President Barack Obama yesterday acknowledged technical problems with the Affordable Care Act’s online marketplace. In remarks at the Rose Garden, he said, “There’s no sugarcoating it: the website is too slow; people have been getting stuck during the application process, and I think it is fair to say that no one is more frustrated by that than I am.” Obama underscored those benefits of the new law which do not depend a website, and he said a “tech surge” is underway to solve the problems. About 20 million Americans have visited the site in the past three weeks. But experts say substantial improvement is needed in the next few weeks to meet the administration’s enrollment targets. Diane and her guests talk about the challenges of fixing HealthCare.gov.

Guests

  • Julie Rovner health policy correspondent, NPR; author of "Health Care Policy and Politics A-Z."
  • Dan Mendelson CEO and founder, Avalere Health, and former associate director for health, White House Office of Management and Budget.
  • Dan Schuyler director of exchange technology, Leavitt Partners, and former director of technology, Utah Health Insurance Exchange.

Transcript

  • 10:06:53

    MS. DIANE REHMThanks for joining us. I'm Diane Rehm. President Obama has said yesterday "nobody is madder than me about the botched rollout of the Affordable Care Act's online health insurance exchange." He insisted the technical problems would be fixed, and all Americans seeking insurance would be able to sign up.

  • 10:07:17

    MS. DIANE REHMBut it was not clear how quickly that could happen. Joining me to explain the technical and political problems: NPR's health policy correspondent Julie Rovner and Dan Mendelson, CEO and founder of Avalere Health. Dan Schuyler, director of exchange technology for Leavitt partners joins us from KUER in Salt Lake City.

  • 10:07:44

    MS. DIANE REHMI'm sure many of you have perhaps tried to get on these websites, have your own stories to tell. We'll talk about help available and perhaps solutions when you call us, 800-433-8850. Send us an email to drshow@wamu.org. Follow us on Facebook or send us a tweet. Welcome to you all. Thank you for being with us.

  • 10:08:13

    MS. JULIE ROVNERGood morning.

  • 10:08:14

    MR. DAN MENDELSONThanks for having us.

  • 10:08:14

    REHMGood morning to all of you. Julie, how far do you think the president went in explaining the rollout and what's happening?

  • 10:08:26

    ROVNERWell, I think a lot of people were frustrated that the president didn't say more about what the administration, one would think, knows what's wrong with the website. I think people were expecting him to come and say, this is what's wrong, this is how we're going to fix it, this is when we're going to fix it.

  • 10:08:39

    REHMBut do you think they know what's wrong with the website?

  • 10:08:44

    ROVNERWell, one hopes they know by now what's wrong with the website and how long it's going to take to fix. That's clearly the question of the hour. What's wrong? How long is it going to take to fix? When is it going to be working properly? Those are pretty much the big questions that are out there. And those are questions--I think a lot of people came away from that speech frustrated--that he didn't really answer.

  • 10:09:04

    REHMAnd I want to refer people to this morning's Washington Post. There is--on, let's see, page A4, under insurance marketplace--What's going on with healthcare.gov? Your questions answered. But, still, nobody really knows. Dan Mendelson, you were associate director for health at the White House Office of Management and Budget in the Clinton Administration. What do you know about what's going on here?

  • 10:09:42

    MENDELSONWell, first of all, I think it's hard to say more if you don't know more. And it's actually not smart to say anything if you don't have a really clear sense of what's going to be happening 'cause you don't want to correct yourself twice. And I think that, you know, what the president did yesterday was redirect to call-in centers. There are other ways to enroll.

  • 10:09:59

    MENDELSONI mean, the fact is people are not going to get healthcare from a website. They are potentially going to be able to enroll. But there are other ways to get signed up for this insurance. So what he did was try to redirect towards, really, what he felt was kind of the more important piece, which is that we're going to have 7 million people who are going to have insurance at some point over the next year.

  • 10:10:20

    REHMHelp me to understand, would this perhaps be considered normal for as big a rollout as this?

  • 10:10:30

    MENDELSONNo, this is not normal. This is a problem.

  • 10:10:31

    REHMThis is not normal.

  • 10:10:33

    MENDELSONIt's embarrassing. It's something that they will suffer for. But, you know, what sits on the other side of that is the bigger picture. And the bigger picture is that reform has been passed. There's now a mandate that says that everybody has to carry insurance. There are going to be these 7 million people who are going to sign up at some point. And, you know, we're now three weeks into a six-month open enrollment period. And the insurance isn't even available until 1/1 of next year, so, you know...

  • 10:10:58

    REHMAll right. I want to talk now with Dan Schuyler. You, I gather, were responsible for launching Utah's health insurance exchange in 2009. What kind of problems did you encounter?

  • 10:11:17

    MR. DAN SCHUYLERSo in 2009, we did launch the Utah health exchange. But we did what's called a beta test or a limited launch where we opened up the exchange to just a select few small businesses so they could test drive the system and we could make any tweaks to the technology to ensure that, when we opened the exchange later in 2010, that we wouldn't have problems that we're seeing with healthcare.gov.

  • 10:11:45

    MR. DAN SCHUYLERAnd so we used that beta test to fine tune the exchange and make those adjustments. And then we -- when we relaunched or reopened the exchange in January of 2010, we didn't have any technical problems, and the system worked fairly smoothly. But, you know, in all fairness, the Utah health exchange is much different than healthcare.gov. But we chose to do a beta test to avoid the issues that we're seeing with healthcare.gov. I think Dan...

  • 10:12:12

    REHMOK. Go ahead. Sorry.

  • 10:12:15

    SCHUYLERI was just going to say I think Dan's right. This is not something that you would expect from a project or initiative this big to open up on day one and people can't even create a user account. So Dan's right. This is a problem that needs to be resolved quickly.

  • 10:12:35

    REHMTell me if you can, Dan Schuyler, how this rollout compared with Medicare Part D. I know you are working for the firm founded by Mark Leavitt who was HHS secretary under George Bush, which is when Medicare Part D came out.

  • 10:13:01

    SCHUYLERSo there are some similarities, and there are some differences. You've got a huge population that Medicare Part D touched. And as well as healthcare.gov is touching a huge population, 30 to 40 (sic) uninsured Americans. But the difference with healthcare.gov is it needs to connect with different systems at both a federal and state level. And all of these systems are different.

  • 10:13:27

    SCHUYLERIt also has to connect with all of the insurance companies across the nation in order to provide the enrollment data to these carriers. And so you're talking about probably one of the biggest IT initiatives the federal government has ever taken on. And we anticipated that there would be issues, but we didn't anticipate that they would be at the beginning parts or the initial enrollment phase where you're trying to create a user account. And so the complexities were definitely indicative of a problem. But -- so this is a much bigger project in scope and size than Medicare Part D.

  • 10:14:06

    REHMSo are both you, Dan Mendelson, and you, Dan Schuyler, saying that there is a core design flaw with the federal health exchange? Dan Mendelson.

  • 10:14:21

    MENDELSONYeah, I mean, there's no question that there is given the performance to date. But, you know, I think -- and, again, thinking about this as a purchase, it's also very different from Medicare Part D. With Medicare Part D, you're going online, you're trying to figure out, you know, what drug benefit is best for you. But this is not only a drug benefit. It's a medical benefit. And there's not only a premium, but there's also significant co-pays that you have to figure out. So the complexity of this system is, I think, on a different order for the consumer as well as for the federal government.

  • 10:14:52

    REHMDan Schuyler.

  • 10:14:54

    SCHUYLERYeah, I agree with Dan. This is definitely a core design flaw. And I say that because if it were ancillary issues with their coding or with integration with different systems that they could easily have fixed, we would have seen that happen, but not by now. But to Dan's point, we're already three weeks into open enrollment, and users are still having problems getting through the entire process from the beginning to the end. And that really is an indicative of a core design flaw.

  • 10:15:21

    REHMOK. Dan Schuyler, put this into context for me. The New York Times quoted one specialist saying as many as 5 million lines of software code need to be rewritten before the website is going to run properly. What does that mean? Is the site too big to fix? Does the whole thing need to be rewritten?

  • 10:15:55

    SCHUYLERSo I think there's a little bit of uncertainty. And, to Julie's point, I think only the administration and the developers who built healthcare.gov really know what the problems are with the system. And looking from the outside in, you can definitely see that there is a core design flaw with the platform. The question is, how long is it going to take to fix?

  • 10:16:20

    SCHUYLERWhat is that core design flaw? And, honestly, the only folks that can tell you that are the developers. But I think the issue is we have a window of opportunity to start resolving these issues. And that window's really in the next two to three weeks, if you will, because we need to start enrolling individuals in large numbers.

  • 10:16:39

    SCHUYLERSeven million people is the CMS target for 2014. That's an average of 38,000 a day. We're not anywhere near that volume. And in order to get that volume, the system has to be fixed. And in order to do that, that system has to be fixed within the next two to three weeks so the insurance carriers can get the files that they need to start processing the applications.

  • 10:17:02

    REHMOK. Let's hear what the president said.

  • 10:17:06

    PRESIDENT BARACK OBAMAAnd in the meantime, I've said many times, I am willing to work with anyone on any idea to make this law perform even better.

  • 10:17:17

    REHMSo, Julie, with whom is the president working?

  • 10:17:21

    ROVNERWell, that comment was actually aimed at Congress, and that was aimed at something that hasn't happened with this law, which is something called technical corrections. You know, he was talking there about making other fixes to the law. Right now, what the administration's doing is something they're calling the tech surge. They're bringing in people within the administration and, so they say, from outside the administration, you know, with significant IT expertise to try to, you know, do kind of a crash course, if you will, to get this up and running.

  • 10:17:51

    REHMHe says we're well into a tech surge.

  • 10:17:56

    ROVNERThat's right. Well, they announced the tech surge over the weekend. That's what they said. They're going to...

  • 10:17:59

    REHMSo are we well into it, Dan Mendelson?

  • 10:18:02

    MENDELSONYou know, I think as embarrassing as this is and as sexy as the tech surge is, I think it's important to keep it in perspective. And the fact of the matter is that people are not going to sign up for this benefit until we get closer to the period where they actually have to enroll.

  • 10:18:19

    REHMDan Mendelson, CEO and founder of Avalere Health, former associate director for health at the Office of Management and Budget. Short break, right back.

  • 10:20:01

    REHMAnd welcome back. We're talking about the attempt to roll out the president's health care, the Affordable Health Care Plan. Here in the studio, Dan Mendelson, he's former associate director at the White House Office of Management and Budget. Julie Rovner is health care policy correspondent for NPR and author of "Health Care Policy and Politics A-Z." On the line with us, Dan Schuyler. He is director of exchange technology at Leavitt Partners, former director of technology for the Utah Health Insurance Exchange. Julie, you've got some numbers about D.C.

  • 10:20:53

    ROVNERThat's right. Remember there are 14 states in the District of Columbia that are running their own exchanges. So you don't have to go through this not-very-well-working federal website in these states. And they are starting to give us some numbers. And yesterday the District of Columbia put out a really useful sort of snapshot of where they are. And in the first two weeks, they said that 12,294 people have created accounts. Of those people, 1,894 have completed applications.

  • 10:21:19

    ROVNERBut of those people who've completed applications, only 321 have actually selected the plan they want. And of those people, only 164 have requested an invoice. And the reason for that, as Dan was saying, none of these plans start until Jan. 1. None of the insurance begins, and you're not considered enrolled until you've paid that first months' invoice.

  • 10:21:38

    REHMI see.

  • 10:21:39

    ROVNERWell, why would you pay that, you know, first month's invoice until a lot closer, until this is going to take effect? So nobody's really expected to sign up until much closer to when this insurance is going to begin. October was always expected to be a month mostly for people shopping. So, in that sense, the administration is kind of lucky that if they're going to have these, you know, glitches, it's now. This is when people were expected to be window shopping, not expected to be buying.

  • 10:22:04

    MENDELSONThis is just normal consumer behavior when making a really big purchase. And this is a big purchase. While the prices are reasonable, it's going to cost a couple thousand dollars for someone to buy this insurance. And when we look at prior federal programs, Medicare Part D and others, people will tend to sign up a month before the deadline. So you do not expect to see a linear progression of enrollment towards the deadline. You expect to see it clumped up. And the first real deadline is Dec. 15 because that's the last day that you can purchase and have your insurance actually start on 1/1/14.

  • 10:22:39

    REHMBut, Dan Schuyler, you still have all these reports of people waiting online for hours. The best way to get information right now, I gather, Julie, is to call the 800 number.

  • 10:22:56

    ROVNERThat's right. And that's one of the improvements that they have made to the federal website. I mean, there's a couple of things. You no longer have to create an account before you can do any shopping. That was making people absolutely insane. So now there's a button where you can go and you can actually look. It won't tell you what your savings might be because you don't have to put in your income information, but you can put in your zip code, find out what plans are available in your area and what the -- sort of the retail cost is of those plans.

  • 10:23:21

    ROVNERAnd right on the front page of the website is the 800 number if people want it. It's 1-800-318-2596. You can call that number. It's obviously a little bit harder to shop on the phone. But if you can get on and look at the plans, you can then get an idea of what's out there. And then you can call, and one of the call center people can walk you through it. And I understand it varies, but the call center wait times have come way down.

  • 10:23:46

    REHMTo, like, what?

  • 10:23:48

    ROVNEROh, sometimes less than a minute. So obviously, right after the president announced the number yesterday during his speech, the call wait times went up because everybody started flooding the call centers. But, in general, they're a lot shorter.

  • 10:24:00

    REHMOK. Dan Schuyler, tell me what other problems people are encountering besides long waits or being tossed off a website. You know, what -- is it because they're trying to enter information that the website is asking for and then they get tossed off? Tell me what happens.

  • 10:24:27

    SCHUYLERSo, to Julie's point, you can browse the health plans without actually completing the enrollment process or creating a user account. But once you decide to enroll, you have to enter a bunch of personal information, your income, your family size, and the system then uses that information to calculate your premium subsidy.

  • 10:24:49

    SCHUYLERThat's a very complex process, and the system needs to connect with a bunch of federal agencies in order to facilitate that eligibility determination. And there are people that have indicated that they've had problems when they've started to complete that process, that they haven't been able to complete the process. And they get to the end of the application process, and the system hangs up or doesn't function correctly.

  • 10:25:12

    SCHUYLERAnd so, to Dan's point and Julie's point, I think a lot of people are window shopping right now. But in two or three weeks when we get closer to the Dec. 15 deadline, I think you're going to see people start switching from window shopping to actual purchasing and going through that complicated eligibility process. And the concern is that the system needs to work correctly in order to facilitate those applications.

  • 10:25:38

    REHMAnd what about the insurance companies themselves? Are they also having problems, Dan Schuyler?

  • 10:25:48

    SCHUYLERSo when you fill out an application after you've chosen a plan, that information is sent to the carrier that you've chosen in an electronic format called an 834 file. Initially these files were coming through to the carriers with missing data or errors, and the carriers were having to go through those applications and manually correct those errors, sometimes having to call the consumer to get some information that didn't come through correctly. There were some occasions where some of the applications were missing 'cause they send them every night a batch. Those issues are being resolved every day.

  • 10:26:28

    SCHUYLERThey go through a testing phase, and then they go into production. The issue is those files really need to be clean and accurate when individuals start enrolling and purchasing these plans because, to Dan's point, that's when you're going to have tens of thousands of people enrolling on a daily basis. And the carriers won't have the time or resources or ability to go through those applications and clean them up. And so the issue is that those application files need to be clean and accurate when people start actually enrolling and paying for their coverage.

  • 10:27:03

    REHMJulie.

  • 10:27:03

    ROVNERYou know, there's a big concern. A lot of people are saying that if you can't get on the website, you can always fill out a paper application. And that's true. You can fill out a paper application. But at some point, that paper application is going to have to be turned into an electronic application to go to the insurers. In fact, the State of Connecticut is not allowing paper applications because...

  • 10:27:22

    REHMWhy?

  • 10:27:23

    ROVNER...because of this concern that when somebody inputs that into electronic form that errors will be introduced. So there is a worry about getting clean information to the insurer so that errors won't end up in it.

  • 10:27:38

    MENDELSONThere's one other set of issues that I think it's important for consumers to understand. When you actually look at this insurance, it is generally high-deductible insurance. So the average deductible on a silver plan is about $2,500, so that means that a consumer would have to pay that amount before they begin to see a benefit.

  • 10:27:57

    REHMThat's the silver plan. What about something a little less glittery?

  • 10:28:03

    MENDELSONWell, the silver plans are the ones we think most people are going to buy. The bronze plans, the deductibles are even higher. They're about 5,000 on average. So these are high-deductible plans. And one of the concerns that I have in looking at some of the websites is that they actually don't give the consumer the information that they need to make a good selection based on their own medical costs.

  • 10:28:25

    MENDELSONSo when you're buying an insurance plan like this, you should understand what drugs you're taking, who your providers are and how much it's actually going to cost you. And one of the things that some of the websites don't do -- and I don't expect this to be fixed -- is really give the consumer a complete picture of what their out-of-pocket costs are going to be when they buy the plan.

  • 10:28:45

    REHMOK. Dan Mendelson, are you suggesting that the problem is with the law itself, or is it with the website?

  • 10:28:57

    MENDELSONNo, the problem is not with the law itself. And, frankly, I think most of these problems with the website are going to get resolved. I think that the more fundamental issue that will emerge once we're through this cycle of hysteria around the websites not work...

  • 10:29:12

    REHMFrustration, yeah.

  • 10:29:13

    MENDELSON...exactly, for the frustration -- is that this is really different insurance. It's not the kind of insurance that I have. It's not the kind of insurance that you have. It's high-deductible insurance. And it's the kind of insurance that really requires consumers to be very smart about what they're purchasing. And I think, you know, again, one year from now, two years from now, we'll need better tools to enable good shopping for this type of insurance.

  • 10:29:37

    REHMJulie.

  • 10:29:37

    ROVNERI think most people, unless you've actually been in the individual insurance market where you have bought your own insurance, really don't know what it's like. I mean, people are used to having -- if they've had insurance or used to having insurance from their employer, which is usually sort of higher quality insurance, you know, covers more, and they're paying less. And this is really not that. I mean, people are getting -- most people will be getting subsidies from the federal government to help pay the premiums. But in general, this is individual market insurance. I mean, there's more to it.

  • 10:30:07

    REHMYou're saying most people will get subsidies.

  • 10:30:11

    MENDELSONYes.

  • 10:30:11

    ROVNERYes. Most people who -- that is expected that the majority of people who go to the exchanges will be eligible for subsidies.

  • 10:30:18

    REHMBecause they have no insurance now.

  • 10:30:21

    MENDELSONWell, our estimates are -- it's based on their income. And our estimates are that 80 percent of people who come to the website or who sign up for the insurance are going to be subsidized. So that's very significant. And, as Julie said, you know, some of them will be getting premium assistance. Others will actually get help with the co-pays that they have to pay for drugs and specialists.

  • 10:30:40

    REHMAll right. Let's hear what listeners have to ask. First let's go to Joe in Lansing, Mich. Hi there. You're on the air.

  • 10:30:52

    JOEHi, Diane. Thank you so much.

  • 10:30:54

    REHMSure.

  • 10:30:55

    JOEI went through the process here in Michigan, a couple of hiccups first couple of days, but managed to get through, got my insurance, got everything all set. I actually had bought my own insurance myself. My plan ended but went right straight through the same company that I had my previous insurance, Blue Cross, and everything was Jim Dandy. And I just am flabbergasted that people are so worked up about this.

  • 10:31:19

    JOEThis is not an iPhone or an iPad. This is my child's health care and mine. You know, I'm going to actually expect a few hiccups. If I have to wait and be patient, oh, well. As Americans, we're just so used to everything, oh, it has to work right now, right now, right now. It just staggers me that people are so upset that they're, oh, my gosh, a hiccup or two, again...

  • 10:31:40

    REHMThanks for calling. You know, is that part of the problem that we as Americans expect because we can go to Amazon.com and within three minutes order exactly what we want, have it delivered to us two days later? Is that part of the problem?

  • 10:32:01

    ROVNERWell, I'm so glad for the caller that it worked for him. In fairness, though, to some of the people, there are a lot of people who have been waiting a long time for insurance and have really not been able to get through. I mean, there are stories of people who've been on, you know, every hour for days. I mean, there really are problems with the website. And for some people, it really has been kind of hellish.

  • 10:32:19

    REHMIs something good going on in Michigan that we don't know about?

  • 10:32:22

    ROVNERI think this caller was just very lucky. And it's true not everybody has had a problem. Obviously there have been thousands and thousands of people who've gotten on, created accounts, gotten through, done their shopping, made applications. We know that some people have signed up. It's not all a disaster, but a lot of people have had problems.

  • 10:32:40

    REHMJulie Rovner of NPR, and you're listening to "The Diane Rehm Show." Let's go now to Sean who's in Jacksonville, Fla. You're on the air.

  • 10:32:55

    SEANHi, Diane.

  • 10:32:56

    REHMHi.

  • 10:32:57

    SEANHi. I think there's something that has been lost in the technical problems in getting things going with this website. There is -- and I'm a conservative guy. I'm a business professor. I actually own a business. But 10 years ago when I started my business, I shopped for my own insurance. And I remember getting what is probably in today's terms at best the silver plan. It probably was a bronze plan.

  • 10:33:19

    SEANAnd 10 years ago, I was paying over $340 a month for that plan. I just went to the website before your program started. It took me under 60 seconds to go to the plans and shop for them. And right now I could get a bronze plan for $132 a month. Silver is $186. I could move all the way up to platinum for $270. And if I can tell you...

  • 10:33:42

    REHMBut what about your deductible, Sean?

  • 10:33:47

    SEANWell, I think your panelist Dan Mendelson was talking about the deductibles. I'm just saying, they're not listed on the website here, so I'd have to go into the plans, which I've chosen not to do right now. But I'm just using the tiers of the basic catastrophic bronze, silver, gold, platinum. I mean, it's clearly there. Now you have to go digging. And currently I'm a finance professor. I've got my own plan. I'm just doing this for informational purposes.

  • 10:34:10

    REHMSure.

  • 10:34:11

    SEANBut, to me, that's a huge success that's been lost in the technical snafus, which admittedly are a problem.

  • 10:34:19

    REHMYeah.

  • 10:34:19

    SEANAnd smart people will figure it out. But I'm blown away by how low the costs are. I think that's being lost in the noise.

  • 10:34:25

    MENDELSONI think the listener makes a really important point. This is a very competitive marketplace. And what's happening is that the plans are fielding these offerings. It's regulated but not overregulated. And the plans are really beating each other up to get the prices -- to get the premiums low. Now, you have to look at the premiums -- at the deductibles, and you have to look at the co-pays.

  • 10:34:50

    MENDELSONBecause the other thing that this insurance does is it calibrates to reduce the premiums as low as possible because the plans know that that is really the first thing that people are going to look at. And you really need to look behind that to understand what the full costs are going to be for insurance for you and your family.

  • 10:35:08

    ROVNERAnd it does depend where you live. I mean, you know, there's more competition in some parts of the country. That's -- you know, this is not...

  • 10:35:13

    REHMBut isn't Florida one of the states that's opted out so therefore...

  • 10:35:19

    ROVNERThat's not an issue actually.

  • 10:35:22

    SCHUYLERA very competitive market...

  • 10:35:22

    ROVNERYeah, it's where the insurance market is more competitive.

  • 10:35:26

    REHMInteresting.

  • 10:35:27

    ROVNERIt's not a question of who's opted in or out. It's just where the insurance companies decided to compete.

  • 10:35:31

    REHMDan Schuyler, do you want to comment?

  • 10:35:35

    SCHUYLERI was just going to comment about Dan's advocacy for these consumer decision support tools, which are very important, because you're going to have a large percentage of individuals who will have had no prior experience or exposure to health insurance. So, to Dan's point, they won't know what a deductible is or a co-pay is.

  • 10:35:55

    SCHUYLERAnd you really need robust and intuitive decision support tools to assist these people in finding a plan that best fits their needs or the needs of their family that looks at prior out-of-pocket spending, prior utilization. And it's -- I think that's really the core in the fundamental philosophy of the exchanges providing those tools, so consumers can make an informed decision.

  • 10:36:21

    REHMFascinating to me that the first two callers we've heard from have had such an easy path. That's clearly not the case for millions of people who tried to get on without success. And I'm sure, in the moments of this program that we have left, we will be hearing from lots of you. Do give us a call, 800-433-8850. Send us your email to drshow@wamu.org. Follow us on Facebook or send us a tweet. Tell us your experience thus far with these health insurance exchanges and whether you've had problems, whether you have questions. I want to hear from you. And we'll be right back.

  • 10:39:58

    REHMAnd what else are we talking about today but the website connected with health policy, the frustration that people have had. But here is a good reminder from Rick, in Dallas, Texas. He says, "Diane, you have the power to ask guests to stop reminding us of how bad the website is. That subject has now been flogged in the press and on your own show and on other programs. Can we not just talk about how to make it better without constantly talking about what a failure the beginning has been? I think this would be far more constructive." Dan?

  • 10:40:48

    MENDELSONI agree completely with the listener. And I think, again, you know, the failure of the website is the little picture. The big picture here is that you're going to have millions of people in the State of Texas -- a million and a half people are going to be signing up for insurance under this exchange. And, you know, in the State of Texas, the question is, why didn't the governor expand the Medicaid program? And that is -- I think in some respects -- a much more important question from a policy perspective, as well as from a healthcare prospective. But it is important to keep things here.

  • 10:41:17

    REHMJulie?

  • 10:41:18

    ROVNERThere was an interesting poll out yesterday from the Pew Center that found that one of the things that's happened in the first couple of weeks, the frustrations with the website, that at least the awareness of the exchanges has gone up dramatically. So sometimes bad news is good news. So at least way more people, including uninsured people who should be making use of the exchanges, are much more aware that they're out there. So once the glitches, as they are, are fixed, perhaps more people will be going to the websites.

  • 10:41:47

    REHMAnd we've had a number of emails saying, "Please do not forget to mention that, according to the healthcare reform law, all new plans must cover preventative care with no cost-share from the patient. That means that even if you have a high deductible, you can go for your routine checkup and other preventive services at no cost. The high-deductible plans are ideal for the young, healthy people who are most needed to make this work.

  • 10:42:31

    SCHUYLERThis is very true. And both of the points are correct. The thing that I worry about are individuals who have multiple chronic illnesses, multiple sclerosis, diabetes, et cetera, and, you know, what effectively happens in a high-deductible plan is that if you need medications or services to care for those multiple chronic illnesses, you are going to be facing higher out-of-pocket costs. But the listener is absolutely correct, that preventive services are free in most cases and that, you know, it is ideal insurance for people who do not have healthcare costs.

  • 10:43:07

    REHMAll right. Let's go to Jim, who's in St. George, Utah. Hi there, Jim.

  • 10:43:14

    JIMHi, Diane. Thank you so much for taking my call.

  • 10:43:16

    REHMCertainly.

  • 10:43:17

    JIMI first wanted to say I've been without medical insurance since 2005 when I got divorced. And I'm an over-the-road truck driver, so I am all over the country. Potential for getting hurt is pretty high in this business. I just wanted to say I think people are concentrating so much on what we've heard before about, you know, the website being so horrible, this and that and everything. You know, Diane, I'm willing to sit back and to wait for all of that to be taken care of and just for the fact of knowing that I will have something there, just in case something like that does happen to me.

  • 10:44:01

    JIMIt's sad to see that my old political party has put so much time and effort into destroying this healthcare plan that can do so much for so many. If they would just take that effort that they've put into destroying it and try to help make it better, I mean, there are so many people that can benefit from this. It's just too bad that that's what has to happen in this country.

  • 10:44:28

    REHMAll right. Jim, thanks for your call. Dan Schuyler, do you want to comment?

  • 10:44:34

    SCHUYLERI mean, I think the caller makes a good point. And I think we need to be positive and proactive in addressing all of the issues with not only the exchanges but with the Affordable Care Act. And I think the president articulated that to some extent in his press conference yesterday. As, you know, let's come together, look at the entire legislation from a whole and see how we can make changes. Because, you know, quite frankly, the Affordable Care Act does have some flaws, and there are some ways to improve it.

  • 10:45:06

    SCHUYLERAnd you could apply that philosophy to the exchanges, as well as the entire legislation. And so I think it does make sense for us to be constructive and proactive in working to make this whole entire process, from the entire legislation all the way to the exchange and the enrollment process as smooth and as efficient as possible.

  • 10:45:26

    REHMAnd let's hear one more clip from the president's statement.

  • 10:45:31

    OBAMAI want everybody to remember that we're only three weeks into a six-month open enrollment period when you can buy these new plans. Keep in mind, the insurance doesn't start until Jan. 1. That's the earliest that the insurance can kick in.

  • 10:45:51

    REHMSo, Julie, if that's the earliest the insurance kicks in, people right now are simply window shopping?

  • 10:46:03

    ROVNERPretty much. And that's really what was expected. The largest number -- the administration's own estimate for people signing up for October was half a million. So even if they don't get that because of these glitches, there's plenty of time to catch up. The Pew Research Center poll that I just mentioned found that 58 percent of the people who were actually on the website the first two weeks were, what I term, tourists. They were people who actually had no intention of buying their own insurance.

  • 10:46:34

    ROVNERThey were people with their own employer-provided insurance or people who had Medicare, who had government insurance. Now, perhaps they were people who were looking for relatives or, you know, grown children, but those are people who really just were on to see kind of what was out there, what all the fuss was about.

  • 10:46:48

    REHMHere's an email from John in Baltimore. He says, "Call centers are not able to discuss plans with callers. Your guest is giving misinformation."

  • 10:47:04

    ROVNERThat was not what we had been told, but I have not been on the phone with the call centers. So…

  • 10:47:08

    MENDELSONYeah, there had been some issues with the call centers. Early on, the call centers were relying on the website for their backend. And now that should be fixed, and so the call centers actually should be able to discuss plans with call-ins.

  • 10:47:22

    REHMAnd here's an email from Bob in Charlestown, W.Va. "Dan Schuyler," he says, "please provide an example illustrating a 'core design flaw.' Does the system interface with Social Security and IRS computers? If so, that might be a core problem." Dan Schuyler?

  • 10:47:52

    SCHUYLERSo, yes. Healthcare.gov not only interfaces with the IRS Treasury but Homeland Security, Social Security. It also interfaces with state systems, and it also interfaces with systems at the carrier level as well. And so there are a multitude of integration and touch points that the healthcare.gov, as well as state exchanges, need to integrate and communicate with. And as a result, we are seeing some -- this is part of the problem with the platform. And we're hopeful that these issues can be resolved quickly.

  • 10:48:33

    ROVNERBut obviously, I mean, the state exchanges have to do that, too. And many of the state exchanges are working just fine. So it's not -- that's not so much a core design flaw. They need to do that in order to do things like verify income, verify, you know, citizenship, those are designed necessities. It's a matter of making them work properly.

  • 10:48:50

    REHMAll right.

  • 10:48:50

    SCHUYLERBut some state exchanges have chosen to use state-based resources to verify income instead of relying on the federal government. One example is Connecticut. Another is Minnesota. And so in that respect, the state has decided to utilize their own data and there may be some efficiency in doing that.

  • 10:49:10

    REHMAll right. To Hebron, Ill. Hi there, Phil. You're on the air.

  • 10:49:16

    PHILHi, Diane. I've got some experience. I've been in the individual marketplace for health insurance for 20 years. We're considered successful, and we carry a $10,000 deductible, which was the minimum my insurance man recommended to me. And years ago I was at a dinner party with an executive that was a high-level employee at an underwriting firm of insurance. And he said if the world knew what you people have to do, the world would end -- as small businessmen and entrepreneurs. People who have insurance from someone else have no idea what you people do to keep going.

  • 10:49:55

    MENDELSONYou know, I think one of the most important things about this law is that there is now a functioning individual insurance market in every state in the country. And you will be able to, you know, not only purchase a $10,000 deductible plan, but also a $5,000 deductible plan and $2,500 deductible plan in most markets. And, you know, again, this is really what the law was intended to do. It was to make, you know, more options available, and I think it will.

  • 10:50:25

    REHMAll right. To Doug in Elkhart, Ind. You're on the air.

  • 10:50:31

    DOUGThis may be a silly question -- and I'm not a big conspiracy theorist. But I was wondering if there's been any discussion of the possibility of the detractors of this law, the people that supported, you know, 40 repeals of the law, supported a government shutdown of the law, wondering if anybody thought that maybe someone would somehow try to hurt this website from the outside in the way of -- I don't know if a cyberattack would be the appropriate term.

  • 10:51:02

    DOUGBut I was just curious. I mean, there's a lot of people out there that do not like the president, do not like this law. They could employ people to, you know, be malicious and go in there and overwhelm the website in some way. And I haven't heard any discussion of that or even a possibility of it. I'll take my answer off the air.

  • 10:51:21

    REHMDan Schuyler, what's your reaction?

  • 10:51:24

    SCHUYLERSo what the caller is referring to is sometime referred to as a denial of service attack, where you have multiple users or a computer system that's repeatedly trying to ping the website. And while that's always a possibility, those types of attacks are easily mitigated by blocking specific IP addresses or domains. And so that's always a possibility. It could have happened on Oct. 1 for a couple of hours, but it's not something that we would have seen that would be consistent throughout the last three weeks.

  • 10:51:54

    REHMAll right. And here is something that lots of people have wondered about. It's from Eric in Wellfleet, Mass., who works for a federal government agency responsible for the allocation and disbursement of billions of dollars annually. He says, "I have no doubt that the problems related to healthcare.gov are the result of government officials with little or no understanding of computers, having hired an incompetent contractor to build the site.

  • 10:52:36

    REHM"In 10 years of experience working with federal government computer systems, not a day has gone by when my work has not been ended by utterly inept IT design." What do you think of that, Dan Mendelson?

  • 10:52:55

    MENDELSONWell, I think sadly there is some truth to that. And, again, we talked about how this is a very complex system. And there are a lot of design decisions that needed to be made in putting the system together. You know, for example, do you calculate the reduction in premiums for the individual before they can see the premium itself?

  • 10:53:16

    MENDELSONAnd that's the kind of thing that adds to complexity. And I think the other issue here is that the federal government didn't even know how many states they were going to be designing this federal website for until really about a year ago. And so, you know, it was complexity, it was timelines, and then I think, you know, the caller has a point.

  • 10:53:32

    REHMAnd you're listening to "The Diane Rehm Show." Dan Schuyler, you wanted to say something.

  • 10:53:41

    SCHUYLERYeah, I just wanted to -- I agree with Dan. And in all fairness to the vendors, the technology vendors at the federal level and the state level, they were dealing with very tight deadlines, and HHS was -- there were a lot of delays with getting rules and regulations out to the states that the vendors needed to use in order to build these systems. These are like business processes or business rules, if you will. And so the vendors had very tight timelines to build and test these systems. And as a result, we're seeing some of the errors that come from a lack of testing.

  • 10:54:16

    REHMAnd here's a final comment from President Obama.

  • 10:54:21

    OBAMAEverybody who wants insurance through the marketplace will get insurance, period.

  • 10:54:27

    REHMJulie, is that so?

  • 10:54:30

    ROVNERWell, that's certainly the theory, I mean, that they can…

  • 10:54:31

    REHMThat's the goal?

  • 10:54:32

    ROVNERThat's the goal. I mean, you know, one of the things that the president, I think -- in finishing that thought, he pointed out that this is not like, you know, shopping on Black Friday after Thanksgiving. It's not like they're going to run out. It's not like buying, you know, a flat-screen TV. It's not like there are only 20 and when they're gone, they're going to be gone. The prices are the prices.

  • 10:54:50

    ROVNERThe prices that are there now are going to be the prices that are going to be there on Dec. 15 and on Jan. 15 and, frankly, if you want to avoid the penalty for not having insurance you can buy all the way up until Feb. 15. So there is time to get this all straightened out and fixed. It's not like they have to do it in the next three days, but there is a concern that a lot of the shopping may take place over Thanksgiving weekend when, you know, grown kids are home with their parents and, you know, moms say…

  • 10:55:13

    REHMOK. Help.

  • 10:55:15

    ROVNERReally, you ought to have insurance.

  • 10:55:17

    REHMYeah.

  • 10:55:17

    ROVNERSo, you know, I think that's that goal, is to get this all squared away by about the middle of November.

  • 10:55:22

    REHMAnd do you think that will happen, Dan, that the quirks in this system, Dan Mendelson, will be worked out?

  • 10:55:32

    MENDELSONAbsolutely. I think this will all resolve, and it'll come together. It might take a while. There might be a few slipped deadlines, but it's really important for the president and others in the White House to be out there advocating for this insurance and making sure that people are aware of their obligations under the law.

  • 10:55:47

    REHMDan Schuyler, do you agree?

  • 10:55:50

    SCHUYLERI do agree. And as the president mentioned and as Dan and Julie mentioned, you can also enroll by calling the 800 number. It's a much slower process, but that's also a path to enrollment that consumers can use as well.

  • 10:56:03

    REHMSo from your perspective, Julie, you see this, what, as a big mistake on the part of the U.S. government or a natural part of a huge rollout?

  • 10:56:20

    ROVNERWell, I think it definitely went worse than expected. They warned us that there would be glitches. As I think had been mentioned, the rollout of the Medicare Part D drug program was messy. The rollout of the Children's Health Insurance program was messy and slow. The rollout of Medicare, itself, was slow. These are big changes to the healthcare system. You don't expect them to go completely smoothly. This one has been particularly ugly, but, you know, they have time to fix it.

  • 10:56:47

    REHMJulie Rovner, Dan Mendelson, Dan Schuyler, thank you all so much. Let's hope it gets better soon. Thank you. And thanks for listening, all. I'm Diane Rehm.

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