"Exchanges mostly worked poorly or not at all in the beginning," said Karen Pollitz, a Kaiser Family Foundation fellow working on the Program for the Study of Health Reform and Private Insurance. "Maryland has this totally new website now, and fingers crossed it works better. This year is really a do-over."
The stakes are high for Maryland, which had one of the worst-performing exchanges in the nation last year. Those problems led to a shake-up among exchange officials and contractors, a federal investigation and a shadow that lingered over Lt. Gov. Anthony G. Brown's failed campaign for governor.
Those working on the exchange expect a different outcome this year as they seek to re-enroll tens of thousands of Marylanders and persuade more who lack coverage through employers to buy plans over the next three months.
They've spent an added $41 million adopting code from the more successful Connecticut exchange for Maryland's site, which informally opens at 10 a.m. Sunday when consumers will be able to browse — but not buy — plans.
Critics and supporters alike will be closely watching the Maryland exchange to see whether it will squander the opportunity, and added funding, to insure more residents.
"It's more than it just doesn't break; it's a much more effective, helpful system," said Dr. Joshua M. Sharfstein, Maryland's health secretary and board chair of the exchange, who believes that users will share their experiences with friends and family.
However, reaching consumers might be a bigger challenge than improving the exchange's technology, according to consumer surveys and interviews with officials and experts.
National surveys of participants by personal finance publisher Bankrate.com found that 51 percent would not use the exchange again, though slightly more said their household's experience was good or they were confident the exchange would operate properly this year. About 43 percent said much higher prices were their top concern.
"Households that have already used the health exchanges are just as leery about the new enrollment season as the general public and share the concerns about higher insurance rates and glitchy websites," said Bankrate.com insurance analyst Doug Whiteman.
That is important because everyone who bought private insurance through an exchange will have to re-enroll to keep their federal subsidies in 2015, and about 85 percent of buyers nationally were subsidized, Pollitz said.
Another challenge will be reaching people who didn't engage the first go-round. Kaiser surveys found that 95 percent of the uninsured don't know open enrollment is coming.
Open enrollment begins nationally Nov. 15. After a week limited to browsing, Maryland plans to hold an enrollment fair Nov. 15 in Glen Burnie and to offer limited access through call centers, "navigator" groups contracted to assist in enrollment and health departments. On Nov. 19, the public will get full access to the website, marylandhealthconnection.gov.
The staggered launch will allow exchange officials to test the new system again once it goes live and address problems early before it is deluged with users, officials said.
Other states, including Oregon and Massachusetts, also had to dump or retool their health exchange websites last fall, and the federal marketplace, which served 36 states, faced early troubles.
But in the end, the federal exchange exceeded expectations and enrolled more than 7 million people in private insurance plans. Eight million more accessed Medicaid, the federal-state program for the poor, and millions more gained coverage on state exchanges. Surveys, including one from the independent health research group Commonwealth Fund found that the percentage of uninsured nationwide might have dropped from about 20 percent to 15 percent.
Maryland enrolled about 450,000 people, the majority through Medicaid, though it is unknown how many already had insurance. Exchange officials said that about 10,000 of the 80,000 who bought private plans stopped paying, either because they moved, got a job that offered insurance or found little value in paying a premium for insurance.
Pollitz said others who kept their coverage could be put off this year when they discover that the dominant carrier in many states raised rates and the increase might not be covered entirely by their subsidy, which is calculated using the cost of a midprice plan in each state and a person's income.
In Maryland, CareFirst BlueCross BlueShield — which insured the bulk of those who bought private plans through the exchange — raised rates up to 16 percent for 2015 while other insurers lowered rates.
"The whole evolution of the exchanges is going to continue for a couple of years," Pollitz said. "It'll be a good idea for people to check in at open enrollment and see what is the new normal."
There could be more changes as Republicans across the nation look to the courts and their own new legislative powers, though their reach isn't yet clear.
In Maryland, the health exchange and Medicaid expansion were authorized by the Democratic-controlled General Assembly, and the quasi-governmental exchange is not overseen directly by state officials. It is run by a nine-member board, with six members appointed by the governor and three from state government.
In his campaign, Gov.-elect Larry Hogan made an issue of the exchange's poor performance and officials' lack of transparency, blaming Brown, who was the state's point man on health reform. Now Hogan "will be under some pressure to make sure it works," said David Hogberg, a senior fellow for health care policy at the conservative National Center for Public Policy Research.
"That will probably mean firing people who are running it, if it continues to have problems," Hogberg said. "One could hardly blame [Hogan] if he tried to push the whole mess over to the federal government, but it seems unlikely that the Maryland legislature would let him do that."
Exchange officials rejected that option as they searched for replacement technology this year, because the federal site cannot enroll people in Medicaid and the new Maryland site aims to do that.
Hogberg said he doesn't expect Hogan to "antagonize the Democrats by urging a rollback of the Medicaid expansion" as he tries to get them to pass tax cuts, a cornerstone of his campaign.
Hogan has not answered questions about policy since the election and did not respond to a request for comment for this article. He has expressed support for an ongoing federal investigation into the Maryland exchange, which received millions of dollars in federal funding.
That investigation was requested by Rep. Andy Harris, the state's lone Republican in Congress. Chris Meekins, a spokesman for Harris, said the congressman will be watching the site's performance.
"False assurances during the wasting of tens of millions of dollars on last year's failed exchange should make us skeptical of any claims until a system actually works for Marylanders," he said. "Because of the disastrous failure of last year's exchange, the bar for this year's exchange to be considered better is pretty low."
Exchange officials said their only focus now is open enrollment. They have hired and trained hundreds of call center workers and planned more than 20 enrollment fairs, four times as many as last year, catering to people's desire for face-to-face help in choosing among dozens of plans, said Carolyn Quattrocki, director of the Maryland Health Benefit Exchange.
The site itself is more consumer-friendly, Sharfstein said. Mailings, emails and calls have gone out to about 45,000 enrolled families, offering help with re-enrolling, though he believes many won't need it.
Ads targeted to young adults, Spanish speakers and other groups are planned, with an emphasis on finding those who earn too much to qualify for Medicaid. Sharfstein acknowledged that the exchange did not effectively reach that group last year.
HealthCare Access Maryland, a navigator group, plans to open storefronts where consumers can walk in for assistance, said director Kathleen Westcoat. She said staff members have been trained to answer questions and to use the system, whose website was so faulty last year that they spent much of their time on manual work-arounds.
"We're optimistic because we've been able to touch it and feel it and run scenarios and have experience with it," she said about training. "We had none of that last year, and we didn't know what we were getting."
Some consumers, even those who had extensive enrollment problems, are also feeling hopeful.
Marc DelMonico, 40, an Adelphi resident who co-founded a Web marketing firm, told the exchange he was grateful for coverage and would offer his testimonial in advertising — something the exchange declined to pursue last year.
DelMonico said it took persistence as well as calls for help over a number of weeks to get insurance, but his plan was $300 less per month than the one he used from a previous employer and helped him get care for a pre-existing asthma condition. He also got dental coverage. This year, he'll shop around for an even better deal.
"I anticipate the exchange will continue to serve more people this year and the enhanced website will be a success," he said.
Rhonda Friedman was less enthusiastic last fall when she contacted The Baltimore Sun because of intractable troubles enrolling her son. Among the problems: He was inadvertently labeled a Native American and was asked to specify his tribe. Exchange officials couldn't help for months. Eventually, he enrolled in a plan that cut his monthly insurance bill by hundreds of dollars.
"The insurance worked out fantastic," Friedman said.
But she remains apprehensive about the revamped exchange.
"We are very concerned about re-enrolling," she said. "He will start trying on the first day possible and will keep trying until he is enrolled."
©2014 The Baltimore Sun
