ACA in Wash. state: 'No frills' success

OLYMPIA, Wash. — In this far corner of the Pacific Northwest, Washington state shows what can happen when an Obamacare exchange launches — and doesn’t crash and burn.

In contrast to the other Washington’s HealthCare.gov, this Washington’s Healthplanfinder has run fairly smoothly almost from the start. While programs elsewhere sputtered and the federal portal didn’t work at all, the state signed up more than 1 in every 5 Americans who enrolled in an Affordable Care Act plan during the first month.

The 2014 enrollment season is winding down Monday with the Obama administration touting numbers above 6 million, far better than many expected. States will soon start making decisions about their exchanges for next year and thinking about how to repair deep and persistent glitches. Some are calling Washington to see how to replicate its success.

“It’s important for the whole country to have an exhibit” that others can follow with confidence, Gov. Jay Inslee said in an interview. “We know that other states have had substantially more challenges … but I think what we’ve learned is, once you get the software systems, hallelujah, it works, and we’ve been getting numbers that are sustainable in the long term.”

(WATCH: Confusion, little information on Obamacare in Mississippi)

Interviews with people who have worked on health care here show that Washington’s success came down to clarity, consistency and simplicity. This land of a thousand baristas, high-tech giants and evergreen-scented landscapes designed a straightforward exchange, chose a contractor that delivered, and kept lawmakers, policymakers and advocates from getting in the way with their own priorities, no matter how attractive or well-meaning.

Washington had enrolled more than a half-million people as of March 20 — more than 125,000 of whom who got private insurance coverage in the exchange, (plus another 66,000 who have chosen a plan but not yet paid) and about 380,000 newly enrolled in Medicaid. That gave it the sixth best enrollment record in the country as of March 1 according to a Kaiser Family Foundation survey. Those ahead included California, which has a massive and well-funded outreach effort, and a few small states where it’s easier to reach the uninsured.

And unlike most states and the federal exchange, Washington is sticking closely to the Monday deadline, allowing only case-by-case review for people who hit technical glitches before midnight.

(Also on POLITICO: Obamacare in Oregon: A failed exchange)

Washington’s liberalism is well established; in no other state are assisted suicide, same-sex marriage and recreational marijuana all legal. And the state really wanted to be a trailblazer in expanding health coverage. But — as neighboring Oregon can attest — ambitious intentions and liberal politics aren’t enough.

A critical mix of factors made the difference in Washington: Its Legislature was on board from the start, and a bipartisan governing board supported the exchange. But what set Washington apart from some other blue states sympathetic to the president’s health law was that Deloitte, the contractor on Healthplanfinder, designed and built a functional website. And, crucially, the exchange’s initial capabilities stuck to the basics. No frills, like extra Medicaid features, were added.

“Part of it is luck of the draw with contractors,” said Chris Jennings, a former senior White House health care adviser. “But also hard work, planning, good management, a limited number of systems that have to interface with one another, a good vision about what you want and acceptance that you will have 2.0 versions to take care of things you can’t and should not attempt to do all at once.”

Successes … but a work in progress

That doesn’t mean Washington state got everything right. In some respects its exchange is still a work in progress.

Medicaid re-enrollment through the exchange has been cumbersome. Officials hope to clean that up this summer.

The state has some nasty battles going on about whether the health plans include a broad enough network of doctors and hospitals. Washington’s only children’s hospital is an “out of network” provider for half of the state’s health plans, and it has filed a lawsuit against the state insurance commissioner to force changes.

Sandy Melzer, senior vice president and chief strategy officer at Seattle Children’s Hospital, said families of some young patients in treatment have faced tough decisions about keeping coverage or being charged expensive out-of-network prices.

“We have 300 kids who have been referred and scheduled to be seen at our hospital,” Melzer said. In January alone, the hospital treated 125 patients who had lost coverage. “It’s worse than we first thought.”

Insurers limit networks to control cost, but there have been questions — here and in other states — about whether they are too narrow in the exchange plans and whether the process was transparent enough for consumers to make good choices as they selected their health plan. The Obama administration says it will review network adequacy nationwide for 2015 plans.

Insurance Commissioner Mike Kreidler says he takes the problems seriously — he’s working now to address network adequacy, he says. But while he recognizes the “bumps and the imperfections and challenges that we have,” he also tries to keep them in perspective.

“I always liken this to my family reunion,” Kreidler explained recently. “When we have everybody together you say, ‘Boy, we’ve got some real screw-ups here.’ But then you pull back and look at other families, you say maybe ours aren’t so bad after all.”

A disciplined strategy

That took work.

Managing “scope, schedule and budget” was key, CEO of the Health Benefit Exchange Richard Onizuka said from his office overlooking the Olympic Mountains. So was reining in first-year ambitions, “trying to decide what can you do — what is necessary versus what are … nice to have.” When the state made plans, it stuck to them.

The leaders set a hard deadline, allowing no major modifications to the blueprint for a year before the exchange opened. Legislators and the governor’s policy team were gently told that they couldn’t add more Medicaid options or other “very tempting” ideas, recounted state Rep. Eileen Cody, a senior Democratic lawmaker deeply involved on health policy.

The cutoff date helped streamline decisions and ensured that the tech team knew precisely what had to get done and when. “They really drew the line, and we actually listened to them and didn’t try to force them to do things differently for that year,” Cody recalled.

And because the tech team built in a mechanism for calculating how many enrollees pay their first premium — the last step to actually getting coverage — Washington is one of the few states with a definitive number for who actually has insurance under Obamacare. Washington also knows who is new to Medicaid, which the state expanded, and who had that coverage before.

Only a few of the 14 other states that built their own exchanges this year have similar stories, including Kentucky, California, Vermont and Rhode Island.

The health care law’s backers need these successes if they hope to persuade the nearly three dozen states that declined to run their own exchange to change their mind and get off HealthCare.gov, the federal exchange.

“The president felt very strongly that we did need to have state-sponsored marketplaces do very well,” Jennings said. “He felt there were things we could learn from them and they could learn from us.”

People working in the sign-up trenches in Washington agree. Seamus Petrie, an in-person assister with Planned Parenthood of the Great Northwest, personally has signed up at least 250 people. Unless someone has a complicated family or financial situation, he said, enrollment may now take less than 15 minutes.

“The vast majority of people, when they leave, you can just see their whole body start to relax,” Petrie said. “And they exhale.”

This story was produced with the support of the Dennis A. Hunt Fund for Health Journalism, a program of the USC Annenberg School for Communication and Journalism’s California Endowment Health Journalism Fellowships.

This story was originally published on POLITICO.com