Nightmares just beginning for


Future upgrades will include cost information, provider directories and tons of scale

When legislators work through an especially contentious negotiation process to arrive at a final policy, many refer to it as “sausage making.” The reason is obvious: There’s an end product, but you do not want to know how it was made.

Millions of Americans who tried in vain to sign up for an exchange plan feel the same way about They don’t want to know about the servers or the multi-million-dollar algorithms behind it; they just want to get their new health plan.

Yes, the launch of the federal site was an embarrassing disaster, but states fared a bit better. For example, within the first two weeks (according to their respective Twitter feeds):

  • Covered California had 94,500 applications.

  • Nevada Health Link had 2,275 live accounts.

  • MNsure completed 3,769 enrollments.

  • WA Healthplanfinder  had 24,949 enrollments.

  • Kynect had 13,000 enrollments.


The first update from federal administration officials didn’t come until October 19, in which they said 476,000 applications had been filed-not processed to the point of enrollment, mind you, just filed. And by the way, that number includes applications for the 16 more successful state-run marketplace exchanges, not just

Federal officials are likely trying to spin the facts by failing to separate the application totals for the federally operated site from those of the state operated sites. Either that, or they don’t have the technology to do it. It’s probably both.

Sure, it’s easy to beat up on the Department of Health and Human Services, the White House and Kathleen Sebelius in particular for the inexcusable failure, but I have yet to hear anyone discuss what will happen after open enrollment. The wave of sign ups for January 1 coverage is just the beginning. Even with enormous fixes by A-team programmers working long hours, isn’t ready for the next stage.

Stage Two

Consider the fact that health plans will need to update and reconfigure their benefits and pricing for 2015 after they review their 2014 populations. Mid-year additions, such as an adopted child or a new spouse will be rolling in constantly and will need to be tacked onto the coverage plan for the primary policyholder. How’s that going to work?

Also consider that consumers were promised side-by-side quality information, which they are still owed. Provider directories also are not accessible from

It’s quite a laundry list.

Also remember that today, the exchanges are really only meant for individuals and small businesses-a minority of people compared to those accessing benefits through a large employer. Beginning in 2017, under the Patient Protection and Affordable Care Act, states may allow businesses with more than 100 employees to purchase coverage in the marketplace exchanges. Employers with defined contribution models might be tempted to go that route, but they’d be better off in private exchanges. If employers really want to get out of the benefits business, defined contribution and sending workers to some type of exchanges might be a way to do it. But that's a big "if."

Plus, I can’t see any state willingly sending more people to the notorious Its failures will be etched deeply into everyone’s memory, unlikely to fade by 2017.

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