Amid all of the chaos of the first open enrollment period for the first year of a reformed individual health insurance market, many insurance exchanges have been focused on just making the experience work from start to finish.
Waves of shoppers have tested the limits of servers, particularly for Healthcare.gov. Glitches of various sorts and severity remain a problem across the country, from Maryland, where consumers can (usually) apply online but workers still have to manually process applications on the backend, to California, where the help chat function has been inconsistent even as most of the site works. Then there are the call centers, where people who can't make it through the website are sent only to encounter hours of wait times and conflicting information sets.
All of which might prompt an American consumer to turn to the digital public square to seek enrollment help or to air frustrations: I made a payment weeks ago but haven't received my insurance card is one common complaint aired on Twitter. Others, as one New Yorker tweeted to the State of Health exchange, might be: "Whenever I try to finish my application, I get an error message. It's been like this for days now."
With Healthcare.gov and state exchanges scrambling to manage the front and backends of their websites, call centers, and operations with insurers, social media can be a blessing and potentially a curse.
Exchange staff may have started using Twitter as one of several digital outreach and marketing channels, but in many states it's become a chief venue for consumers to report problems and air frustrations, forcing the exchanges on some days into triage mode -- and raising potential privacy concerns.
Take this Twitter exchange between one shopper from Long Island (whose identity was scrubbed) and the New York State of Health:
Does asking about a health plan selection, or other personal information, in a public venue cross privacy lines or expose consumers to digital security risks? Should troubleshooting that gets into such detail be done in private?
Insurance exchanges themselves are not HIPAA-covered entities (although they could be subject to penalties for willful disclosures of personally identifiable information) and that type of information sharing in a public venue -- a consumer's health plan selection -- isn't violating any federal or state law, said Bob Belfort, a health attorney with Manatt, Phelps & Phillips, especially since the consumer volunteered the information and the exchange staff wasn't disclosing anything.
"Whether it's a wise practice is another idea," Belfort continued. "It's not the ideal way for these issues to be resolved. It's not typically the way government programs address problems citizens may have."
Bill Schwarz, public affairs director at the New York State Department of Health, which oversees the exchange, would not say whether they had set standards for what information could be asked in a public venue and what should be relegated to email, direct messages or in-person or over-the-phone help. But, he said, the exchange staff "uses, as appropriate, social media channels to provide information to and answer questions from New Yorkers," and in compliance with federal and state law.
Ideal or not, many exchanges, like health organizations in general, are facing social media and Twitter especially as a main venue to manage complaints. And even if they aren't HIPAA covered entities, Belfort and other lawyers say they should still try to have consistent practices for dealing with personal questions.
The team running @HealthCareGov, the Twitter site for the federal exchange through which Americans in 36 states are getting new health coverage, has veered in and out of situations that New York State of Health encountered, in some cases deferring to more private settings and in others troubleshooting out in the open.
One consumer from Georgetown, Texas recently tweeted to Healthcare.gov and Humana: "I signed up over a month ago with Humana, no info, no forms, no statement. They refuse to take calls on their 800 #."
"Were you able to submit a payment?" @HealthCareGov staff responded. "They said to wait for my packet, until I get that packet, they can not help me," he wrote back.
At that point, Healthcare.gov staff transitioned the conversation off of Twitter as they tried to move forward to resolve the issue: "Follow us & send us a DM. We'll try to help you resolve this with @Humana. Thanks!"
In many other instances, Healthcare.gov immediately refers consumer complaints to the call center, such as for one man who said he uploaded his documentation in October but still hadn't had his plan confirmed by Jan. 20.
Other times, Twitter serves as a good venue for answering largely non-private questions, which can reduce the strain on the call center -- for instance, confirming that people changing residencies will have special enrollment periods.
Or one Washington, D.C., man who tweeted to Healthcare.gov that prices quoted to him through the call center were inconsistent and that he was "on hold so long that the battery on my home phone died." Healthcare.gov staff replied to him: "You can also go to https://localhelp.healthcare.gov/ & find someone for in-person assistance."
But at times Healthcare.gov has veered into the personal, if not so deeply as to stir significant concerns.
A woman from California took to Twitter to air a bit frustration: "Help @HealthCareGov ! Why does my 23 yr old brother who's a student have to pay $212/mo for health insurance under the ACA? That's INSANE"
"Hi," Healthcare.gov responded, "what state does your brother live in?"
@HealthCareGov has asked consumers on Twitter which health plan they selected, and then typically referring them to one of the self-help pages. Federal exchange staff have also asked some consumers with specific complaints -- such as being unable to add a child to their application or uncertainty over the status of their submitted application -- for their city and state to look into the issue further.
Other exchanges have been more circumspect on Twitter. Maryland Health Connect, a state exchange that is still experiencing technical woes, asks most consumers reaching out on Twitter to immediately direct message them a description of the issues they're experiencing or other information -- taking much of the troubleshooting process out of the digital public square.
Covered California, the largest exchange, seems to be falling somewhere in between with its Twitter strategy, in some cases asking consumers for bits of information to help answer their questions and in others, such as payment concerns or enrollment wait times, simply directing consumers to the health plans or the call center.
For instance, one woman from San Francisco recently tweeted "@CoveredCA Been calling nonstop! Registered weeks ago but can't enroll in a plan bc of system errors on the site. PLEASE HELP!"
@CoveredCA responded: "Unfortunately, you'll have to get through to the Service Center to get that fixed."
And a consumer from the eastern mountain valley city of Bishop, who told the exchange in early January: "We still have not received anything from the Health Insurance Co. We filled out our application over the phone in November!"
"You can call the health plan directly to check on your application and ask about how to pay your first premium," exchange staff replied.
For Covered California, an exchange that's trying to enroll well over one million residents in private health plans over the next few years, trying to troubleshoot every complaint individually on Twitter could become unwieldy. At the same time, the exchange's call center, where many Twitter complaints are referred to, are themselves overwhelmed, often with hundreds or even more than a thousand people in the queue during peak hours.
For all of the exchanges, now until the end of March is a bit like a marathon of managed chaos -- with social media being just one component, a tool to use and a risk to mitigate. Once they have a chance to catch their breath, perhaps the websites and call centers will be working well enough and few consumers will have reason to seek help.
Then exchanges can use Twitter the way many may prefer: to attract consumers with a nimble, hip marketing channel.