In the week since the launch of insurance exchanges — a centerpiece of the new healthcare law — nearly 9 million Americans have visited the federal health care website. And thousands more have visited online exchanges run by the states. But both federal and a few state online marketplaces continue to have problems. Some say the technical glitches are caused by higher-than-expected traffic to these sites. Others warn they have serious, underlying flaws that aren’t easily resolved. Diane and a panel of experts discuss strong interest, technical issues and other roll-out challenges for the new insurance exchanges.


  • Susan Dentzer Senior policy adviser, The Robert Wood Johnson Foundation and on-air analyst on health issues, PBS NewsHour
  • Louise Radnofsky Health policy reporter, The Wall Street Journal.
  • Jon Kingsdale Managing director, Wakely Consulting Group; former founder and Executive Director of the Commonwealth Health Insurance Connector Authority, the agency that implemented the Massachusetts health insurance exchange in 2006
  • Audrey Tayce-Haynes Secretary of the Cabinet for Health and Family Services for the state of Kentucky
  • David Simas Assistant to the President and Deputy Senior Advisor for Communications and Strategy

Flow Chart: How Health Insurance Exchanges Work


  • 10:06:53

    MS. DIANE REHMThanks for joining us. I'm Diane Rehm. Nearly 9 million people have visited the federal government's insurance exchange website since it opened last week. But that site and some of the state's online marketplaces have been plagued with technical glitches causing long waiting times. Here to talk about rollout challenges for insurance exchanges: Susan Dentzer of The Robert Wood Johnson Foundation, Louise Radnofsky of The Wall Street Journal, joining us from a studio at WGBH in Boston, Jon Kingsdale of the Wakely Consulting Group.

  • 10:07:33

    MS. DIANE REHMHe led the agency that implemented the Massachusetts health insurance exchange. But first, we are joined from the White House by David Simas. He's assistant to the president and deputy senior advisor for Communications and Strategy. Thanks so much for joining us, sir.

  • 10:07:55

    MR. DAVID SIMASDiane, good morning, and thanks for having me on.

  • 10:07:57

    REHMDavid, the federal website,, was down again early this morning, I gather, for some technical updates. Have you figured out what's causing the problems so many folks are having?

  • 10:08:16

    SIMASSure. Diane, as you stated, we made the decision to take the website down overnight for some additional maintenance so that engineers in our team could increase the capacity of the website. Because, here, in essence is what we've seen. In that first 72-hour period, there are 8.6 million unique visitors that came on to That exceeded by numerous factors the expected volume in one day or even over those three day period.

  • 10:08:53


  • 10:08:54

    SIMASTechnically, what happened is that at the initial stage of the account creation, when people come on, they create an account. Then they do an application, and then they shop for insurance. There was -- the system at that initial stage couldn't handle the volume. So CMS, what they did is essentially created waiting rooms where people would be directed into and then released from the waiting rooms at periodic levels throughout the course of the day, which created a...

  • 10:09:26

    REHMAnd how long was that first waiting period?

  • 10:09:30

    SIMASSo I don't have that number, Diane, in terms of that first day of what the waiting period was. What I do know is the numbers that CMS have released for us yesterday is that the wait times have been reduced by 50 percent over the course of the first week. And it is our expectation with the improvements and the fixes that we're putting into place, and have been doing through the weekend, we're going to be seeing increased improvement in usability throughout the course of the week. And so...

  • 10:09:58

    REHMThat's good to hear. David, explain to our audience whether in fact, and to what extent, the system was tested before it went online.

  • 10:10:17

    SIMASSo, Diane, of course the system was tested. But it's important to understand about is that something like this on this scale has never been created before. And when you look -- and I'm glad that you have Jon on from Massachusetts. When you look at different examples, when you try to establish some base line for comparison, one thing you look at is

  • 10:10:40 on one day only had one-eighth of the volume that we saw in the first day -- in the first couple of days of, so that's the first point. The second point is, from what we saw in Massachusetts is that enrollment actually ramps up over periods of time and triggered by benefit days. And so when the team was thinking about what to expect in October, November, and December, because benefits only kick in on Jan. 1...

  • 10:11:08


  • 10:11:08

    SIMAS...the expectation that the real volume, the real intense volume, would come in at November and then in early December as we saw both with the Massachusetts experience as well as with Medicare Part D. So, you know, bottom line, the surge at the beginning was something that was completely unexpected.

  • 10:11:29

    SIMASAnd from our perspective, now just looking at it very clinically, this is good news because we will fix the wait times. We will fix these delays. But we've already established something very, very important, which is there's huge demand for this product and that once this is up and running we believe that this will be just an enormous success.

  • 10:11:53

    REHMSo you said that 8.6 million unique visitors came on in the first three days. Do you have any estimate of how many of those actually were able to enroll?

  • 10:12:11

    SIMASSo we know, Diane, that there has been enrollment. Enrollment continues. Like we do with Medicare and other programs, we are going to be releasing all of the aggregate data in terms of enrollment, whether it be online, over the phone, which is now an option for folks to call 1-800-318-2596, to go through the enrollment period, as well as enrollment that's occurring in person in the 36 states for which the federal government is running the marketplace.

  • 10:12:40

    SIMASSo we will release those numbers on a monthly basis the beginning, you know, probably in early November.

  • 10:12:47

    REHMOK. And I have heard one anecdotal report that people on the phone ask or are questioning whether it's Obamacare or the Affordable Care Act because they think that Obamacare is what they don't want.

  • 10:13:09

    SIMASSo I am not aware of those anecdotes. What I do know, Diane, is that each state -- you know, Kentucky's a perfect example in this. They set up their own marketplace. It's called Kynect. California's called Covered California. And what we've seen over these past seven days is that, at the end of the day, people don't care whether it's, you know, Obamacare or the Affordable Care Act.

  • 10:13:38

    SIMASThey want to get on to the plan comparison and do something that they've never been able to do before, which is line up plans side by side, factor in what subsidy they're going to get depending upon their income to help pay for it, and then make a decision. And just one final point on this, Diane, because I think that this is really important. Folks who are going on to, many of them are people who have experience with the individual market the way it existed before last Tuesday.

  • 10:14:06

    SIMASAnd that process was generally paper applications with seven pages or more of underwriting that was intended to exclude you if you had a preexisting condition. There were some websites that you could go onto that you could do the comparison shopping. But once you thought you were done, then you would be cycled in once again to the preexisting condition underwriting process. That will never happen again.

  • 10:14:28

    REHMHmm. Hmm.

  • 10:14:30

    SIMASAnd so that is one of the most important and salient facts because, think about this, one out of two Americans under the age of 65, under insurance industry standards, had a preexisting condition. Starting last Tuesday, that no longer matters, and no one will be discriminated against because of...

  • 10:14:48

    REHMAnd finally, what about the politics of all this? What about the Republican efforts to repeal or defund Obamacare? Have they negatively had an impact on the rollout?

  • 10:15:05

    SIMASI think that the fact that 8.6 million people showed up, notwithstanding a 3 1/2-year sustained program and campaign of misinformation, really speaks to the fact that when families are making decision about their health and their healthcare and their health insurance, the last thing on their mind, Diane, are talking points from either Democrats and Republicans. The first thing on their mind is what they can do to take care of their families and do it in a price that meets their budget.

  • 10:15:36

    SIMASAnd that's the beauty of this is that millions upon millions of people are going to put the politics aside, choose what works for them. And what that means in terms of the politics going forward is on a daily basis, as more and more and more people get enrolled, repeal and defunding now becomes, from this day forward, about actually taking healthcare insurance away from people who have earned it and are paying for it.

  • 10:16:01

    REHMDavid Simas, he is assistant to the president, deputy senior advisor for Communications and Strategy at the White House. Thanks for joining us, David.

  • 10:16:16

    SIMASThanks, Diane.

  • 10:16:17

    REHMAnd turning to you, Louise Radnofsky, from your reporting, was that an accurate representation of the problems we're seeing?

  • 10:16:29

    MS. LOUISE RADNOFSKYWell, what the administration is focused on is the volume as sign of the law's popularity. But it's important to note that it's not just waiting rooms or additional capacity that they're trying to build into the site. They are also dealing with design and software changes that are required to withstand the volume.

  • 10:16:43

    REHMSo that we're putting new software in almost every day?

  • 10:16:48

    RADNOFSKYWell, it's not just making the site bigger essentially. It's making it stronger because what the volume seems to have revealed is some fairly deep flaws both in the software around the account creation function but also essentially the hardware in the system, too. And so the maintenance that's being done on this site in the last few days has gone at some problems that are a little bit deeper that the administration has to resolve before they get what they're now saying will be an even bigger surge of interest later on in the fall.

  • 10:17:17

    REHMNow, I've read that one of the biggest flaws is the process of confirming enrollee's identities. Is that correct?

  • 10:17:29

    RADNOFSKYThat's a complicated process, and it appears to have been complicated again by both software and design issues. But there's a series of questions. The aim is to do a couple of things. One is to verify that you are who you say you are, and the other is to verify...

  • 10:17:40

    REHMAnd that's first?

  • 10:17:42

    RADNOFSKYAnd the other is to verify that you are who you think you are when you come back, if you can't remember your password. So there's a couple of different issues involved and a couple of different types of questions that are involved in that, too. But it appears to have been something that people haven't even been able to get to because they've been in the waiting room. And then when they have been there, they're telling us they are getting locked out or bumped off.

  • 10:18:02

    REHMLouise Radnofsky of The Wall Street Journal, she's the health policy reporter for that newspaper. When we come back, we'll talk with Susan Dentzer and Jon Kingsdale who have been watching this process and been involved in it very closely. Stay with us.

  • 10:20:00

    REHMAnd as we talk about the rollout of the healthcare program, you've already heard from White House Spokesman David Simas. Now here in the studio, Susan Dentzer of the PBS News Hour, Louise Radnofsky of the Wall Street Journal. And, joining us from WGBH in Boston, Jon Kingsdale. And Jon is the former founder and executive director of the Commonwealth Health Insurance Connector Authority, a very long title.

  • 10:20:39

    REHMThat's the agency that implemented the Massachusetts health insurance exchange in 2006. And what I want to ask you, Jon, since you've had lots of experience setting up the exchanges, what has been your impression of the problems on the federal site this week? Did you, in Massachusetts, encounter anything like that?

  • 10:21:09

    MR. JON KINGSDALEGood morning, Diane.

  • 10:21:10

    REHMGood morning.

  • 10:21:11

    KINGSDALEWe call it the Mass Health Connector here. It's a little less of a mouthful. And, frankly, we didn't encounter quite these problems. We did have other delays in starting up. But, you know, there are really two campaigns here. One is the enrollment campaign. And I think the federal site will overcome its issues in time, I hope, certainly for the enrollment campaign which really is going to pick up in November.

  • 10:21:38

    KINGSDALEThen there's the political campaign. And of course in Massachusetts we had a very different political situation with the really bipartisan support. So there wasn't an organized political campaign to take advantage of and use any glitches, if you will, against us.

  • 10:21:52

    REHMSusan, do you think that that political campaign has had an impact on this rollout?

  • 10:22:02

    MS. SUSAN DENTZERWell, clearly it has in many respects. Many of the organizations that were being enlisted to help sign up people for coverage backed down under pressure from Republicans in the Congress. So that obviously had a role.

  • 10:22:17

    REHMFor example.

  • 10:22:19

    DENTZERWell, the National Football League, for example, was approached about trying to do some awareness raising, and other companies, for example, H & R Block, which would have an interest in helping make people aware because, of course, there are tax credits available.

  • 10:22:34

    REHMAnd they backed out.

  • 10:22:35

    DENTZERYeah, pretty clearly backed out because of the allegations that, if you were helping sign up people for coverage, you were a partisan supporting Obama and not actually helping sign up people for coverage. So -- but I think, you know, to go back to what David was saying, this -- the way the administration, I think, is looking at this is this is sort of a high-class problem to have if you have so many people wanting to get on the exchange in the first day.

  • 10:23:03

    DENTZERAnd, as David said, there were widespread expectations not just among the administration, but almost every single state exchange director would've told you and did tell many people that they were not expecting Americans to buy coverage on layaway. They were not expecting people to buy coverage in October for use in January. They were really expecting people to come on in November, you know, Black Friday, just as the big Christmas shopping day was going to be a big health insurance shopping day. And guess what? It turns out people seemed to have been much more interested.

  • 10:23:37

    REHMHow did we get to this bifurcated plan of federal and state exchanges, Susan?

  • 10:23:44

    DENTZERWell, the law gave -- the Affordable Care Act law gave states the ability to set up exchanges and also allowed for a federal exchange and, in fact, allowed for the federal government to do all of the exchange operation if states didn't want to do that. Again, the widespread expectation was that most states would take the option of running their own exchanges. In the end, it was only 16 states and the District of Columbia that came forward to do that, which meant by default the federally-facilitated exchange had to pick up the rest. And, as David said, that was 36 states.

  • 10:24:19

    REHMHere's an email from Ralph: "Is there any evidence of denial of service attacks?" Louise?

  • 10:24:30

    RADNOFSKYWell, we haven't heard anything about that yet. New York State's exchange also reported in initial days that it had what appeared to be an unusually high number of hits. But they appear to have ruled out any hostile action as much as just that the hit count was out of whack a little bit because of something else that was going on with the site. It really doesn't seem like there's anything that's gone on in this part.

  • 10:24:50

    RADNOFSKYAnd of course it's worth noting that, from a strategic point of view, if one did want to in some way cripple the act, certainly the administration has been able to use what it says is a strong evidence of demand as a reason to continue fighting not to delay implantation of the law. So it certainly -- even if you could've been able to do it, would've had some complicated political ramifications.

  • 10:25:08

    REHMHere's a question from Chris. He says, "In North Carolina, insurance rates are going up. We have mostly Blue Cross/Blue Shield. North Carolina did not take the federally funded Medicare expansion. If North Carolina did, wouldn't that lessen the rates?" Susan?

  • 10:25:33

    DENTZERWell, I think he's talking about the Medicaid expansion, which would not have had any impact on the commercial insurance rates at all. What is going on with the commercial insurance rates -- and I suspect he may be overstating the case because there are lots of different policies available from lower cost plans, catastrophic plans for younger people, et cetera. And we have to remember that the winds of change in insurance regulation are blowing in many different directions, and that's going to affect people in different ways.

  • 10:26:05

    DENTZERFor example, on-balance for women are lower because no longer are women able to be charged extra because they may become pregnant and have children. So on-balance rates for women are falling. On-balance rates for older people are lower than they would've been otherwise because we've compressed the difference of what people can be charged if they're older.

  • 10:26:26

    DENTZERSo there are lots of different things going on. And how this nets out is really very much going to depend on who you are, what your age is, what your gender is, and I think if people look very closely, they will find on-balance more affordable options with better coverage than was the case historically in the individual insurance market.

  • 10:26:44

    REHMJon Kingsdale, based on your experience in the Massachusetts exchange in 2006, what about those people who can't get onto the site now because of these technical glitches? Do you expect them to come back?

  • 10:27:04

    KINGSDALEYes, I do. In fact, I think that there is a surprise in the high volume, and it's probably folks who -- because I was one of those voices saying that we wouldn't see much volume until November. And I still believe the bulk of enrollment will be in November and December. But probably the -- most of those who came on in October were, A, either curious or, B, highly motivated because of their own medical conditions and will certainly come back.

  • 10:27:33

    KINGSDALEThe other number here that's from Massachusetts that's extremely relevant is the ratio of folks who actually get on to the site versus those who actually enroll and pay for insurance. And we did a study a few years into one of the exchanges -- we had two different exchanges. And for the self-pay exchange, the ratio was something like 18:1, those who actually got through the login process, got to the prices and the options and the shopping pages. And then, of those 18, only one actually bought insurance.

  • 10:28:09


  • 10:28:09

    KINGSDALESo you get a lot of shopping and a lot of looking before people enroll.

  • 10:28:11

    REHMYeah. Yeah.

  • 10:28:14

    KINGSDALEAnd they typically got on the site and also talked to a customer service person. They get on the site four, five, six times and then talk to a customer service rep before actually buying.

  • 10:28:27

    REHMLouise, can you take us through the process -- the online process? What happens when you go to the site?

  • 10:28:37

    RADNOFSKYWell, certainly worth noting, as Jon just did, that for people it is a complicated decision that they're making. And in some ways what the administration is focused on and support is a little focused on in messaging is that it's easy, but people have clearly shown in the focus groups that they consider it to be something that they do take time over. So what we've heard with some people who thought they've enrolled, for example, is what they'd actually done was that they had gone on the site. They had successfully created an account. These are two of the processes.

  • 10:29:02

    RADNOFSKYAnd then they had applied because their income suggested that they might be eligible for tax credits. And what they appear to be receiving is determinations that they are going to get help towards the cost of paying their premiums. What they haven't done in the case of this gentleman from Georgia who created a little bit of a controversy earlier this week over whether he had enrolled or not. So they haven't then taken their premium subsidy, essentially a voucher, and applied it towards the cost of a particular plan.

  • 10:29:28

    REHMOh, I see.

  • 10:29:29

    RADNOFSKYThey hadn't picked which one they're going to do. There's a final stage beyond that in which the carrier receives the government's portion of the premium and whatever premium portion the person's going to pay. That's not going to come until much later, but that's a very final stage.

  • 10:29:43

    RADNOFSKYWhat we're really talking about now when we're talking about people who have successfully completed enrollment is people who have not only discovered their legibility for assistance. They've picked which plan they're going to use with it. And we expect that people may be taking a while to make that decision.

  • 10:29:56

    REHMOK. So "The Diane Rehm Show" website has the website for And of course we have the toll free number to call. I understand, Susan, that the first thing I have to do when I go on that website is to prove that I am who I say I am. How do I do that?

  • 10:30:24

    DENTZERWell, actually, the first thing you have to do is write in what state you're from because you will get that directed to -- if there's a state-based exchange to serve you, you'll be directed there.

  • 10:30:28

    REHMOh, of course. Right.

  • 10:30:34

    DENTZERBut actually what is happening is you type in various information that the site prompts you through. And what is going behind the scenes is very important. Essentially that information is going through a federal data hub to various places: the IRS to verify your income, the Treasury to verify whether you're eligible for the tax credits, Social Security to verify whether you are a citizenship or not, Homeland Security to verify your residency status, et cetera.

  • 10:31:03

    DENTZERSo there's a lot going on behind the scenes which should be completely -- you should be completely oblivious to. And of course that's part of the issue that we're trying to work out now, is to make all of that work as effectively as possible.

  • 10:31:15

    REHMAnd how long does that initial process take?

  • 10:31:19

    DENTZERWell, I think that is part -- well, the problem right now is the -- first, there's the waiting time to get in, and then this process is taking a while. It is supposed to be happening very, very fast.

  • 10:31:31

    RADNOFSKYIt sounds like it's varying a great deal, and we honestly don't know. What we do know from the administration, the only number they have put out -- and the secretary said this last night -- is that hundreds of thousands of people, they say, have successfully now created accounts. Now that's hundreds of thousands of what was 8.6 million people as of Friday night.

  • 10:31:47

    RADNOFSKYBut it's also worth noting that there are probably a fair number of people who are on that site because they're window shopping. They may not actually be the people for whom the site is intended. They have employer-sponsored coverage right now. They have Medicare, but they're curious to know if they can get a better offer. Certainly we've got a lot of email about that. It's also a fair few journalists probably among them.

  • 10:32:06

    DENTZERAnd health plans looking at each other's rates.

  • 10:32:09

    RADNOFSKYThere's a lot of gawking.

  • 10:32:09

    REHMYeah. Jon, you wanted to add to that?

  • 10:32:12

    KINGSDALEJust that the problem here is we don't know what we don't know yet. The process that Susan described actually involves downstream, once you get logged on, get an account and start shopping, a whole multitude of other interactions. And until we test those gates with some high volume of folks going through the turnstiles, we actually don't know how those turnstiles are going to work.

  • 10:32:39

    KINGSDALESo that's a bit of a problem. And, you know, it doesn't really matter in October because the bulk of the volume's going to be in November. But if they haven't tested and fixed all the gates to get to the endpoint by November, I think then we'll run into some real volume problems.

  • 10:32:53

    REHMAnd you're listening to "The Diane Rehm Show." Time to open the phones. I'd like to hear what our callers have experienced, if they've been to one of these websites, 800-433-8850. First to Jim in Houston, Texas. You're on the air.

  • 10:33:19

    JIMHi. Good morning.

  • 10:33:20

    REHMHi, Jim.

  • 10:33:20

    JIMI'm just listening to this, having been a technology person for most of my life, and I'm going -- this is a prime example of people who don't understand what they're building -- trying to build. I mean, there's no way that they couldn't have done testing -- regression testing. And the kinds of processes that they're using to verify the volume capacities to the system is flawed in general.

  • 10:33:46

    JIMAnd that brings me to my second statement which is, if you guys can't -- if the Feds can't run a website like that and they can't get post office mail to go to the right place and that's losing billions of dollars, what are we in store for with them taking over the health care system? Even though, yes, they're providing health care through the private market, but the private market's got to be eating this up because they wouldn't be doing this if there was no profit motive for it.

  • 10:34:13

    REHMAll right, Jim.

  • 10:34:14

    JIMAnd I think it's very, very scary what's going on. And I think if and when it fails -- and I think it will fail -- we are going to have a very catastrophic problem because people are going to find themselves paying lots more and getting lots less.

  • 10:34:27

    REHMAll right. OK, Jim. Thanks for your call. Go ahead, Susan.

  • 10:34:32

    DENTZERWell, I think it's important to note that the federal government and the state governments did not build these themselves. They contracted these exchanges out to be built by -- in the case of the federal government, the master contractor was a private multinational company called CGI. California used Accenture, the consulting firm. Other states used Deloitte, Microsoft, Xerox.

  • 10:34:55

    REHMSo it wasn't amateurs who were doing this.

  • 10:34:57

    DENTZERNo, no. It's just -- I think, you know, to be fair, as administration spokesman David Simas said, this has never been done on quite this scale before. And if even these very sophisticated firms couldn't get it right with all of the requirements that seem to be inherent in putting this together, it tells you that it was a challenge.

  • 10:35:17


  • 10:35:17

    RADNOFSKYThe administration did say earlier this year that one of the reasons that people should feel confident in their ability to do something like this was that they had done something similar before in the form of Medicare, which of course has 49 million people. They were pretty confident (unintelligible) because doesn't crash.

  • 10:35:30

    REHMBut how did they do Medicare? How did they do Medicare? Certainly not online. That came in in a very different way.

  • 10:35:39

    RADNOFSKYNo. They have pointed to their ability to run the website without crashing as a reason to believe that wouldn't go down as well.

  • 10:35:44

    REHMSure. OK.

  • 10:35:46

    DENTZERAnd the annual Part D enrollment is carried out online as well with the prescription drugs.

  • 10:35:49

    REHMBut how did they -- how did they initially enroll people in Medicare?

  • 10:35:53

    DENTZERWell, there were problems at the outset of Part D.

  • 10:35:56

    REHMOf course.

  • 10:35:57

    DENTZERIt's forgotten now, but for several months it was a very rocky startup. But we got past it. And now Part D is considered a preeminent success story. So we'll see what happens this time.

  • 10:36:10

    REHMJon, what do you think of our caller's comment?

  • 10:36:14

    KINGSDALEWell, I've got two reactions. One is that it illustrates the partisan nature of this where technical "issues" or managerial issues get mixed up with sort of pro- and anti-"Obamacare." But the other element is, you know, this is different from Part D. Part D was one rollout. This is 17 or 18 different states plus the federal rollout all at the same time. There are only a limited number of vendors. Many of them have multiple teams in the field trying to develop separate systems.

  • 10:36:49

    KINGSDALEAnd it clearly is -- it has been a challenge for them. Part of that may be their fault. Part of that may be the way it's been managed. Part of it is inevitable. As I say, they've got about a month to figure this out and get it right before it starts really cutting into enrollment. And hopefully they'll get it right by November. If not, I think Jim's criticism of government's ability to do some basic functions is going to be a lot more resonant with people around the country.

  • 10:37:17

    REHMAll right. And we'll take a short break here. And when we come back, more of your question, your comments as we talk about the rollout of the Affordable Health Care Act, the kinds of problems, glitches people are running into and how they might be solved.

  • 10:39:58

    REHMAnd joining us now from her office in Frankfort, Ky., Audrey Tayse Haynes. She's secretary of the cabinet for Health and Family Services for the State of Kentucky. Welcome to the program, Audrey.

  • 10:40:16

    SECRETARY AUDREY TAYSE HAYNESThank you, Diane. It's a pleasure to be on this morning with you.

  • 10:40:19

    REHMThank you. Tell us how your state decided to handle the insurance exchanges and what has happened since implementation.

  • 10:40:31

    HAYNESWell, we're one of those few states that chose to have our own state-based exchange. And our governor made that decision, and the primary reason was he felt as though that we would be more inclusive by utilizing a state-based exchange with our insurance carriers and all of the stakeholders, as well as all the healthcare provider groups.

  • 10:40:54

    HAYNESSo a much more inclusive, open, and transparent process would take place. And, of course, we have a call center that is located right here in Kentucky, and it's answered by our friends and neighbors who know Kentucky. So he just felt as though that a state-based exchange was the best route to go for Kentucky.

  • 10:41:13

    REHMSo I gather your online enrollment went very smoothly. How did you manage to avoid the kinds of problems that the federal site has seen?

  • 10:41:27

    HAYNESWell, I'm not saying that we have gone completely, Diane, without our own problems. And last Tuesday when we launched, we were down -- no entirely, but there were a few glitches for two or three hours. We had an IT command center, and we were back up soon. We had to add a bit more horsepower, as has been discussed, I think, by your folks on your show earlier. Nevertheless, we have been able to -- we had a great campaign to roll out. We had great contractors.

  • 10:42:04

    HAYNESThe Cabinet for Health and Family Services houses the Health Benefit Exchange, as well as Medicaid, as well as community-based services, public health, all of the agencies that, really, it takes to interface with the Health Benefit Exchange and for it to be successful, except for our Department of Insurance. So the regulatory agency over the insurance companies is in a different cabinet. The rest of them that it takes to interface to help to support and make this successful is all in my cabinet. And I do believe that plays a big role, as well.

  • 10:42:41

    REHMSo, Secretary Haynes, how many people have you actually enrolled in a plan?

  • 10:42:50

    HAYNESWell, we've had over 22,000 applications that have been started for health coverage. And we have almost 15,000 that have been completed. We also have over 200 small businesses that have started applications. And that number really does exceed what our expectations were. We have about 640,000 Kentuckians that are uninsured.

  • 10:43:17

    REHMAnd what kind of feedback are you getting from Kentuckians about the new healthcare law?

  • 10:43:26

    HAYNESWell, as you know, we have a mixed-bag of feedback here in Kentucky about the healthcare law. We have two U.S. senators who are often heard speaking against the law, Sen. McConnell and Sen. Paul. However, our governor has been gung-ho, full speed ahead with the law. And, you know, it is amazing that our call center has fielded under 29,000 calls. And there is a lot of enthusiasm.

  • 10:44:00

    HAYNESAnd last Tuesday, at our federally qualified health centers, public health departments and other places across the state, where you could go and have assistance in signing up, there were lines to get in. And so I think, as John from Massachusetts described this, you have sort of a policy and technical side of this, and you have a political side. On the policy and technical side, it's very clear that Kentuckians have waited a very long time -- if you're uninsured -- to have this opportunity.

  • 10:44:34

    REHMBut I gather there was some questioning about whether it was Obamacare or the Affordable Care Act.

  • 10:44:45

    HAYNESWell, that's correct. I think the late-night comics have got that down perfectly for us, that, as they go out on the street and interview folks about Obamacare, people often want nothing to do with it. But when they talk about the benefits and the specifics of the Affordable Care Act, people are quite intrigued and interested and ready to sign up. And so it does take a while.

  • 10:45:14

    HAYNESWhen you're on the phone -- I worked a phone bank last Tuesday night for three hours. And actually on our public TV station, we were on for an hour last night fielding calls. And I assure you there is a great deal of misinformation out there. I believe those of us that are on the side of supporting the Affordable Care Act have done the job that the people who are against it have done. We should have stepped up…

  • 10:45:41


  • 10:45:41

    HAYNES…our campaign about what it is and what it's not a long time ago. So there's a lot of misinformation, and we have to field through that as we are trying to get people to make the decision to sign up.

  • 10:45:54

    REHMAudrey Tayse Haynes, secretary of the cabinet for Health and Family Services for the State of Kentucky. Thanks for joining us, Secretary Haynes.

  • 10:46:07

    HAYNESSure, Diane. Thanks so much.

  • 10:46:08

    REHMOK. And now, let's take a caller in Lincoln, Mass. Sheila, you're on the air.

  • 10:46:17

    SHEILAHi, Diane. As you said, I'm calling from Massachusetts, where we've had healthcare exchanges, as you know, for many years. And my question is about this phenomenal outpouring of callers on the first day of the computer website. I have read in Connecticut newspaper, in the Connecticut Mirror, the CEO of Access Health CT, Kevin Counihan, I believe, who, even before the website went live, was worried about potential for Tea Party hackers and said that there had already been attempts by Chinese hackers to get into the website.

  • 10:47:00

    SHEILAIt seems to me that with the massive campaign against Obamacare -- which the success of which is exemplified by your first caller, Jim, from Texas -- that it's naive to believe that there wasn't an attempt to crash the website and to make it look as if, you know, there were significant glitches.

  • 10:47:24

    REHMAll right. I'm afraid you're breaking up on us a bit. Jon Kingsdale, can you comment on that?

  • 10:47:32

    KINGSDALEWell, it'd be an easy excuse, I think, for folks -- and I include myself in that category -- who are very supportive of the Affordable Care Act, but there's no evidence at this point. And, in fact, if you look at the 17 or states around the country, you see that even with modest levels of volume some of them had and are still having real problems. So, you know, in the absence of information conspiracy theory is fertile territory, but I'm not sure we have any evidence to that affect. In fact, a number of the experts have opined that that's not what's going on here.

  • 10:48:10

    REHMLouise, would you agree with that?

  • 10:48:11

    RADNOFSKYI think that's absolutely right. But, even if it were to be the case, there's also an issue that the sites are supposed to be able to withstand this sort of thing.

  • 10:48:18

    REHMI see. OK. Let's go to -- I think we lost Laura. Let's go to Anthony in Virginia Beach. You're on the air.

  • 10:48:28

    ANTHONYGood morning. How you doing?

  • 10:48:30

    REHMGood, thanks.

  • 10:48:32

    ANTHONYGood. There's been a tremendous amount of change in the Obamacare since it's been rolled out. The major healthcare site associated with the Obamacare program,, it used to say free healthcare. And it has been changed to low cost healthcare. And it was cited in a major news publication. They actually showed two windows on the computer screen citing this. One window said free, and the other showed low cost, you know, highlight this. Could your guests speak to this issue of change from free to low-cost healthcare?

  • 10:49:12

    REHMSusan Dentzer, have you ever seen anything like that?

  • 10:49:16

    DENTZERI, personally, have never seen that. And if it existed at all, it was obviously in error. I don't know anybody responsible who understood the contours of the law who would have ever maintained that it was free in any respect.

  • 10:49:32

    RADNOFSKYWell, the messaging that the administration has used, in conjunction with what its focus groups are telling it, is that it needs to emphasize two points to people who don't have insurance who are really skeptical about getting it possibly 'cause they've had bad experiences with it in the past, but also because they don't think that they have the money for it. It's to emphasize that it's affordable.

  • 10:49:48

    RADNOFSKYYou hear the word affordable a lot, including in the law's name. The other thing that they emphasize is that the new insurance is going to be available to people as quality. So you're possibly paying more than you might have before for what you considered to be an insurance policy, but, as Susan said, it covers so much more. And so the argument is that the price tag is worth it.

  • 10:50:05

    REHMJon, have you ever seen anything that says free?

  • 10:50:11

    KINGSDALENot on government websites. You know, there's a lot of -- I tried to log onto Kentucky's website. I eventually found the right one. But the first time I logged on, I got onto a private sector website that was using the same name.

  • 10:50:26


  • 10:50:28

    KINGSDALESo there's that possibility. I doubt it said free, but there is actually one element of it that is free. So we have an eligibility determination system, and that's a huge technological challenge. That's not something that you hear talked about a lot, but it's very different from what we did in Massachusetts. And that eligibility determination system has three different branches.

  • 10:50:48

    KINGSDALEYou're not eligible for any subsidy. You're eligible for a subsidy through the exchange for private commercial insurance, but you pay something. Or you're eligible for Medicaid. And in half the states, that eligibility has expanded with the Affordable Care Act. And, of course, that Medicaid coverage would be free for folks up in an expansion state up to 138 percent of the federal poverty level, so even above federal poverty.

  • 10:51:13

    REHMAll right. Emin (sp?) in Florida is asking -- he says he asked his doctor which exchanges he accepts, so he could continue receiving his services. His office answer was, we don't know. Nobody from the government contacted us to inform us how we are to interact with the Affordable Healthcare Program. What's the deal? How do doctors in private practice integrate with the program, Susan?

  • 10:51:48

    DENTZERWell, this is another huge area of confusion. In fact, healthcare providers don't have to have any interaction with exchanges.

  • 10:51:55

    REHMIt's the patients.

  • 10:51:56

    DENTZERThe enroller -- the enrollee, I should say, the subscriber has to enroll in the health insurance. But the same way providers relate to health insurance now is going to be what is in place under the Affordable Care Act. That is to say, if the particular plan has signed up the doctors in a particular network, or the other providers, hospitals and so on, then they are part of the network. But that is the case now.

  • 10:52:28

    DENTZEROne of the -- it is instructive for many people to note that one of the facets of the Affordable Care Act and the standup of exchanges has been that part of the reason there is more affordable coverage available is that certain health insurance plans have struck deals with particular networks of physicians and hospitals so that they pay them less.

  • 10:52:49

    DENTZERAnd that's how the coverage has been made more affordable. So it is very important for individuals to go online and see what providers are in particular plans. That is what they need to basically examine. It is not the case that physicians and providers and so on have to worry about the exchanges. What they have to worry about is what they have negotiated with particular insurance companies, insurance plans.

  • 10:53:16

    REHMOK. And to Brian in Clearwater, Fla. after I remind you, you are listening to "The Diane Rehm Show." Go right ahead, Brian.

  • 10:53:28

    BRIANYes. Good morning, Diane.

  • 10:53:28

    REHMHi there. Oh, dear, what happened? You dropped. Sorry about that. Let's go to Cody, in Charlotte, N.C.

  • 10:53:39

    CODYHey, Diane. I was calling in reference to a comment that someone else had made and add some other stuff to it. In North Carolina, there are 61 counties in North Carolina and Blue Cross/Blue Shield is the only person -- or only, you know, insurance offered on our network. And then the rest of the counties have a second one. That's why the insurance is higher in North Carolina.

  • 10:54:07

    CODYAt the moment, it's some of the highest on, you know, using the Affordable Care when you look across the board with the states. I'm all for affordable care. I think that's great. The thing about it is though is, like, I work for a company that owns 125, 130 restaurants. They're dropping insurance for employees that aren't, you know, hourly management or hourly, you know, just employees.

  • 10:54:37

    REHMSure. Employees, yeah.

  • 10:54:40

    CODYAnd, you know, withholding -- you know, we're being told to withhold them below 30 hours, you know.

  • 10:54:45


  • 10:54:46

    CODYSo it's (unintelligible)…

  • 10:54:47

    REHMFor part-timers, yeah. So what happens to folks like Cody, Louise?

  • 10:54:54

    RADNOFSKYWell, the cost of insurance has long varied between states and also even within different areas within a state. And some of that is to do with the cost of providing care. The way insurance is priced is actually becoming more uniform between the states because of these new federal requirements that say you can't do something like medical underwritings. You're seeing states that had widely divergent premiums coming closer together. But at the same time you're seeing that there are still differences.

  • 10:55:20

    RADNOFSKYNow, some people have attributed those differences to competition and the number of carriers that are offering in a given area. And it is certainly the case that, while the administration is able to point to 90 percent of Americans having five or more options, there are definitely parts of the country -- North Carolina may be one of them. New Hampshire is another -- certain areas that have long had a dominant provider. And that certainly doesn't appear to be changing overnight.

  • 10:55:40

    REHMJon Kingsdale, how long do you think the public is going to be patient with glitches at the federal and state exchanges?

  • 10:55:52

    KINGSDALEWell, I think there's some important sort of basic facts to keep in mind here. Ninety percent of Americans either don't qualify at all or -- actually, about 85 percent of them have some other kind of coverage, like group insurance from their employer or Medicare. And they're not affected by this at all.

  • 10:56:08


  • 10:56:09

    KINGSDALESo they might be curious, but they're not going to be sitting there going on the exchange every other day to see what they can do. Then the exchange itself is just an insurance store. It's a place to go to see if you can get subsidies and whether or not you can. It's an insurance store, so the real interaction's going to be with the private insurance companies. I believe that the exchanges will be largely up and functioning in a matter of weeks, all the way through the whole process, and then, you know, this is going to kind of disappear as an issue.

  • 10:56:42

    REHMOK. And that is Jon Kingsdale. He managed to implement that Massachusetts Health Insurance Exchange in 2006. Susan Dentzer is a reporter on the PBS News Hour. Louise Radnofsky of the Wall Street Journal. And for those of you not using a computer, call the phone line, 1-800-318-2596. Thank you all so much for being here. Thanks for listening. I'm Diane Rehm.

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