Healthgov.snfu? No.

The HHS has released its first detailed statistical report on ACA online applications processed in the first month (October 1 – November 2).
Their summary:ACA marketplace
The split of the 846,184 completed applications between states running their own marketplaces and those relying on healthgov.com is 326,623 (39%) to 519,561 (61%). Some of the other eligibility indicators have similar ratios. However, of the 106,185 individuals who have selected a marketplace plan, it’s 79,391 (75%) to 26,794 (25%). This no doubt reflects the much worse start of the federal site.

The tables exclude all those who have tried to make an application and failed to complete it because of software or administrative snafus. If you read the despairing comments on the hhs blog - a sounding board for the lost without any responses – some unfortunate citizens have been trying since October 1. The best advice seems to be to abandon a jammed application and try again: with paranoid care, a new email address and a virgin browser. On the other side, the report does not include the first fortnight in November, when by all accounts the federal website was working much better than in October.

Healthgov.com is still far from Amazon’s smoothness, as Zients’ team readily admits. The claim that it’s an irremediably broken system is b/s. Healthgov has determined 886,015 Americans as eligible for a marketplace insurance plan or Medicaid. A broken system, as opposed to an unacceptably buggy, unfriendly, maddening one, could not possibly have done this.

It still of course has a long way to go. The 106,185 who have selected an insurance plan represent 1.5% of the estimated total of the eligible – a slightly better rate, as the report cattily notes, to the early take up of Romneycare in Massachusetts in 2007.

Please look at the HHS report before commenting.
Update 18 November
A different thought. One of the surprises in the website enrollment is the large proportion found eligible for Medicaid or CHIP: 396,261. ACA did expand eligibility for Medicaid (outside the neo-Confederacy), so many of these were not eligible before. But I wonder: how many may have been, but did not apply out of ignorance or fear of stigma? The great thing with universal health care (which ACA isn’t quite, but near) is that it’s a right, so there’s no shame in claiming it.

Comments

  1. Warren Terra says

    I’d obviously like to believe there are reasons for hope – but with Obama apparently wilting in his resolve and with a political and media dynamic utterly unlike anything I saw in Massachusetts, I’m far from certain.

    One question (that i’m too lazy to look into for myself): how long was the comparable period in Massachusetts? When you point out that few people signed up in the first six weeks there, was it a similar 14-16-week period (since extended a bit, though still only 10-12 weeks for people wanting coverage Jan 1), or a longer one?

    • James Wimberley says

      Appendix C to the report suggests that Romneycare had no constraining deadline and took 12 months to reach a steady state. Medicare Part D had a 7-month open enrolment, with a surge towards the end. The latter had 10% enrolment at the end of the first month, which is much higher than ACA. Were there immediate benefits?

      Zients has set the target of Healthgov.com “working smoothly for the vast majority of users” by the end of this month. When they release the stats for November, it should be clearer if he has met it. You do notice the media flap has moved on from the website to cancelled policies.

  2. says

    Why, exactly, should I believe the Department of Health and Human Services on this particular issue?

    Look, I’m generally an Obama supporter. But they did lie incessantly about people keeping their health insurance, and in any just society Kathleen Sibelius would not only be fired and investigated for her absolutely abysmal performance of her job duties, but would never do paid work again in her life, even cleaning toilets.

    So Kathleen Sibelius is now telling us the website is working better than we think? I’m sorry, I don’t believe her. If she had any integrity (which she obviously doesn’t), she would have resigned by now.

    • Warren Terra says

      Uh huh. And if our political system had any functionality, she could resign. But she’s literally irreplaceable: as in, it’s inconceivable the Republicans would permit the appointment of a replacement. So she can’t resign.

    • David M says

      The you can keep it if you like wasn’t necessarily a lie, it was just up to the insurers, not the insured. It wasn’t explained very well, but it’s not really worth worrying about.

      Although why anyone thought that Obamacare meant the government was going to prevent insurance companies from ever ending plans is another question.

      • Stephen says

        Well, I suppose people thought that because the President (and scores of his political allies) told them that, over and over again, in both formal (i.e. scripted) and non-formal settings, over a period of many months, in language that was deliberately constructed to imply that there was no chance that they would lose coverage that they liked. And of course the President (and scores but probably not all) of his political allies knew that that was false. Which is to say, they lied. And they lied because it was politically expedient to lie (i.e. they knew that if people understood that the ACA would force the cancellation of many health plans then support for the law, which NEVER crossed 50% of the population in opinion polls, would be so low as to render it politically toxic to any Congressperson who voted for it).

      • FuzzyFace says

        > The you can keep it if you like wasn’t necessarily a lie, it was just up to the insurers, not the insured.

        But it wasn’t up to the insurers at all, if ACA forbade them from renewing the plans (and if that is not the case, exactly what did Obama just announce that he was not going to enforce for a year?) The problem seems to be that what HHS deemed to be “substandard” was actually very much liked by many of the policy holders.

        • David M says

          The ACA gave them a choice: Do X and renew the plans or do Y and you cannot renew the plans. It’s still up to the insurer, as if they did literally did nothing, the plan could probably still be grandfathered.

          Also, many of the plans were designed by the insurer to end in 2013, they never intended or wanted to continue them after that.

          • Stephen says

            That’s simply wrong. The regulations on whether or not a plan could be grandfathered are quite narrow (and in any event only apply to situations where a specific customer has been continuously enrolled since 2010). If a co-pay amount on a plan has gone up by $5.00 or more since 2010 then the plan is no longer eligible for grandfather status. A $5.00 increase on a 2010 $30.00 co-pay would represent roughly a 5% annualized rate of increase, well below the overall rate of inflation for healthcare services over that period. And the co-pay is only one of a large number of plan terms and conditions that, if they changed even a little bit since 2010, make the plan ineligible to be grandfathered.

            And of course someone who “liked their insurance” but purchased it in 2011 is not allowed to keep it.

            The President lied in order to sell his plan to the public.

          • David M says

            Stephen is quite incorrect here, as the allowable increase for a copay or deductible is 15% + the rate of medical inflation.

            If someone liked their insurance policy and purchased it in 2011, and it’s ending, then the insurance company planned on ending in 2013 before they bought it. They bought a plan with a defined end date.

          • FuzzyFace says

            OK, explain that, please. Let’s say you are a 50-something single man. You have a major-medical catastrophic insurance policy; it doesn’t cover things like maternity care or pediatric care, since there is no chance that you will need those. ACA says all policies must include those things, plus cover doctor visits in general. What can the insurance company do to allow you to renew this plan (assuming that, for various reasons, they had increased you deductible a few years ago)?

          • David M says

            “Let’s say you are a 50-something single man. You have a major-medical catastrophic insurance policy; it doesn’t cover things like maternity care or pediatric care, since there is no chance that you will need those. ACA says all policies must include those things, plus cover doctor visits in general. What can the insurance company do to allow you to renew this plan (assuming that, for various reasons, they had increased you deductible a few years ago)?”

            If the insurance company raised the deductible more than the allowed amount, that’s when they decided to end the plan after 2013. The ACA would have allowed the plan to continue indefinitely, but the insurance company did not want to continue offering it.

    • James Wimberley says

      “So Kathleen Sibelius is now telling us the website is working better than we think?” No, it’s the data telling you this. The media reports are biased towards the real problems of a significant minority. “Joe Smith of Peoria completed his online application today” is so far from news it’s invisible.

        • James Wimberley says

          That’s extreme scepticism. Sure, bureaucrats routinely practice economy of the truth. For example, as I pointed out the report does not give any number for incomplete applications: the ones stuck in the system that create all the bad press. If this number had been favourable, they would have published it. But civil servants rarely make outright lies. Some would be prepared to resign rather than publish a falsehood; many more would be prepared to leak the illegal instruction to the press. The pressure that Cheney put on the CIA to tamper with the intelligence analyses before Gulf War 2 came out eventually, and that was for highly secret information, and matters of professional judgement not fact.

          • says

            There’s all sorts of things short of outright lies that can skew data. Statistics are very easy to manipulate. And this is different than Cheney– the HHS bureaucrats are probably responsible for some of the failures and would thus be covering their own asses, not someone else’s.

            What I’d like to see is some outside auditor be brought in to determine the successes and failures of the health care website. I just don’t trust HHS.

  3. Stephen says

    Really? Wow.

    A few points:

    1) Comparisons with the Mass. situation are just silly. The window from when enrollments began there and the deadline for obtain coverage was much longer than the comparable window under the ACA. Enrollments need to be coming in at a MUCH faster rate under the ACA to achieve equivalent levels of performance. But perhaps more importantly, at the time that “Romneycare” was passed Massachusetts had the lowest rate of adult non-coverage in the country, and one of the healthiest, wealthiest and best educated populations in the country. It was MUCH easier to reach the enrollment targets in Massachusetts, both because the distance to close was smaller and because the population demographics (relative to the national average) favored compliance.

    2) The “selected a plan” metric is a joke. It represents people who have placed a plan in an online shopping cart. Nobody knows what % of such individuals will actually enroll – this is terra nova. But it won’t be 100%. Abandonment rates of “shopping carts” in other online commerce categories are well over 50% (i.e. well under half of items placed into online “shopping carts” are actually purchased. Now, on the one hand, there is a legal mandate to purchase insurance, which should push purchase rates above the average for other types of goods. But on the other hand, a year’s worth of health insurance is a bigger ticket purchase than almost anything that people routinely buy online, and there is no guarantee that those individuals who have won the website bug lottery and been able to make it through to plan selection will win the website bug lottery a second time and be able to make it through the process. Both of which should push purchase rates below the average for other types of goods. Of course, HHS knows what % of the ~100K people who have “selected a plan” have actually completed an application for that plan, what % of those have had their data successfully transmitted to their insurer of choice, and what % of those have actually initiated payment. But interestingly enough, HHS isn’t releasing any of those numbers. I find it hard to believe that if these “conversion rates” at subsequent steps of the process were favorable that HHS would be withholding the data.

    3) But even if every single aspect of website functionality up through the actual policy application process were working perfectly (which isn’t even close to reality), that wouldn’t per se represent one bit of progress toward fixing the issues with back-end connectivity with the insurers, which by all accounts is a much bigger problem than the front-end issues with the user interface. And indeed, if there was progress toward fixing the front-end issues, but little progress toward fixing the back-end issues, then the number for those “selecting a plan” would look more favorable than the numbers for those actually successfully completing an application.

    4) But even if we assume that 100% of those who have “selected a plan” are actually going to end up as paying enrollees, the number of such individuals is still well below the targets laid out by the administration for the first month of enrollments. And lest we pin that gap entirely on technical problems with the federal website, the number of people who have “selected a plan” from the states not on the federal exchange still falls well short of the pro-rated share of the first month target for those states.

    5) Early reports suggest that the enrollment population to date is older and sicker than pre-enrollment projects, which is very bad news for the stability of the system. But it also suggests that early enrollees are especially motivated (which of course makes perfect sense). And the highly motivated are the “low hanging fruit” of any process like this.

    I suppose it’s your right to spend the next few weeks/months telling yourself that all is well. But reality is reality. And a self-soothing narrative that things are going but that the famously anti-Obama news media is just whipping up anti-ACA frenzy because the folks who runs the nation’s newsrooms are highly opposed to government action to reduce the number of uninsured adults is about as reality based as belief in the tooth fairy.

    • James Wimberley says

      1: Yes, it’s polemical point-scoring, but pardonable given the political spin to which they’ve been subjected from Republicans.
      2: Why would anybody fight their way through a complicated and sometimes maddening process if they are not in the end going to buy health insurance, an essential commodity in today’s society? If healthgov.com were in competition with Amazon, it would have no customers, but there’s really no comparison.
      3: What evidence have you that errors in data sent to insurers – the 834 problem – are not being fixed? Zients says it’s their top priority. On other metrics visible to users, like error rates and response times, they claim considerable improvements, which seems to correspond to the anecdotal evidence from users. So the chances are the unseen priority is being fixed too.
      4: Why should anybody rush to select their plan from the menu presented, once their application has got that far? At that point applicants have the assurance of coverage, from at earliest January 1.
      5: Older and sicker: quite probably. Also, less good at computing. How many sick 60-year-olds can cope with instructions like “clear your browser’s history and cookies”? There is a real question whether the healthy young will sign up in the numbers required for actuarial stability, or prefer to pay the fine. The first month’s enrollment sheds no light on this either way. If they don’t sign up, ACA will work out rather more expensive in budgetary terms than predicted, because of the subsidies. So what?

      • Stephen says

        2 – People spend time “shopping” online without buying something all of the time – and not just for books and shoes and trinkets but for complicated big ticket items like airplane seats and car insurance. I have no idea why people behave this way, I just know that they do and that thus you cannot take a number of people who have added items to an online shopping cart as indicative of how many people will purchase. And we can’t assume that the process has been maddening for those small sliver of people who have made it as far as the “selected a plan” stage of the enrollment process.

        3 – I have no evidence that these issues aren’t being fixed (just as you have no evidence that they). But if there were meaningful progress on this front it would be curious indeed if HHS, which is under enormous political pressure, did not loudly trumpet this progress. But of course – there have not been such reports. In any event, I’m skeptical that these issues will be fixed anytime soon for the simple reason that building a scalable, functioning wesbite for making purchases (which has still not been done, though I’m certainly willing to believe that good progress is being made) is much, much easier than building a system that can execute complicated purchase transactions, that draw on data from multiple systems, with multiple end parties. Let’s say I intend to go to the beach for the weekend and need to do two things before I go – pack my suitcase and rebuild the transmission on my car. The fact that I have successfully packed my suitcase is nice – all well and good. But it doesn’t mean that I’ve made much progress on my transmission, which is a bit of a bigger task.

        5 – “Work out rather more expensive in budgetary terms than expected because of the subsidies. So what?” I remember a time when supporters of the ACA went out of their way to insist that the program would be long-term deficit reducing. But as we’re finding out, things get said before a bill gets passed that we’re certainly not supposed to remember once it gets implemented.

        • James Wimberley says

          “I remember a time when supporters of the ACA went out of their way to insist that the program would be long-term deficit reducing.” I don’t recall making this argument. The budget neutrality of ACA was a strange piece of technocratic bipartisanship, for which Obama got no credit from the Beltway pundits who care about such things.

          • Stephen says

            Oh but lot’s of people did make this argument, and Obama certainly did get credit from at least some pundits for this “feature” of the law (Andrew Sullivan immediately comes to mind). While the federal budget deficit is currently falling the ACA was passed at a point in time in which the annual deficit was very high – and a lot of people in Washington and elsewhere were deeply concerned about the implications of the deficit for the future economic competitiveness of the US.

            The ACA barely passed. The margins by which the law passed were razor thin, it was necessary to pass the law using a tortuous application of the reconciliation process after Massachusetts (Massachusetts!) elected a Republican (Republican!) Senator in a special election after he campaigned specifically on his opposition to the ACA. And throughout the process public support for the law (as measured by opinion polls) never reached a majority.

            Against this backdrop, “If you like your plan you can keep it – Period” and “The ACA is budget neutral” were important parts of the public case for passage of the law. While we can never prove a “what would have happened” case I believe that if either of these arguments would have been demonstrated to be false that the ACA would have died in Congress (much as public support for the invasion of Iraq would likely have faltered in the absence of the “WMD” narrative).

          • byomtov says

            “razor thin?”

            The House vote was indeed close, but a 60-40 Senate vote is not “razor thin.”

          • Herschel says

            Actually, it wasn’t so much supporters of the ACA who claimed the law would reduce deficits, it was the Congressional Budget Office. As far as I know, they’re still saying that, because the evidence still says that.

      • Brett Bellmore says

        “2: Why would anybody fight their way through a complicated and sometimes maddening process if they are not in the end going to buy health insurance, an essential commodity in today’s society?”

        Because fighting your way through the complicated and sometimes maddening process is the only way they can find out the price, and thus make the decision? The ACA website being about as transparent as anything having to do with this administration, excepting only it’s motives…

  4. CharleyCarp says

    Here’s a simple question. I own a small business, and therefore buy insurance on the individual market. I got a letter from Blue Cross 6 weeks ago telling me my policy wouldn’t be renewed — no surprise since I’ve only had it a year and don’t qualify for the grandfather, and pretty much anything that’s not grandfathered is going to be non-compliant in one way or another — and proposing a bronze plan at fairly similar rates. If I do nothing, they’ll enroll me in the proposed plan.

    I’m probably going to switch, because I want to support our statewide co-op.

    My question, though, is this: if I was to do nothing, and get enrolled in an ACA compliant plan without screwing around with the marketplace, would I show up in those HHS stats at all?

    If the answer is no, then I think a non-trivial number of people are going to be under the radar. If the answer is yes, then I think we’d expect to see a huge spike on Jan 1 when these new auto-enrolled plans take effect.

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