Say what you will about the Affordable Care Act, but give California credit. Not only are we far outpacing Washington’s health care rollout, we’re among several states outpacing our own enrollment projections while states depending on the federal website lag far behind.
Nearly half of October enrollments were in California and New York. While New York maintained its strong opening in November, California figures have improved dramatically. What are we doing right that the feds aren’t?
“We had more time to plan, and we knew exactly what we were planning for,” Peter Lee, the executive director of Covered California, tells me.
After the Affordable Care Act became law in 2010, California passed legislation approving an online insurance exchange. Those next two years provided ample time to develop, revise and test a complex computer system before taking it live last month.
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“We shared our specifications with the biggest vendors who were going to bid, our potential insurance companies and consumer advocates,” Lee said. “They made our specifications better so when we went forward, we were really focused on what matters.”
That timeline wasn’t there at the federal level. The law’s passage didn’t guarantee its survival. Had the U.S. Supreme Court ruled the law unconstitutional or the president lost his re-election bid, prematurely pouring resources into developing and testing a massive digital infrastructure would’ve been for naught. It left the administration with barely nine months for an intense ramp-up effort – hardly enough time. We’ve seen the result.
“If you had asked, ‘Could you use another year?’ Everyone, I think, would’ve said yeah,” said Frank Mecca, executive director of the County Welfare Directors Association of California, which, along with California’s Department of Health Care Services, has partnered with Covered California in the state’s insurance exchange rollout.
“The politics of health care left the president with a Hobson’s choice,” Mecca told me: “Launch something glitchy and problematic, and take your lumps for that, or delay and take your lumps for that.”
That delay would’ve put health care politicking right in the middle of a midterm election, something the administration wanted to avoid.
The administration also miscalculated on what red states would do. Three years ago, Lee explained, everyone thought most states would run their own exchanges. It wasn’t known until about a year ago that 36 states decided not to participate.
“That meant the federal government ended up needing to design something far bigger than anyone had anticipated,” Lee said. Bigger in more ways than one.
“California is an active purchaser,” Lee explained. “We’re picky about our health plans. We don’t take them all. We ended up with 11 plans across the state. Each insurer offers, on average, 36 products. Combined, that’s about 400 products for our computer system to manage.” Simple math: 11 times 36.
The federal government, however, is not an active purchaser, nor selective about which plans to pick; it accepts all comers fitting the Affordable Care Act’s guidelines. HealthCare.gov has 186 insurance carriers, each offering an average of 86 products to consumers. Total number of different products on the federal exchange marketplace: 16,000. Had red states done their “states rights” thing, the rollout story might’ve been far different.
Officials have always maintained that sign-ups would start off slowly and pick up steam. Certainly that’s been true in California. In the first week of October, only 700 Californians a day selected a health plan. And now? “We’re actually signing up 10,000 people every single day,” Lee said.
Analysts expect a health insurance enrollment surge in December. Historically, the Monday after Thanksgiving has always been the single busiest day of open enrollment for Medicare patients. Cyber Monday holiday shopping and the sense that December finally represents a deadline will likely fuel that surge.
In a conference call Friday, HealthCare.gov officials said in addition to upgrading website capacity, they’re beefing up additional paths for enrollment like call centers and in-person assistance.
California has done this from day one.
“Any person can walk off the street into a county human service agency and get help enrolling in the exchange,” said Mecca – rich, poor, middle class; whether eligible for Medi-Cal, tax subsidies or neither. Anyone.
Yes, insurance premiums will rise for some. Roughly 40 percent of the 1.65 million Californians in the individual market will see their premiums increase anywhere from 5 percent to more than 50 percent, according to the exchange.
“This is one of the things Congress should look at,” Lee said. “How to improve the law to make sure everyone has health care that’s affordable.”
But in contrasting that group with the many families financially crushed after spending their life savings on a catastrophic health crisis or accident, Lee insists, “I am absolutely certain we did the right thing.”
“We’re not perfect by a long shot,” he said. “We’ve had stumbles, we’ve had things to learn from, but we’re getting better every day, and you see in California what can be done.”