WASHINGTON Some of the key players rolling out Obamacare to the American public say their work on the program is just beginning, as the real-world effect of the law throws up new questions and problems.
More than 7 million people signed up for new health coverage under President Barack Obama's healthcare law for 2014, the first year in which its main provisions took effect. Obama celebrated the enrollment milestone on Tuesday as a victory for the program which has faced relentless opposition from the Republican Party and major technical hurdles.
Health insurance executives, state officials, lawmakers and policy experts told the Reuters Health Summit in Washington this week that the program is still very much in transition and they expect both major adjustments and smaller tweaks in the year to come.
"This is the beginning of the beginning," said Chet Burrell, chief executive of CareFirst BlueCross BlueShield, which sells Obamacare plans in Maryland, Virginia and the District of Columbia.
For health insurers, more discussions with the government are in store over how to improve and complete the technology behind the federal enrollment website HealthCare.gov, which serves 36 states, as well as some of the online exchanges run by 14 states.
The talks will include making it easier for consumers to shop for new health plans, compare doctor networks and adjust their policies due to a life change.
"So far none of the exchanges have the ability to handle, in any automated manner, life event changes," Burrell said. "So what happens is it's coped with behind the scenes, manually, which is fraught with problems, inefficiencies, as well as errors."
Dr Ezekiel Emanuel, a health policy expert at the University of Pennsylvania and a former adviser to the White House, said that such changes need to happen before enrollment for 2015 begins in November.
"What I worry about is, we've got 7-1/2 months to the next open enrollment, we've got to beef up the website, we've got to make the user experience better," Emanuel said. "You need all of that to come together. I don't think we're there yet, and the question is whether we will get there."
The site should allow people to sort options more easily and the servers need to handle surges of traffic. It should also have a chief executive officer who can run it like the start-up company it is, Emanuel said.
Some insurers are also raising the possibility of changing the kinds of health plans on offer, from the availability of doctor and hospital practices to allowing more flexibility in pricing plans according to the benefits they cover.
Burrell said he would support adding a new tier of plans that would include fewer benefits and potentially be priced lower. Cigna Chief Executive Officer David Cordani said that could create more choice for consumers.
"I'm not going to say whether a ‘copper' program is right or wrong but to me that's offering some additional choice," Cordani, referring to the idea of adding a new tier to plans now labeled "bronze," "silver," "gold" and "platinum." "We are a company that believes in choice. The open question is how much choice is available to the individual versus choices taken away."
Among the states whose exchanges are run by HealthCare.gov, Idaho and New Mexico plan to leave the federal website and launch their own technology platforms next year. Meanwhile, state-run exchanges in Oregon, Maryland and Hawaii have grappled with repeated technology failures.
All of the 14 state-run exchanges face a requirement to become financially sustainable next year.
The Connecticut marketplace is selling its own technology as an "exchange in a box" solution to its counterpart in Maryland. Kevin Counihan, chief executive of AccessHealthCT, said that the U.S. agency overseeing Obamacare is drawing a sharper line between exchanges that should operate on their own and those that are defaulting to the federal government.
"I do get the sense increasingly that states are more on their own than ever," he told the Reuters Health Summit. "I'm sensing a change ... so if a state says ‘I need more money' or ‘it'll be tough for me to be self-sustaining,' then (the federal government) says if you really think that, you ought to think about moving" to HealthCare.gov.
Longer term, the state exchange structure could change further to save costs and cut down on infrastructure, from technology build-outs to call center staff.
"Do we really need 50 (state) exchanges, or can we have regional exchanges?" Emanuel said.
(Additional reporting by David Morgan; Editing by Michele Gershberg and Jim Loney)