Micah Sifry, cofounder of the website techpresident.com, says the companies that end up winning big federal contracts—for instance, CGI Federal and major defense contractors—"are not known for their innovative or up-to-date technology. They are known for their ability to win contracts." Political decisions by the Obama Administration, such as requiring consumers to determine their subsidy eligibility before they can shop and see rates, also may be factors in the online mess.
The 16 states that built their own sites have used a variety of contractors and many of their marketplaces have launched more smoothly than the federal healthcare.gov. The bottom line is that the pressure on the federal exchange would have been far less and its design flaws would have affected many fewer people had, say, 20 more states set up their own exchanges using a variety of contractors and approaches.
There's also a toll that comes from having to set up systems to run or help run three dozen exchanges. That took time that might have been spent preparing for a smoother opening. "The federal exchange has to interact with health plans that are submitting bids in 36 states, and also has to work out data agreements with how to handle information flow with 36 different Medicaid agencies, and they've had to work out insurance oversight with 36 state insurance departments," says Alan Weil, executive director of the National Academy for State Health Policy. "It's a huge workload that competes for resources with building the exchange functionality."
Some of the states that left exchanges to the federal government have not put any or many resources toward signing people up. Since the law depends on high enrollments to broaden the risk pool and keep coverage costs relatively low, these governors may have helped create conditions ripe for higher rates and consumer backlash against the law.
More backlash could arise when unfair aspects of the law become fully apparent. Democrats wrote into the bill that people below a certain income would qualify for a Medicaid expansion paid 100 percent by the federal government for three years. But when conservatives on the Supreme Court turned that into an option rather than a requirement, most Republican governors either chose not to do it or couldn't get their legislatures to agree to the expansion. The upshot is that low-income working people will get subsidies on the exchanges, but workers with even lower incomes will be cut out of subsidies because they qualify for Medicaid coverage their state has chosen not to offer. There's going to be anger and criticism about this—the only question is whether it will be directed at governors or the law itself.
The January 2010 special Senate election in Massachusetts was another pivotal moment for the Affordable Care Act. Republican Scott Brown won in part by promising to stop Obamacare. He did not succeed at that. But his victory did end the Democrats' filibuster-proof 60-vote majority and the possibility of any changes or improvements in the bill. The Democratic-controlled House had to simply accept the Senate bill if anything was going to pass at all.