Pent-up demand for health insurance and curiosity about what the exchanges have to offer proved too much for the federal and many state systems to handle upon opening of the health insurance marketplaces.
But capacity, website design, software code and processes is steadily improving.
Even with the bumpy performance, in the first 10 days, there were 14.6 million unique visits to healthcare.gov, the Health and Human Services Department reported. State-based exchanges have had more success in enrolling individuals.
Nevertheless, there is still plenty of time for customers to sign up – but perhaps not as many as the Obama administration was counting on because of the snafus.
Health plans are engaged in a variety of activities to help individuals understand their options and enroll in a plan that is right for them and work through the early confusion, the Blue Cross Blue Shield Association noted.
"Experienced systems experts from across the industry are working closely with federal and state exchange officials to help address operational issues as they arise, similar to what was done during the introduction of the Medicare prescription drug program," said Robert Elfinger, a spokesman for BCBSA. "As the new marketplaces move forward, we are confident consumers will be able to get the coverage they need."
State-based exchanges are operating better, said Caroline Pearson, vice president at Avalere Health. "Our sense from the plans and the states is that the state exchanges' websites are working and are able to communicate enrollment information to the health plans, which can then finalize that process," she said.
The exchanges are typically supposed to batch data to the health plans on a daily basis so that they get files and all the information of who is enrolled and process that. "We've heard mixed results in terms of the accuracy and usability of those files," Pearson said.
The state-based exchanges seem to be on a really rapid path towards smoothing out their processes and making enrollment quicker, she said.
As an example, Washington's exchange, Washington Healthplanfinder, reported that it had enrolled 25,000 individuals in the first two weeks. An additional 37,000 residents had completed online applications that were awaiting payment due in December. "Enrollments are coming in across the state – through our website, toll-free customer support center, local in-person assister organizations and registered brokers," said Richard Onizuka, CEO of the Washington Health Benefit Exchange, in a release.
Connecticut's Access Health CT reported that in its first 10 days 126,000 unique visitors came to its website, the call center answered 11,000 calls and 2,000 applications were processed. During the same time period, the Maryland Health Benefit Exchange reported 217,000 unique visitors to its website, 15,000 calls to its call centers and 25,000 who have created accounts.
On the federal side, however, it will take at weeks before the kinks are solved, Pearson said.
"Years from now, people will not remember what a mess it is," she said. "We definitely see a lot of comparison with the Part D prescription drug plan, with a lot of confusion and consternation in the market about how the roll out occurred. Now there is very high satisfaction among beneficiaries for the program."
Many large insurers view 2014 as a test year, participating in exchanges in six or eight states in the first year. "Most have indicated to us that they expect to add other states in future years, but 2014 is that trial period," said Ceci Connolly, managing director of PwC's Health Research Institute, adding that the introduction of exchanges is the "start of the marathon and not a sprint."
Premium rates are a bright spot, said Sandy Hunt, principal in PwC's health services industries' practice, adding that the rates offered through the exchanges are attractive relative to what has been available in the market. "That offers a great opportunity for consumers to look at what their current insurance coverage is and what they're paying for it," she said.
One of the issues that have required insurers to rethink their processes and workflows is premium reconciliation in order to bill accurately, said Sarah Wiley, senior manager Deloitte Consulting. For some members, plans will receive some amount of subsidy toward their premiums, some of which will come from the federal government or through the exchanges. Plans will also bill individuals for their premiums.
Insurers have worked with a variety of strategies to make sure that they can administer payments from multiple sources accurately, she said. They have had to understand the workflows and sources of data and how to reconcile them in their system.
Insurers are also trying to figure out who the new population is, and what their health status may be, and that will be an ongoing challenge even after they sign up for health coverage, Connolly said. "That's going to be the next big theme."