America's Bitter Pill

by Steven Brill

  As Tavenner, Bataille, Brooks-LaSure, and others walked the halls in the building that night, lights flickered on and off in a way that conveyed how surreal the day that they had been anticipating for years had become. The office lights were set to be off unless motion was detected, and with so many people having been furloughed, almost all the lights were off unless one of the survivors walked by an empty office, whereupon they would flash on, then shut back off. Enough, perhaps, to trigger a bureaucratic version of PTSD.

  FURY IN THE FIELD

  Anne Filipic, the president of Enroll America, told the press and her staff she was frustrated by the crash of the website, but that she was sure things would be fixed soon. Actually, she was furious. In the Obama campaign, the technology had been like plumbing, an afterthought. Of course, it worked. Now, the sign-up rallies she had planned around the country, run by all those field troops she had recruited, and backed by all the social media advertising she had placed, had become the equivalent of a postponed election.

  Enroll America’s campaign machine hit a wall. Her people—hundreds of whom were paid and thousands more who were volunteers—were turning over the prospective customers they had attracted to the navigators, who were supposed to help them enroll. But the navigators couldn’t get online, either, nor could they get through on the phone lines. “We had to take down names and hope to contact them when the website was fixed,” Filipic later told me.

  Filipic’s Ohio director had been a legal aid lawyer whose cases had included defending patients being hounded by hospital debt collectors. He was excited to be doing something proactive instead to head off that problem. Only now he and his volunteers could only take names.

  A QUICK FIX IN KENTUCKY

  From midnight through 10 A.M. on October 1, 2013, in Frankfort, Kentucky, everything worked as planned.

  Health and family services secretary Audrey Haynes did some early morning TV and radio shows. Her boss, Governor Beshear, continued a series of “fly-arounds” across the state urging people to try out kynect. Banahan stayed in the shack.

  They were all tired, not only from the celebration the night before, but also because in the weeks leading up to the launch they had crisscrossed Kentucky with town halls and community group meetings, and with those “fly-around” appearances by the governor.

  “It doesn’t cost you a dime to go online and check it out,” Beshear had told dozens of audiences. “You owe it to yourself and your family.… If you want your ideology to stand in the way, fine.”

  There was predictable hostility, especially in the poorest parts of Kentucky, where the Obama administration’s perceived anti-coal policies made most people more than a little cynical about any Democrat, especially those selling an Obama healthcare reform scheme.

  “Some people showed up at meetings, showing guns on their holsters,” Banahan would later recall. “But that’s okay. You have to meet people where they are and take them for who they are. We told them we didn’t want to talk about politics. We wanted to talk about their healthcare, about why they should talk to one of our ‘kynectors’ ”—Kentucky’s version of navigators—“in their community and check this out for themselves.”

  By 9:30 A.M. on October 1, “the trends were incredible,” recalled Mohan Kumar, who led the Deloitte contractors building kynect. Twenty-four thousand people had visited the kynect.​ky.​gov website, and 858 had completed applications. Everyone in the shack knew that because they had a dashboard set up to monitor everything in real time. In fact, within a few days, anyone logging on to the Kentucky.​gov website could have known the numbers because they would be posted online in daily updates.

  Then at 10:45, just as the governor was about to do another television appearance, part of the website crashed. “I told them to get busy fixing it,” Beshear later recalled. “I actually wasn’t worried. If we’ve got a down hour or a down day, it wouldn’t matter. This is a lifetime event. To me it was the most important project I would ever do in terms of people’s lives.”

  The problem was one they had anticipated and, in fact, rehearsed, and it had nothing to do with kynect.​ky.​gov. Rather, it involved the state’s overall consumer website, the place people log on to for transactions involving driver’s or hunting licenses. The team had decided early on that it would be easier and faster to use the current system for people to establish an account with the state rather than build a new system just for health exchange accounts. The drawback was that visitors to kynect would have to go through a registration system that had not been built to accommodate all of this new traffic. They thought they had accounted for that by adding servers to the state system. However, despite repeated tests to simulate the traffic, they were uneasy about it.

  That was the pipe that broke at 10:45. But because the kynect team had decided not to require people to register their information before browsing, it did not affect anyone’s ability to browse, get prices and estimates of their subsidies, and even save their tentative choices. It was fixed by about 3 P.M. because Deloitte had arranged to have extra servers standing by just in case.

  “I was rattled, sure. You always are in a situation like this,” Kumar later told me. “But not outwardly so,” he added with a chuckle. “And not that much. I knew we had all that extra capacity we could plug in.”

  “If Mohan was worried, he didn’t show it,” Banahan later told me. “He is just not the type.”

  By 7:30 the next morning, October 2, kynect had had 88,119 unique visitors.

  One thousand eight hundred and thirty-three people had been enrolled—compared to six on the federal exchange covering thirty-six states.

  Kentucky’s website data demonstrated this was not anything like buying an airplane ticket or a book online—how infinitely more complex the challenges are when a country insists that healthcare can be sold as a consumer product in a conventional marketplace. Those 88,000 visitors viewed an astounding 1,168,000 pages, or thirteen pages per visit. And they spent an average of twenty-eight minutes. Visitors spend an average of nine minutes on Amazon.

  More important, unlike the Amazon experience, nearly 95 percent of visitors did not even complete a transaction when they visited kynect. In fact, the Kentucky team’s research had told Banahan and Kumar that people would have to visit seven to ten times before they would think they had enough information to make a purchase.

  No one buys a book or an airplane ticket that way.

  And in Kentucky, relatively few insurance companies had decided to participate in the first year of the exchanges, which meant that the options consumers had to choose from were more limited than in other states.

  Everyone working on all the exchanges—the federal version and the fifteen built by the individual states and the District of Columbia—had done research telling them how long an online process this would be. But the ratios of visitors to page views or time spent still surprised everyone that first day—if, unlike the people in Washington, they had the dashboards to see it happening.

  AT OSCAR, NO NEWS IS NO NEWS

  Oscar’s launch day was all about waiting. It was as if Joshua Kushner and his team should have had T-shirts made with “shooting in the dark” as their start-up’s business plan.

  The night before, most of the team had stayed in the office until after dinner listening to (and, in some cases, fielding themselves) the several dozen calls that came in from people who had seen their online ads and wanted more information. Many seemed especially enthused about the telemedicine feature. At their hioscar.​com website there had been over a thousand visits in the last week, and a video they had posted on YouTube had had two thousand views.

  Small numbers, but it seemed like people were interested. Still, throughout the launch day, they had no idea whether anyone was buying from their weird new insurance company.

  Nor would they know the next day, or the day after that, or even the week after that. No insurance company would. The way the New York State exchange had been set up—and the wa
y the federal exchange also worked—insurance companies would not get enrollments as they happened. Rather, they would be sent in batches if and when that piece of the technology hook-up worked. New York State officials had told Oscar that it might not be until November 1, 2013, before they would get their first batch, though they were shooting for mid-October.

  Potential customers could go to hioscar.​com for information, and 5,177 did on October 1, which Kushner and his team were able to track by the second. But if they wanted to enroll they were sent to the state exchange, where, of course, they would see the options offered by all eight competing insurers, six with established names.

  The only news the morning of October 1 was that New York, like Kentucky, had gone down by midmorning. However, as in Kentucky, New York had arranged for standby servers and was back up within a few hours, although, unlike Kentucky, the site would suffer other glitches and outages through the first month.

  Other than that, all that Kushner and his team were sure of by the morning of October 2 was that they had close to forty enrollees, because most of the now-forty-person staff had enrolled that morning. They also knew from a tweet that someone had been so impressed with their website that “I almost signed up—then realized I don’t live in new york.”

  THE OBAMA TEAM FUMBLES THE EASY STUFF, TOO

  The next day, October 3, 2013, a process server near New Haven, Connecticut, proved that the Obama administration hadn’t just stumbled in building the complicated website. It was failing at the easy stuff, too.

  Jeremy Kopylec, a warehouse worker who lived in Northford, Connecticut, was sued by Yale–New Haven Hospital for $6,129. The suit was the result of a bill Kopylec incurred four years earlier, when he was taken to the emergency room after what he later told me was a “minor motorcycle accident.”

  At the time of the accident, Kopylec said, he had just gotten a job following a period of unemployment, but that his “insurance hadn’t kicked in yet. So they came after me for the whole bill.… I told them I could not afford it.”

  “I spent about two and a half hours in the ER, and all they really did was clean up some road rash,” Kopylec, twenty-seven, recalled, adding that “since the marshal came with the summons, I’ve worked out a plan to pay all of it off in monthly payments” of $100, extending over the next five years.

  But what about those provisions that Iowa senator Chuck Grassley had inserted into Obamacare prohibiting exactly that kind of collection suit by purportedly nonprofit hospitals unless and until the hospital made aggressive efforts to determine if the person needed financial aid? And what about the related provision prohibiting chargemaster rates to be charged to such people? Under the law, those provisions could have taken effect the day the president signed the law in 2010.

  That Kopylec did not get the protection that Obamacare now required was not a matter of Yale–New Haven violating the law. It was not about a website not working. Nor was it about Republican efforts to sabotage the law or some judge blocking it. It was because the simple rules still hadn’t been written by the Obama administration to enforce the law.

  It was surprising enough that such an obviously appealing and important consumer protection rule had not been written in time to protect California cancer patient Steven D. in early 2011—ten months after the law had gone into effect—leaving his widow to fight off bill collectors. But the suit against Kopylec was filed more than three and a half years after Obama’s East Room signing celebration.

  A first draft of the rules had not been published for initial comment in the Federal Register until June 26, 2012—more than two years after Obamacare was passed. That was just an initial draft, called “Proposed Regulations.” The American Hospital Association had then complained—no surprise—that the drafted rules were too prescriptive. Nothing had happened since. No final rules had been issued. There were still no restraints on hospital bill collection practices or chargemaster charges for the neediest patients.

  About a month after Kopylec was sued, I tried to find out from the Obama administration what had happened to the regulations. Assistant Treasury secretary Mark Mazur, who oversaw the IRS and was the administration’s point man for tax issues related to Obamacare, told me: “These things take time. It’s something we’re actively working on.”*20

  * * *

  *19. When I later talked with Beigel, I found that because of problems with the state-run website in Maryland, where she lived, she was not able to enroll until November, and only then with the help of a navigator. But when she was able to see a doctor, on January 3, 2014, he discovered a life-threatening infection, requiring urgent surgery. Obamacare, she told me, “literally, truly was a lifesaver for me.”

  *20. Soon after I wrote about the delayed regulations and the Yale–New Haven suit in Time in December 2013, the IRS promulgated them. On February 1, 2014, Yale–New Haven changed its billing policies and now charges all uninsured patients the average it charges to all insurance companies, not chargemaster rates, according to the hospital system’s spokesman.

  CHAPTER 21

  MELTDOWN IN D.C., DANCING ON EIGHT TOES IN KENTUCKY, AND FRUSTRATION IN OHIO

  October 4–17, 2013

  “HERE’S WHAT WE KNOW AFTER SEVENTY-TWO HOURS. WE’VE HAD over seven million unique visitors … come through. It is a volume that no one anticipated.”

  So began a breezy, banter-filled live conversation between White House healthcare communications czar David Simas and the crew at Morning Joe at 7:44 A.M. on Friday, October 4, 2013. “Just for perspective,” Simas added, talking to the New York studio from the White House lawn, “Southwest Airlines in an entire month has 6.4 million unique visitors. NBC in an entire month has 12 million unique visitors. We had 7 million. And so the overwhelming volume has really caused us to add more servers, more engineers, to tackle the problem, identify the issues, fix them. So today is going to be better than yesterday was.… We’ve got another 178 days left to go. So I feel pretty good about where we are.

  “Where the holdup has been has been at the initial stage, when people try to create the account,” Simas continued, sidestepping a question about enrollment numbers. “Once you create the account, as you saw, you go into the application and the plan compare, and it’s easy and it’s intuitive and it makes a lot of sense.… And we believe that within a couple of days the wait time is going to be significantly, significantly reduced, as we saw from yesterday and the day before.”

  He had no way of knowing it, but nothing in Simas’s statement was accurate. In fact, by now, as the identity verification layer that Simas blamed as the gating problem was being fixed, more problems were exposed. And wait times, while barely improved, were irrelevant because people were hitting errors on almost every page that were throwing them off the website completely once they got past the wait on the home page.

  The various war rooms knew that, even if they hadn’t told Simas or White House healthcare reform boss Jeanne Lambrew. About thirty-six hours before, at the late afternoon October 2 CCIIO war room meeting, someone reported that there were now forty thousand people waiting interminably in the “waiting room”—staring at the website page carrying the “please wait” message that had flashed at me on October 1.

  By then, the end of the second day, “approximately 100 enrollments” had happened, according to minutes of the war room meeting, although no one in the war room had an exact number. And the target for any significant changes to be made to fix the site had been extended from October 15 to November 22, implying that real fixes were going to take that long.

  By October 4, the morning Simas took the microphone on the White House lawn, the same war room group reported that the identity verification process was broken again. When they had added capacity to handle traffic going through that pipe, the system had quickly failed. “It may not have been a capacity issue,” the meeting minutes reported. “Now they are looking at changing the software.”

  As Simas spun the Morning Joe crew from the White H
ouse lawn on the morning of October 4, enrollments totaled just 248 people.

  A DANCE IN KENTUCKY

  Kentucky had 4,739 by that morning, and by midafternoon would have nearly 2,000 more.

  Among them were Tommy and Viola Brown, who were sixty-three and sixty-two years old respectively and two weeks away from celebrating their forty-sixth anniversary.

  As he got up from a card table at a community center in Shelbyville, Kentucky, at about 2 P.M. on October 4, 2013, where one of Carrie Banahan’s “kynectors” had been huddled with him and his wife, Tommy Brown was all smiles.

  “Everything go okay?” I asked.

  “Perfect,” he said.

  Pointing to a poster just outside the entrance advising people of counseling sessions available at the center for those with heart disease, arthritis, or diabetes, he said, “See that? Between us, Viola and I have all of that and a lot more.”

  Brown explained that in 2007, while hauling merchandise at the auto parts wholesaler where he worked, he had tripped and broken his neck and crushed five vertebrae in his back. The vertebrae had been fused together in an operation, but the fact that his neck was broken, he told me, wasn’t discovered for several years. As a result he continued to suffer painful nerve damage, and had not been able to work for the last three years. Before that, he had fought off two bouts of cancer.

  Once Brown was unable to work, he had been unable to get insurance. Every insurance company, he said, “turned me down because of my condition, or wanted to charge me a price that was way out of my league.” He had not seen a doctor in so long, he told me, that “I have no idea who my doctor is.”