Why some exchanges succeeded where others failed

Top performing sites were simple, well tested

While most state-run online health insurance marketplaces have vastly outperformed their federal counterpart, four states—Connecticut, Kentucky, Rhode Island, and Washington—have emerged ahead of the rest, serving as models for states preparing to launch their own sites next year.

According to the latest numbers, approximately 365,000 U.S. residents have selected a health plan through the Affordable Care Act's (ACA) health insurance exchanges since they launched on Oct. 1. Even though the 15 exchanges run by states and the District of Columbia serve less than one-third of the U.S. population, they accounted for more than 50% of Medicaid enrollments and 75% of private plan sign-ups in October, largely because of technical problems with the federal exchange, which serves 36 states.

Still, not every state-run exchange has performed well, according to Stateline's Christine Vesteal and Michael Ollove. In fact, Oregon's exchange has yet to enroll a single resident through its website.

This week, Ollove and Vesteal examined factors that led some exchanges to fare better than others, pinpointing several common characteristics shared by the top performers.

Simple and well tested

In lieu of creating a complex exchange with multiple features and graphics, the successful states pursued simpler "version 1.0" websites and plan to add more complex functionalities in the future.

"Our system doesn't have a lot of bells and whistles," says Carrie Banahan, executive director of the Kentucky exchange. The state has enrolled consumers for private coverage at a steady rate of nearly 1,400 a week, and it signed up 29,000 residents in Medicaid during the first month. Per capita, more Kentucky residents have enrolled for private plans and Medicaid than any other state.

Three states wanted to lead on Obamacare. One is setting the pace.

Kentucky and other top-performing states allow consumers to browse insurance policies sold through the exchanges without creating a password-protected account. The tactic avoided many of the error messages and stalled pages encountered by users of the federal website.

Additionally, the most successful states devoted months to round-the-clock testing. For example, Kentucky tested its website for three months, while HHS reportedly only left the last two weeks of September to troubleshoot HealthCare.gov for potential problems.

Strategy, money, and contractors

Dan Schuyler, director at health care consultant Leavitt Partners, highlights other strategic decisions that benefitted the top performers:

  • Hiring outside contractors. States hired outside management teams to develop and test the new websites, as well as "system integrators" to ensure their exchange communicated with the state's Medicaid enrollment systems and other state and federal databases. By contrast, HHS performed both roles in-house.
  • Utilizing existing platforms. States integrated off-the-shelf system components with the states' existing platforms, while the federal government ordered a customized system.
  • Cashing in on funding for state exchanges. States took advantage of $3.2 billion in federal funding offered under the ACA to build and design their websites, leaving HHS to rely on existing departmental funding for the monumental task.

Lessons from the top performance

The successes and failures of this year's state exchanges are being watched closely by officials in states that plan to launch their own websites in 2014.

Debra Hamer, chief communications officer for the New Mexico exchange, says she's learned just as much from the star performers as states that got off to a weak start. "[They've] shared a lot, which is very helpful because they ran into obstacles and absorbed a lot of lessons," she says.

The Idaho exchange's operational manager, Alberto Gonzalez, also learned from states that were forced to take their exchanges offline to deal with technological problems, angering many customers who did not know if their applications had been completed. If the same problems arise, Gonzales wants to make sure customers are able to complete their initial applications.

"If we have to go back and validate and clarify, we can do that but at least we’ll have enough in place to take the application," he says (Vestal/Ollove, Stateline/Kaiser Health News, 12/11).

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