The Good, the Bad, and the Oregon: Lessons from Last Year’s Open Enrollment Period

October 22, 2014

At the end of last year’s 2014 open enrollment period for purchasing health plans on the ACA’s public marketplaces, a little over 8 million people had enrolled.

Seventeen states and the District of Columbia ran their own exchanges, with California, New York, and Kentucky standing out for the overall success and smoothness of their exchange rollout and the number of state residents they enrolled.

In contrast, certain states provided a cautionary tale of what not to do, perhaps most notably Oregon, whose exchange never really got off the ground. Oregon blamed the technology provider behind its exchange, claiming that the exchange implementation was rife with flaws and the process plagued by technical delays. As a result, Oregon was forced to enroll people exclusively by paper applications, causing a sizeable backlog.

Minnesota’s exchange also had technical problems with its online enrollment system, driving people to its over-the-phone help lines, resulting in hour-long wait times.

As we prepare to head into the 2015 open enrollment season, which starts November 15th, we might still see some technical issues with the public exchanges. But with a year to work on making their exchanges more reliable, states are hoping that most of the technical issues are behind them.

Instead, the operators of public exchanges are turning their attention to making their exchange offerings more robust and their outreach efforts more effective at reaching underserved and underrepresented populations.

Here are some perspectives on what we will see, what we might see and what we shouldn’t see this year.

What We Will See

  • Increased outreach to minorities and underrepresented demographics. In December 2013, less than 5% of the 109,296 people who enrolled in plans identified as Spanish-speakers. This had to do in part with the late launch of the Spanish language Healthcare.gov site Cuidadodesalud.gov/es.
  • Increased outreach to younger people, aged 18 to 34. The success of an exchange lives and dies with its ability to recruit young, healthy individuals who offset the cost of people with chronic health conditions. Last year, in Colorado, Baby Boomers dominated enrollment in the first two months, with 43% of enrollees being 55 to 64 years old. In contrast, only 17% of enrollees fell into the target demographic of 18 to 34 years old.
  • More insurers offering plans. The U.S. Health and Human Services department has reported a 25% increase in the number of insurers that will provide plans during this year’s open enrollment period, which will likely translate to more plan options in more parts of the country. More choice, however, does not necessarily mean more business for all of the insurers participating in the newly energized individual market for health plans. In California, for example, although 11 insurers offered plans on the Covered California exchange, 96% of enrollees bought plans from just four large providers: Anthem, Kaiser, Blue Shield, and HealthNet.
  • Retail storefronts as a means of reaching suburban or rural populations. California and Connecticut, among other states, opened enrollment “storefronts” to help individuals and families enroll in plans. The storefronts served the dual purpose of reducing strain on online enrollment sites and increasing visibility of the exchange in underserved or remote areas. Expect to see more retail outlets participating in public exchanges this year.

What We Might See

  • Concerns related to automatic re-enrollment for current ACA subscribers. A new uncertainty in this year’s open enrollment period is the introduction of automatic re-enrollment for people who enrolled in ACA plans last year. Intended to streamline enrollment by reducing or eliminating human intervention, and to minimize stress to online enrollment sites that were brought down by high traffic last year, automatic re-enrollment poses a perceived risk to consumers, who may be complacent and not explore other options. In particular as more insurers provide plans on the exchanges, the likelihood grows that a better, more affordable plan is available for them. People could also face issues with their subsidies, if their income information has changed since last year.
  • More wacky ad campaigns. Last year, ad campaigns for public exchanges ranged from straightforward and informative, such as the campaign for Covered California, to Oregon’s hilarious and memorable folksy guitar ads and Minnesota’s strange but compelling ads featuring an accident-prone Paul Bunyan. Colorado was also a standout – and somewhat controversial – in that its ads aimed at young people put the message in the mouths of college students doing a keg stand and an eager coed pondering a new hookup. It remains to be seen what type of ad campaigns we will see leading up to this year’s open enrollment period, but chances are they won’t be dull.
  • Doctor directories and other tools that help consumers make better plan choices. Doctor directories and other consumer tools were largely absent from last year’s exchanges as states struggled just to get the basics right. For example, Covered California introduced a doctor search tool for consumers wishing to find out of their current doctors accepted the health plans of their choice. The state recalled the tool almost immediately, calling it “premature.” These tools are essential to helping consumers make the right choices, and we should see an increasing number this year.

What We Shouldn’t See

  • High numbers of technical glitches that crippled some exchanges. We will no doubt continue to see technical glitches in various public exchanges, especially as they introduce new advanced functionality such and decision support tools, but nothing like last year (we hope).
  • High turnover of exchange staff. Many states saw firings and resignations as beleaguered officials bowed under the pressure of failed websites and low enrollment numbers. Hawaii’s exchange director resigned following repeated delays and problems launching the online exchange. The head of Maryland’s exchange also stepped down following a delayed launch of the online exchange and low enrollment numbers in subsequent months.
  • Enrollment deadline extensions. Last year, extensions to enrollment deadlines were permitted for people who were unable to enroll because of technical glitches with the Healthcare.gov site and for “high risk” patients who have chronic health issues and for whom a gap in coverage would significantly affect their health outcomes. This should be much less of an issue for the coming open enrollment period, since people will not be transitioning from an old system to a new one.

Bottom line, everyone involved in the public exchange open enrollment period last year learned a lot – some the easy way and some the hard way. With this’s year open enrollment period just around the corner, we don’t have long to wait to see which public marketplaces were able to apply what they learned and which ones will have another rocky year.

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