By Julie Appleby
Kaiser Health News
They’ve got a few weeks.
But if federal officials can’t get the new online insurance marketplace running smoothly by mid-November, the problems plaguing the three-week-old website could become a far bigger threat to the success of the health law, hampering enrollment and fueling opponents’ calls to delay implementation, say analysts.
“The system needs to be operating reasonably efficiently – I’m not saying flawlessly – before the middle of November,” said Insurance Commissioner Sandy Praeger of Kansas, one of the 36 states relying on the federal marketplace because legislators opted not to do their own state-based market.
On Monday, President Barack Obama addressed the problems directly for the first time, saying “no one is more frustrated than me” and promising that technology experts from around the country were working with the administration “to get this working better, faster, sooner.”
Still, he did not offer details about the scope of the problems, a timeline for the repairs or the number of people who have successfully enrolled out of the more than 19 million site visitors.
The stakes are huge – not just because of public opinion, but practically, in terms of creating the broad insurance pools which are key to the law’s success. The marketplaces are supposed to be one-stop shops where individual consumers could compare policies, find out if they are eligible for subsidies, and enroll in coverage. But without robust participation – and the government is counting on 7 million enrollees the first year — the program could fall short of attracting the necessary numbers and balance between healthy and unhealthy consumers, potentially resulting in premium hikes in future years.
“If we’re not seeing a substantial improvement in next two or three weeks, we’ll be in a bad place,” said Dan Schuyler, an exchange expert at Leavitt Partners consulting firm. “We’re already behind the curve in getting to that 7 million mark.”
The risk in frustrating consumers is that those who are healthy or on the fence about enrolling may give up, leaving the unhealthy to persevere and enroll, which could drive up premiums in future years, potentially leading to what experts call “a death spiral,” where only the sickest people sign on.
“The people who will go back will be precisely the ones who need health insurance because they’ve got ongoing problems,” said Joe Antos, economist at the American Enterprise Institute.
Experts outside the government debate the scope of the problems with little information coming from the Obama administration. What is known is that bugs have made it difficult, if not impossible for consumers to create accounts and have also resulted in insurers getting misinformation about those who do manage to enroll. The troubles have been most severe with the federal website, although a few of the 14 states operating state exchanges are also experiencing serious problems.
If the administration solves the problems before the end of October, “this would just be a blip on the radar,” said Dan Mendelson of consulting firm Avalere Health in Washington.
If problems cannot be resolved that quickly, Mendelson said “there are other options for getting people enrolled,” noting that Medicare beneficiaries signed up for coverage for decades without using computers.
The president also mentioned those options Monday, saying consumers could sign up by telephone, in person with trained assisters or by downloading an application and mailing it in.
But those options are not ideal, mainly because millions of applications would have to be manually checked across several federal agencies.
“That would take significantly longer than if it was automated,” said Schuyler. “While it’s a fallback, it’s not going to resolve the issue that if Healthcare.gov doesn’t improve in two or three weeks, we’re going to have this backlog of people who are trying to enroll.”
Consumers have until Dec. 15 to enroll for coverage that starts Jan. 1, although the open enrollment period goes to March 31.
Some analysts suggest that if problems persist into late November or December, that the Obama administration will need to consider extending the open enrollment period.
Such a decision, however, would have political and financial ramifications.
Republicans are already seizing on the troubles as a way to advance their effort to delay or eliminate the law, and may obstruct changes that require congressional approval.
Insurers may not support a longer enrollment either, said Antos. That’s because a later deadline means more time without premium revenue coming in from potential healthy customers while costs mount from providing care to sick customers, who probably signed up before Jan. 1, he said.
Extending the enrollment period could also lead to a domino effect, bolstering efforts by Republicans and other critics of the law to delay the fine for those who fail to sign up for coverage. With some exceptions, nearly all Americans are required to have insurance next year, or they face a penalty of $95 or 1 percent of their household income.
In addition, it could hurt public perception of the law and of the federal government, said Geoffrey Joyce, director of health policy at the Schaeffer Center for Health Policy and Economics at USC.
“From a political standpoint, it just shows that this is not working well and it gives fuel to the opposition,” he said. “It doesn’t build confidence that these people know what they are doing.”
Others, however, are less concerned about a slow start. “The law would not reach its target of insuring as many people as possible,” said Carter Price, a mathematician at the Rand Corporation. “But [the federal government] will get a second chance the next year if things don’t go off as planned the first year.”
Greg Mellowe, policy director of consumer group Florida Chain, said that while the troubled website makes it more difficult for groups doing outreach and education, “most people understand that problems with technology are to be expected early on in an initiative of this magnitude.”
Because the health law is primarily aimed at low to moderate income people – and their household cash flow is often drained by holiday gift spending and replenished by February tax refunds — getting the exchange working by November isn’t critical, said Brian Haile, senior vice president of healthcare policy at Jackson Hewitt tax service.
“If you’re trying to sell something you need to do it at a period during which you don’t have competing consumption,” said Haile. “After Nov. 1 … foremost on their minds is not, ‘Am I going to buy insurance?’ but ‘What am I going to put under the tree?’ ”
Jay Hancock, Anna Gorman and Philip Galewitz contributed.
Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.