Affordable Care Act's Website Reflects Law's Complexity

One reason the rollout of the Affordable Care Act has been so rocky is the difficult landscape the health care overhaul is trying to cover. The system was a complicated contraption to begin with, and the hybrid replacement is just as hard to negotiate.

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STEVE INSKEEP, HOST:

Its MORNING EDITION from NPR News. I'm Steve Inskeep.

LINDA WERTHEIMER, HOST:

And I'm Linda Wertheimer. We'll get a look this week at how many people have signed up for health insurance on the new government exchanges. According to the Wall Street Journal, fewer than 50,000 people have obtained coverage so far through the federal website. That's well below the government's original forecasts.

The Obama Administration says there's still plenty of time for people to get coverage, but officials acknowledge that technical problems with the website have slowed the sign-up process. As NPR's Scott Horsley reports, the complex challenge facing website designers is partly the result of trade-offs made in crafting the Affordable Care Act.

SCOTT HORSLEY, BYLINE: To understand the challenge that software writers are now grappling with as they try to get the insurance website working properly, you have to go back to 2009, when the newly-elected President Obama was traveling the country and getting a lot of questions like this one from Linda Allison in Albuquerque.

(SOUNDBITE OF TOWN HALL MEETING)

LINDA ALLISON: I talk to a lot of people about health care. My question is why have they taken single-payer off the plate?

(APPLAUSE)

HORSLEY: Obama admitted a single payer system, with the government providing health insurance for everyone, does have a certain appeal.

(SOUNDBITE OF TOWN HALL MEETING)

PRESIDENT BARACK OBAMA: If I were starting a system from scratch, then I think that the idea of moving towards a single-payer system could very well make sense. That's the kind of system that you have in most industrialized countries around the world. The only problem is that we're not starting from scratch.

HORSLEY: The private insurance system already covers about 200 million people in America, most of them through their employer. And while that system could be inefficient and frustrating, and left tens of millions of people with no coverage at all, the president was reluctant to blow it up.

(SOUNDBITE OF TOWN HALL MEETING)

OBAMA: We don't want a huge disruption as we go into health care reform where suddenly we're trying to completely reinvent one-sixth of the economy.

HORSLEY: Instead, Obama struck a political compromise that left the private insurance market intact, with a new requirement that insurers could not deny coverage to anyone. The government then offered subsidies to help lower-income families buy private insurance. And it tried to expand Medicaid for those who still couldn't afford it.

That's the patchwork system that the new health insurance exchange is designed to showcase. Health policy expert Harold Pollack of the University of Chicago says while it's no excuse for the website's performance failures, building such an exchange, on top of the sprawling private insurance market, was always a big challenge.

HAROLD POLLACK: We end up with a very klugey system. But the reason why it's klugey is because it's set up to minimize disruption and to allow for a series of really very delicate compromises that had to be made along the way.

HORSLEY: The website also has to verify income to see if applicants qualify for that federal subsidy, and that means tapping into the IRS database. Elaine Kamarch, who helped create the National Performance Review in the Clinton White House, says that requires a lot more security than your typical e-commerce site.

ELAINE KAMARCH: If somebody sees what books you're reading on Amazon, it's really not the end of the world. If somebody sees your income tax data for the last ten years, that's a big problem.

HORSLEY: In crafting the health care law, the administration was especially eager not to disrupt the employer-provided health plans that most Americans rely on. Here's something else the president said during that Albuquerque town hall meeting in 2009.

(SOUNDBITE OF TOWN HALL MEETING)

OBAMA: If you already have health care through your employer and you're happy with it, you don't have to change doctors, you don't have to change plans. Nothing changes.

HORSLEY: It's clear in that case the president was talking only about insurance that workers get through their employer, not the more volatile individual market where many policies are now being canceled. As time went on, though, that distinction disappeared from the president's talking points.

Many policy experts would like to see the U.S. shift away from its reliance on employer-provided insurance. But the University of Chicago's Pollack says Obamacare was designed to be a gradual revolution.

POLLACK: Our political system demands minimally invasive reforms. And when you have something as huge and as complicated as the American health care system, wow, that's really hard to do.

HORSLEY: If over time, the insurance exchanges prove successful, they could provide an alternative to health coverage through the workplace. For now, though, that's still a big if. Steve Horsley, NPR news, the White House.

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