SEATTLE - By nearly any metric, Washington had one of the most successful Obamacare launches. Unlike Healthcare.gov or neighboring Oregon's failed marketplace, the state exchange ran smoothly within days of going live.
Washington has enrolled 32 percent of residents eligible for private coverage through the exchange, putting it among the top ten states in terms of reach. The state has done a good enough job to convince an additional four health insurers to join the marketplace in 2015, increasing the total number of plans to 12.
"There's a story that it's all broken and terrible," says Bob Crittenden, senior health policy advisor to Washington Gov. Jay Inslee. "That's a hard narrative to tell about Washington. People here are much happier, but we're so far away they tend not to believe us."
At the same time, there is still frustration among legislators that Obamacare doesn't work as well as hoped. Thousands of applications are still stuck in limbo, where shoppers aren't sure if they have coverage or not. New private plans for Medicaid patients have clunky online portals that can make it difficult for patients to obtain speciality care.
Washington was, in many ways, a best case scenario for Obamacare: a technologically-savvy state with every branch of government in firm support of the federal law. And its experience over the last eight months shows what that type of strong political will can and can't do to make the country's largest coverage expansion in decades work.
"When you're a better performer than others, but the others are so-so, that means you're just doing better than so-so," says Teresita Batayola, chief executive International Community Health Services in Seattle.
Making Obamacare work in the other Washington
Washington was among a handful of states that quickly embraced the Affordable Care Act, jumping at the opportunity to expand its Medicaid program and build a state-based exchange. Like the rest of the West Coast, Obamacare moved forward easily in a state where Democrats controlled the legislature and governorship.
Setting up the website wasn't easy, even with the political will in place. The first time Washington got to hook its system up to the federal database was at 4 a.m. the morning of October 1 — just hours before Washingtonians would start shopping for coverage.
"The last set of guidance we got was on August 31 and we had to go live by October 1," Washington Health Plan Finder executive director Richard Onizuka says. "There were several places where we'd build something and say, hopefully it will be okay. We often didn't have the requirements."
The Washington exchange did work in that early morning test on October 1. But as more people began to log onto the website, it melted down. By mid-morning, officials decided to take the site offline to fix the problem. Within a few days, the site was functioning well for most consumers, while Healthcare.gov still remained frustratingly broken.
Washington managed to build a website that not only worked better than the federal marketplace, but also had more complex functions. It is among a handful of states, for example, that collect the insurance premium from the consumer and pass it on to the insurance company. That means Washington can track who has actually paid for their coverage, which Healthcare.gov cannot measure.
More than 164,000 Washingtonians bought private coverage coverage during open enrollment in 2014. That works out to about one-third of those eligible to purchase coverage this year deciding to enroll.
"The front-end is working pretty well," Onizuka says. "About 90 to 95 percent of applications get through."
The back-end of the site — where insurers find out who signed up for their products, check for payment and send out member ID cards — is a slightly different story.
'I don't think anyone imagined it would be as hard as it was'
Eight months after open enrollment began, insurers and community health centers still report significant problems figuring out who has coverage and getting those new insurance plans to work.
"I don't think anyone imagined it would be as hard as it was to implement this website," says Eileen Cody, who chairs the health care and wellness committee at the Washington Legislature. "We're home to Microsoft, after all."
Premera Blue Cross had 70,000 people sign up for its exchange products during open enrollment, more than any other plan in the state. Kitti Cramer, Premera's vice president of government affairs and public relations, says about 10,000 of those members are stuck in limbo, not sure whether the plan they actually have coverage through the plan they selected.
"We're in June and still have members who don't know if they have coverage going back to January," Cramer says. "Those type of calls continue today, mostly from people who are stuck in the accounting system."
Health plans have their own technical problems. Community health centers report that the portals built by insurers who cover patients in the Medicaid program are clunky; it can take up to four hours, for example, just to log into the site so they can see what doctors are in their patients' networks.
Cody, the legislator whose committee oversees health care implementation, says she's frustrated. It's not that she doesn't think Obamacare is a good idea — instead, she thinks its such a good idea, she wishes the state could make it work even better.
"People are still having problems," Cody says. "It's a small percent, but it's embarrassing. In some of these cases, it feels like I created a monstrosity."
Bumps in the road aren't scaring away insurers
Health plans are visibly frustrated with the problems that still exist with the Washington exchange. But they don't seem to be big enough obstacles to scare insurers away from the marketplace.
All eight plans that sold on the Washington Health Plan Finder in 2014 submitted bids last month to continue selling insurance on the marketplace. They will be joined by four new insurance carriers, who see something desirable enough about the exchange to give it a try in 2015.
Insurers' proposed rate increases came in, on average, at 8.25 percent, the lowest average in seven years.
"Some said they blew it and came into the market too high last year," Crittenden, in the governor's office, says. "One carrier asked for a price reduction."
There's no talk in Washington of defaulting back to Heatlhcare.gov, like neighboring Oregon announced it would do in April. It's largely talk about trying to iron out the problems that consumers are still having, and trying to convince Washingtonians that the plans they purchased this year are a good enough deal to re-enroll in 2015.
"There have been a lot of bumps," Crittenden says. "That's what drives me a little crazy, that we're still building the plane when its in the air. We'll be doing that for a long time, since this is a big IT project. I have to look at the glass as half full: people who gained coverage really like it."