, affordable deductibles, and affordable prescriptions.

    • Thanks Russel. These are the untold stories that get shouted over in decible level by the negative ones, which do exist, yet are dwarfed by the positive stories like yours.

  4. I wanted to give three quick updates: The exchanges continue to trudge uphill. October numbers will not break records, but they do need to show progress in November. A couple of states are ahead of expectations. I have been on the healthcare.gov a few times to browse and it is fine for this. I will be enrolling later this month, so I hope it is ready for me. The big success story in October is the Medicaid expansion in the states that are doing this – 444,000 folks have signed up thus far. Too bad the other states are not doing this yet, as the states not doing this are giving money away to the states that do, not to mention not helping people and causing the exchange prices to be higher as a result with the higher risk participants. Employer plan participation is increasing due to the mandate as well. Employees who opted out are opting in during the employer open enrollments.

  5. Another update for numbers through November month end. 803,000 people have signed up for the Medicaid expansion in the states where offered and 365,000 had signed up on the exchanges for coverage. The first two months of December on the federal site said 29,000 per day set up coverage. I have written another post where I lost my coverage, but was able to find a cheaper replacement and a better, similar cost replacement even without a subsidy. There is still a rocky road left over the next several weeks into January, but Americans deserve the politics of this issue to get out of the way and let them make the best choice for them.

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