Connecticut's health exchange had one of the most successful open enrollment seasons of any Obamacare marketplace this year — largely meaning its website, AccessHealthCT, had no major, months-long meltdowns like Healthcare.gov or some state-based sites.
It's no surprise then that the White House has now tapped AccessHealthCT executive director Kevin Counihan to run Healthcare.gov as chief executive. As the federal website's new chief executive, he will provide some of the leadership that was sorely lacking during the first open enrollment.
I had gotten to spend some time in Connecticut last year shortly before launch. At the time, Counihan was taking a unique approach to building an online insurance marketplace. While others bragged about how amazing their websites would be — how they would be like an Expedia for health insurance — Counihan was more concerned with tamping down on expectations.
"This is a two- to three-year implementation we're doing in 10 months," Counihan told me at the time. "I wish we had one more year."
Connecticut decided to launch a barebones exchange, specifically delaying the launch of parts of the website they didn't think they could make work well by October 2013. And that seemed to work: while states that planned more ambitious marketplaces (think Maryland and Massachusetts) had disastrous launches, Connecticut's website worked.
Counihan and I last spoke in June, to debrief about the first open enrollment season and discuss what health reform would look like going forward. What follows is a transcript of our conversation, lightly edited for clarity and length.
Sarah Kliff: I wanted to start off talking about how you all in Connecticut approached this first open enrollment season. What was your strategy for being ready, and do you think it contributed to things going relatively smoothly?
Kevin Counihan: To be frank, I viewed it as a survival period. My goal was to get through open enrollment with as little customer disruption as possible and to make sure we earned the ability to start patching the system up in the summer of 2014. I thought that the time pressure was so tight that this was really just a time to make sure that you gained the credibly with your customers to earn the right to participate in the second year.
I think there were about four things we were doing in the lead-up that worked for us. First it was the management team, it was getting the right kind of people. I hired the types of folks who wanted to prove something because you can't buy that type of commitment.
Two was to create processes you could stick to and have the discipline to stick with our decisions. The third was vendor management. We all had these new vendors, nobody had enough to time to vet anyone as much as you would like, so how you manage the vendors was really important. The fourth is good software code, which isn't everything, but its important.
Whenever we would make a decision, we would ask how does this impact consumers' ease and simplicity. If it added simplicity, it got accelerated. If it was something that didn't, it got cascaded down the list.
SK: Can you tell me a bit about what your launch day was like on October 1?
KC: On September 29 we were notified by the insurance department they had some concerns about the layout of the website. We had two days to get our system integrator to put a couple of qualifications on a couple of pages of the site. It basically required 24-hour around the clock work. It was one of these things were, you have to enter a Zen state. There would be time the technical folks would walk in could tell from the looks on their face they had a big problem.
By the 30th we got this fix made and we worked all night and people were getting a little tired. I remember the night before launch people working very late. I brought in pizza and brought in two cases of red wine increased and that increased productivity about 30 percent. I didn't sleep too well. Then the next day, we flipped the switch and goddammit it worked. We started looking at screens and saw people coming on the site and traffic growing and growing. Some people were getting a little emotional and high-fiving. It's really a day I'll never forget.
SK: One of the things I remember from last fall was that, when other states were boasting about how great their exchanges would be and the president was comparing Healthcare.gov to Expedia, you were very intentionally setting expectations quite low for what you were doing in Connecticut, and warning people that it would be bumpy to start. Was it hard to deliver that kind of message when you would see other states talking about what amazing new things they were building?
KC: Actually it was just the opposite. I didn't feel like we were in the big leagues of the exchanges in the summer of 2010. It felt like we were minors, like Triple-A or something.
During my second week, I went down to meet with CCIIO [the Center for Consumer Information and Insurance Oversight, the federal agency overseeing Obamacare] and they told me we were on the watch list of states that might not make. The Oregons and the Marylands, back then, seemed like these big sophisticated states that always had their act together.
There's no heroes and villains in this thing. Everybody had their heart into this. I think some of us may have had more luck. Everybody tried, and some states are still trying.
SK: When your site seemed to be working in the winter, and some other states' sites still weren't, were you starting to get calls from those places about what you guys did differently?
KC: The calls started coming at the end of 2013. We got, I think, five calls from various states between after Thanksgiving and before January 1. And that's really when this idea about creating the exchange solutions division came from. Like everybody, we need to have a financially sustainable exchange in a few years and this seems like one way to get there. We start hitting the conference circuit and I started putting together an informal marketing plan with different states we could talk to.
SK: Can you explain to me what exactly it is you're selling to other states?
KC: It's basically three things. One is an outsource model. there are some red states looking at this. This is a hypothetical, but if Wisconsin wanted to have a Badger exchange, we can build it and power the whole thing by AccessHealth CT.
The second option is just running the back office, which is what Maryland is looking at. We give them the code, they talk to us and with the help of a system integrator make sure it all works. We could train their in-person assisters if they want or run a marketing campaign.
SK: You mentioned the financial sustainability requirements, that every exchange has to be self-sustaining starting next year. So is the idea here to use these types of sales to essentially pay for the Connecticut exchange?
KC: Right now we have an assessment of 1.35 percent on all licensed health insurers in the individual and small group markets and all dental insurers [that will pay for the exchange]. Part of the point of having this revenue is reach a point where that assessment can be reduced.
SK: One thing I'm curious about is whether there's enthusiasm from other states to buy these products and run their own exchanges. It seems like the first open enrollment season made it incredibly clear that building these sites is really hard work.
It seems to me that, if I'm out in a state that is using Healthcare.gov, which is working decently fine, that I might be thinking, let's just stick with this and not bother with the harder work of setting this marketplace up.
KC: There clearly are states that are either trying to repair what they have or are on the federally-facilitated marketplace [healthcare.gov] and are interested in moving out of it. Some of that can be ideological, like they don't like having the feds in their backyard, and there does seem to be some appetite for that.
But there is another piece of this, which is federal grants and money, and it feels to me the temperature on that has changed. A year or so go there was a tremendous focus [from the Obama administration] in getting states to adopt their own exchanges. Now, it feels like that changed since they're more confident of healthcare.gov. I think the financing of this is getting trickier.
SK: The idea being that the Obama administration might not be as forthcoming with funding as they have been?
KC: That is my understanding. But I have to say I don't know whether that reflects the current environment with Secretary Burwell coming in, and what direction she will take things in.
SK: How do you think the 2015 open enrollment will go? I've had some people make the case to me that it will be harder than 2014, because you're both signing up new people and trying to re-enroll the people who already signed up.
KC: It's going to be very complex. Not only are people going to be enrolling and going to be renewing, but there are going to have to be new determinations of what tax credits people qualify for. The education is going to be critical.
My personal view is there's a little bit of an arc. The arc of complexity is going to go into the third year, 2017. After that, people will be more used to and it more comfortable and the system will run smoother. But I do think this fall is going to be challenging.