Health IT, Hospitals, Policy

With a bang or a whimper? 3 predictions for the launch of insurance marketplaces

October is the make or break day for Obamacare. I predict that the software will be buggy, sign ups will be low and everyone will be unhappy.

Tomorrow is the day. Somewhat like the Grinch and Christmas, Sen. Ted Cruz couldn’t stop it coming. The health insurance exchanges go live tomorrow – state-run exchanges and the big federal one. It remains to be seen whether a government shutdown will stop the launch of the federal insurance exchange or the big data hub (As of this morning, Congress still has 15+ hours to figure that out).

Here are my predictions for Oct. 1 – the biggest day yet for the Affordable Care Act and Barack Obama’s presidency.

The software will be a mess

The launch will be delayed in many states. Earlier this month Oregon said it would be mid-October before they were ready, although California said it will start enrolling on Tuesday. Xerox helped Nevada build its exchange, so I bet that state will be ready too. There will be error messages and even a few security problems as HIT experts and bureaucrats try to seamlessly connect thousands of people and their disparate streams of data.

The software that runs the exchanges is version 1.0 for many states running their own systems. They can’t exactly do a soft launch or be in beta for months. I’m sure (OK, I hope) they have done some user testing, but not at the volume that they will need. I know there are computer simulations of thousands of people using your software at the same time, but I wonder how many states had the budget and the time to run simulations like that. And, as anyone who has worked on a software launch knows, you simply can’t anticipate all the use cases that will crop up when people actually start using the system.

The federal contractors say that the big data hub is ready, but I bet this part of the system will be a big stumbling block too.

Week 1 will be terrible but the state public servants running the exchanges will pull all-nighters until things work. If the public images of the exchanges can survive the social media onslaught of a couple bad days, week 2 will be much better.

Volume will be underwhelming

For all the marketing money and new navigators, many people still don’t know about the marketplaces. I have heard all kinds of confusion.

A former colleague shared a conversation she had recently with a co-worker. The person asked if she was going to participate in Obamacare. He proclaimed loudly that he was not going to do it. Of course, this person gets insurance through his employer so he is not even eligible.

Another friend is a school teacher said that her district may drop their insurance and move everyone to the state exchange. She already has a high-deductible plan but was worried that the dollar figure would double to $10,000 under an Obamacare policy.

Two other friends are freelancers (one is a copy editor and one is a coder) and neither has insurance. They both want to enroll but felt scared and skeptical. Both are “information workers” but didn’t know where to begin looking for information about how to enroll.

I predict less than 10% of all eligible people will sign up in the first week and open enrollment will close with less than 25% of eligible people enrolling. If the technology stabilizes and the pro-Obamacare forces win the PR war, sign ups will go up later in the month.

Red state/blue state trends will pop up immediately

Here is a chart that shows the 15 states with 18% or more uninsured citizens. It also shows what kind of exchange they are running as well as the status of Medicaid expansion there. I added the governor’s political party as well.
The data is from the Advisory Board and the Kaiser Family Foundation.

I predict the states running their own exchanges will see the highest enrollments. Those marketplaces have a built-in sales force and the extra bonus of “we know how to do healthcare in our state for our citizens.” The states with the most uninsured citizens will get the most press around enrollment, even if more people sign up in other states. This means I think these states will see the highest enrollment:

    California
    Colorado
    Connecticut
    District of Columbia
    Hawaii
    Idaho
    Kentucky
    Maryland
    Massachusetts
    Minnesota
    Nevada
    New Mexico
    New York
    Oregon
    Rhode Island
    Utah
    Vermont
    Washington

The bold states have the most uninsured people. Texas will be the example of “Obamacare failed! Obamacare failed!” because it has the most uninsured people in the country and the most hostile governor (it’s a close race, I know).

Bonus prediction: Everyone will be unhappy
Last year I interviewed a researcher at a children’s hospital. He had this quotation from Machiavelli on his door:

It must be considered that there is nothing more difficult to carry out, nor more doubtful of success, nor more dangerous to handle, than to initiate a new order of things. For the reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order, this lukewarmness arising partly from fear of their adversaries, who have the laws in their favour; and partly from the incredulity of mankind, who do not truly believe in anything new until they have had actual experience of it. Thus it arises that on every opportunity for attacking the reformer, his opponents do so with the zeal of partisans, the others only defend him half-heartedly, so that between them he runs great danger.

Last week at the Idea Festival, I listened to Rafe Sargarin talk about how the national security machinery could be more successful by copying the structure of nature. I picked up his book and found the same quote in the first chapter.

Obama supporters are mad because the law doesn’t go far enough. The poorest of the poor are not getting any help. Millions of Americans still won’t have coverage.
Some healthcare providers are skeptical and concerned. Many doctors and nurses and pharmacists will have to to change the way they work. Hospitals and device makers and insurance companies will make less money.
Obama opponents are enraged for many reasons. Some people have to pay more money for coverage. Many people will have to get coverage from a new source. Everyone will have to deal with change.

What this boils down to is a lot of grief for Obama and the ACA – regardless of how well tomorrow goes.

Veronica Combs

Veronica is an independent journalist and communications strategist. For more than 10 years, she has covered health and healthcare with a focus on innovation and patient engagement. Most recently she managed strategic partnerships and communications for AIR Louisville, a digital health project focused on asthma. The team recruited 7 employer partners, enrolled 1,100 participants and collected more than 250,000 data points about rescue inhaler use. Veronica has worked for startups for almost 20 years doing everything from launching blogs, newsletters and patient communities to recruiting speakers, moderating panel conversations and developing new products. You can reach her on Twitter @vmcombs.

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