Reports Suggest Exchange Numbers Are Very Low

“Well, Facebook Wasn’t Built In a Day.” – Unnamed Exchange Developer.

More than 4.8 million users visited Healthcare.gov for the grand opening of the federal health insurance marketplace on Tuesday, according to officials.

It didn’t go quite as planners had hoped. In fact, if there was an unofficial word of the day, it was glitch.

Many users of Healthcare.gov reported long delays and difficulty accessing the federal insurance marketplace,  experiencing “glitches” ranging from error messages to blank pages.  The problems were repeated at state-run exchanges around the country to varying degree, from California to New York.

Pundits like Wonkblog’s Ezra Klein were quick to point out that the political victory the GOP might have gained from the uncertain start was largely lost in the uproar in Washington over the government shutdown, which dominated news reports.

At least one frustrated user chronicled the experience (see related post ‘Descent into Madness: One Man’s Visit to Healthcare.gov, October 1st ). Others took to Twitter to express their outrage or show off their savage or finely-tuned senses of humor.

Users of the federal exchange reported problems including error messages (see above), funky dropdown menu behavior, page freezes, blips, broken links and long page load times — generally either a sign of high volume or inelegantly designed databases.

HHS officials declined to reveal how many people signed up for new insurance plans overall, leading some theorists to speculate that not very many people were able to make it through the process successfully. In point of fact, there were suspiciously few reports of users successfully completing the registration process at all, probably not a very good sign and possibly an indication of a disaster.

The New York Times  interviewed a Wisconsin navigator who said their group was not able to successfully sign up any of the users they worked with.

The Washington Post talked with a West Virginia navigator who confirmed 2 sign ups.

It gets worse. Health plans selling insurance through the new federal site site said they were shocked by the low number. One was quoted by a Washington Post reporter:

“Very, very few people that we’re aware of have enrolled in the federal exchange,” said one insurance industry official, who like many in the industry, spoke on the condition of anonymity out of concern for possibly offending the Obama administration. “We are talking single digits.”

Some reports bordered on the comical.  The Post found a man who thought he had been able to sign up. It later turned out he hadn’t.

Another was happy he had least received a confirmation email informing him that his registration was successful.

Administration officials downplayed the problems and said the issues would be quickly resolved. HHS Secretary Kathleen Sebelius noted that more than 110,000 callers were able to get through by telephone to the HealthCare.gov helpline. Of course, that could either be an indication of a well-designed and executed government call center strategy or an indication that all is not be well on the web site front.

How well did Healthcare.gov actually do? It will be some time before we know.

By way of comparison, officials said that more than 5.0 million people were able to visit the California exchange its first 24 hours of operation. Officials did not provide details on the number of Californians who were able to successfully sign up for health insurance.  Embarrassed California officials later retracted the number – saying the real number was a bit lower. Okay, a lot lower. More like 500,000.

New York said more than 2 million people were able to visit a New York State of Health before the site began slowing down.


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  9. No problems so far with ‘Care and ‘Caid; only with one HMO that required prescriptions be done by “approved” physicians. I can actually take more time with writing the consults and considering whether or not the procedure is necessary than I used to, so the approval process usually is faster in my new office.

  10. Talked with some provider relations folks that believe doctors will be on the hook for up to 3 months worth of preauthorized procedures they perform for public exchange enrollee when it turns out the exchangee doesn’t pay their part of the premium. In other words, there will be up to a three month delay for the administration to inform the carriers and ultimately the providers that the exchangee did not pay their part of the premium and the policy lapsed. Doctor’s offices may want to establish an escrow account to deal with these unreimbursed costs.

    ‘I can’t be responsible for every under-capitalized small business in America’!”

  11. Dr. Rob. I admire your work and putting your money where your mouth is. I am curious how your Medicaid and Medicare patients are dealing with prescriptions and other procedures you prescribe when they are done by providers outside of your office. I have read that patients going to physicians that are not participating with Medicaid and even Medicare have run into problems with having these “outside” procedures not covered by Medicaid. Thanks.

  12. HHS has drawn the red line of success at 7 million uninsured enrolling through public exchange in the first year with at least 2.7 million being the under 35 year olds that are currently uninsured. With an expanded first year enrollment window of 181 days, the quick math says an average of 38,674 uninsured must enroll every day with approximately 15,000 per day being uninsured under 35 years old. So to be on track, the public exchanges should have enrolled over 150,000 previously uninsured people by the end of today with at least 60,000 being previously uninsured under 35. It would be expected that the most transparent administration in history would have a live scoreboard tallying the results in real time. I expect we will see a tote board with the accuracy of Obama twitter followers. I read where only 2 million of those are bogus.

  13. I’ve worked in healthcare for the last 35 years and have seen a downard spiral of quality care over the last 20 years when the foreign doctors swarmed in. The reason the healthcare system is in such bad shape is that it’s a good old boy system. Specialists won’t admit patients (too much paperwork) so the GP admits and requests a consult (higher reimbursement) and another specialist for anything that’s ailing. No one really takes responsibility for the care of the patient. Lots of Indians with no chief. It’s a joke. Especially for Medicare—my ex (a physician) would call it a Medicare gang-bang!!! That’s why we’re in the predicament that we are in today.
    Patients familes need to question why there are so many doctors called in—most of the time they don’t even touch the patient, let alone examine them!!!! Healthcare is in a sad state.

  14. I’ve been trying since the initial start-up and have been unsuccessful. It took over 6 hours of my time along with lots of error messages for me to be able to create an account. I now have an account, but am unable to log in—system error. When I called and spoke to someone (3rd person) one again I’m told there are too many visitors. What a crock of S____!!!

  15. What happens when all the people who sign up on the exchanges to receive the subsidies to offset the premium cost, stop or can’t pay their portion of the premiums? I don’t think the government knows the mess they are getting themselves into here. I guess the insurance company would have to cancel their policy and then we end up back where we started with ER’s full of people without insurance. I guess one solution could be that they will just push all the people who cant pay onto medicaid which will cost even more money and make more people dependent on the government…


  16. Do any of these bloggers know that people have almost three months to sign up for January 1, 2014 coverage. So whether they sign up today or they sign up November 16th , the coverage will still be effective the same day; 1/1/14

  17. I wouldn’t expect people to buy on their first visit.
    There has been very little information available, I imagine most were going on to see what’s being offered, how much it will cost them, etc….

  18. Obamacare is a very serious and sensitive issue for Americans, who have now been divided into gold, silver, bronze and platinium. Different level of premiums will give relief to all the insurance holder. In sincerity, providing insurance would be a burden for the government and the government shutting down is an indirect result of it.

    Read more on: http://goo.gl/cy7tYM

    It is a well written piece on Obamacare and Healthcare.Gov with all the repercussions described in detail.


  19. I charge between 30 and 60/month. This is affordable by many/most Medicare patients and a fair number of Medicaid patients. I have probably 30 Medicare patients, maybe more. Medicaid numbers are predictably lower.

    @CMS trained doc:
    Your argument is not only full of incredible ignorance, it is maddeningly glib in underestimating my what I’ve given compared to what I’ve gotten from them:

    1. I went over $100K in debt.
    2. I worked for 4 years, earning under $30K/year doing about 80-100 hrs/week. This means I worked for close to minimum wage during those years.
    3. I accepted Medicare/Medicaid for the past 18 years out of an obligation I felt to care for the elderly and poor, not a debt I felt to CMS, who did everything they could to convince me to drop them (E/M coding, disparities of payment compared to specialists).
    4. After dropping them, in 6 months I have saved them over $100K.

    Sorry. That just gets under my skin, as I feel like an abused spouse of an unfaithful partner. I want to break out the Monty Python line: “That’s the kind of blinkered, Philistine pig-ignorance I’ve come to expect from you non-creative garbage. You sit on your loathsome, spotty behinds squeezing blackheads not caring a tinker’s cuss for the struggling doctor.”

    But I won’t do that.

  20. Rob,

    I believe you when you say you have Medicaid patients as my sister who is on Medicaid has ample money. Underground economy.

  21. “Why would I charge differently based on someone’s insurance when I don’t accept insurance?”

    Rob, I know you opted out, I find it hard to believe that a Medicaid recipient or someone that does not qualify for the very narrow income/asset requirements (woking poor) can afford your monthly club membership.

    Just who are your Medicaid/Medicaidless patients?

  22. That is great that you treat medicaid and medicare patients but do you take their insurnace? Afterall that is who paid for you to become a doctor wasn’t it? CMS paid for your residency and internships at a cost of 500k to 1.1 million and if it iwas a loan you would be required to pay back 1 million to 2 million – hence the lower payment to treat those patients.

    Oh wait you only take cash so the most vulnerable are automatically weeded out of your practice? Ahh so it is really about your income increasing not your patients. I am guessing you also only have a couple of hundred patients on your panel who pay you up front right? Where did the rest of your patient end up going?

  23. Nothing ever happens quite the way that the planners (who are by their own admission smarter than all the rest of us) tell us. Forty years ago, Einthoven and Ellwood gave us a central planner’s dream of an integrated, holistic, efficient managed care system that would care for patients responsibly and ethically in ways that produced actual health rather than just the shell game of disease management. I’m still waiting for a scintilla of their vision to come true, because while visions are always elegant and thorough, implementation is messy and agenda-driven (right-left, D-R, doesn’t matter, an agenda is an agenda).

    Here we are treated to the launch of health reform intended to simplify and improve access to something that everyone supposedly wants, and it looks like we got neither. What I don’t understand is this: e-commerce is a way of life in our nation. How could the omniscient, prescient, and omnipotent federal bureaucracy not get this right? Why don’t we have details about how they pressure-tested their roll-out model before launch? Was it tested internally or in the real world? Was it tested at all? I have first-hand experience observing the development and launch of large government databases, and I have yet to see a pre-launch test that’s worth its salt. I do more testing of features on my blog than the government appears to have done in the design and launch of the vaunted health insurance exchanges.

    Peter1, above, makes a great point. Why couldn’t they have done a staged roll-out? You could have staged the roll-out in any one of a dozen ways and ensured that at every turn, you could demonstrate success in ways that would not leave people snickering. Who was advising the planners on the development of materials that the AVERAGE American adult (twice as likely to have only a high school diploma than a college degree) would understand? That any potential user should log on and find anything not easily understandable is inexcusable.

    PayPal handles 18% of all e-commerce in the US on a daily basis ($315M daily), in 25 currencies no less, with accounts in 190 countries (anyone think that’s not more complex than accounts in the 50 states?). Yet, based on my experience as a long-time PayPal user, they come as close as they can to making the processes of e-transactions as flawless as possible.

    The developer making the Facebook reference above is an idiot. Facebook is not a transactional environment. Amazon, PayPal, Target.com, etc. are transactional sites. Those are the entities that the government needed to mimic. Instead, the government has fulfilled the public vision of itself as the gang that can’t shoot straight.

  24. Of course. I opted out. Why would I charge differently based on someone’s insurance when I don’t accept insurance? That’s the craziness I am trying to leave behind with a simpler model.

  25. “I have Medicaid, Medicare, private insurance, and uninsured patients in my mix. ”

    All get charged the same monthly fee for access?

  26. I have Medicaid, Medicare, private insurance, and uninsured patients in my mix. Primary care does not need to be expensive and as complex as it has been made, so why not pay cash for it? The ironic thing is that I’ve probably saved Medicare over $100K so far by keeping folks out of the ER, the hospital, and away from procedures/consults they don’t need. I do that by simply being available to my patients. The thing that allows me to save our government this money? Dropping out of the system.

  27. “The good news for docs like me is that this whole thing is so complex that what we offer, a simple payment system and care that focuses on people instead of data, looks much better in comparison.”

    Rob. seeing anyone on Medicaid? Seeing anyone that does not qualify for Medicaid and cannot afford insurance?

    Houses would be much less costly if we only paid cash and did not have a mortgage system which allows higher prices paid for on installment.

  28. It’s hard to understate the total confusion of the people I talk to (patients and families). Some were afraid that on October 1 they would no longer be able to see me “without paying someone else first,” while others just have no good idea of what they need to be doing. Here in the conservative south, most people see this as (as one person put it) “trying to fix a big mess by making another big mess.”

    I wonder how much of a good thing it is to give people better access to the insurance-based health care system, as the system itself is the real problem. Lack of access did not happen by accident; it happened because the system is good at running up bills and passing it on to consumers, making care unaffordable to most people. The good news for docs like me is that this whole thing is so complex that what we offer, a simple payment system and care that focuses on people instead of data, looks much better in comparison. The chaos and confusion has been enhanced by ACA (made worse by mis-information and fear-mongering of the conservatives), and most people are not sure what to do and who to trust.

    I see this as a grand opportunity for a sane, politically neutral alternative.

  29. Separate the tire kickers from the buyers. Did anyone actually buy?

    I guess they should have rolled out the exchange by region – one at a time to keep the volume controllable. Would that not have been discussed at planning?