More than nine months since the rocky launch of the nation's public health insurance marketplaces, the state-level exchanges are still a work in progress.
Collectively, more than 8 million people have signed up through the state marketplaces and the federal site, HealthCare.gov, since their inception, according to the Obama Administration's April tally.
Initially, 14 states planned to implement their own insurance shopping sites. But one state-run exchange has shut down, shifting its workload to HealthCare.gov, and at least two others are keeping this option open.
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In April, Oregon's Cover Oregon said it would shut down and send state residents instead to the federal HealthCare.gov site. Cover Oregon cited costs, including the expense of fixing the site before the next open-enrollment period in November, as among the reasons for the decision.
For Maryland, which is in the process of replacing its website before the next open enrollment period starts Nov. 15, the problematic launch of its marketplace has included an interface that seemingly caused the vast majority of users to pick one plan.
The Washington Post reported earlier this month that 94% of the 72,000 Marylanders who signed up for a plan though the marketplace picked a plan offered by Maryland-based insurer CareFirst.
Since spring, Massachusetts' Health Connector site has been following a dual path: Replacing its original, dysfunctional software while preparing to join the federal exchange.
But last week, following a successful test of the new hCentive software, Maydad Cohen, special adviser to the governor, told The Boston Globe he was increasingly but cautiously optimistic that the state will be able to employ the hCentive software when the next open enrollment starts on Nov. 15.
If the hCentive software passes another test in early August, the state will reportedly stop preparations to join the federal website. Even if the test fails and the state joins the federal exchange, it plans to develop its own system for 2016, according to published reports.
Unfortunately, there isn't one element behind success or failure of state exchanges, Sanjay Singh, CEO of Washington, D.C.-based hCentive told InformationWeek in a phone interview. Apart from Massachusetts, hCentive has helped New York, Kentucky, and Colorado set up their exchanges.
"There's no one thing that they did that made the difference," Singh said, noting the complexity of the deployments, with different approaches to management, system integration, and choice of vendors.
That said, Singh believes the next enrollment period beginning in November will go much more smoothly, thanks to every state "enhancing, tweaking, and fixing" its site. He said performance testing has been "much more rigorous," as has the testing around new features, such as the ability to update plans due to a life-status change.
"Lessons have been learned," Singh said.
While Oregon and other states leverage the federal site, the opposite is happening in New Mexico and Idaho, two states that relied on HealthCare.gov initially but plan to have their own exchanges this year and next, respectively.
"The larger point is that the line between state and federal [exchanges] is getting harder and harder to draw," Joel S. Ario told InformationWeek in a phone call. Now a managing director at Manatt Health Solutions, an interdisciplinary policy and business advisory division of law and consulting firm Manatt, Phelps & Phillips, LLP, Ario was the first director of the Office of Health Insurance Exchanges at the US Department of Health & Human Services, serving in 2010 and 2011.
Looking across the nation, Ario predicts there will eventually be a hybrid system, combining the best of the federal and state implementations.
"Every exchange will have best technology from the best of the state and federal work," he said.
And although the front-end glitches that bedeviled many of the state marketplaces and HealthCare.gov have been largely resolved, Ario said there remain back-office issues.
Also, unlike Singh, Ario is worried about the Nov. 15 enrollment date. "I don't think we're out of the woods," he said.
Indeed, the harshest critics of ACA contend the technical snafus that plagued the early days of the marketplaces remain. They point to a flurry of lawsuits and investigations against integrators like Oracle, Xerox, and CGI Group (the contractor behind the original, unreliable version of the federal HealthCare.gov site) for their work on state and federal exchange projects.
As recently as last week The Wall Street Journal reported that some consumers of online exchanges in California, Nevada, and Massachusetts discovered they weren't insured, despite having picked a private health plan and paid their premiums.
The WSJ story highlighted consumers who had run into problems and were "frustrated by a drawn-out process for resolving mix-ups." The story quotes Chris Stenrud, a spokesman for Kaiser Permanente, who said, "Generally, in our work to process hundreds of thousands of new enrollments, there have been a small number of people who've gotten in situations like this."
Also last week, a small study published in the Annals of Internal Medicine said several simple steps could significantly improve the usability of HealthCare.gov for educated young adults.
Finding that "participants were challenged by poor understanding of health insurance terms that were inadequately explained," the study's authors recommended, among other things, implementing a decision-support tool and providing explanations of health insurance industry vocabulary.
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