California's embrace of Obamacare coverage poses huge new challenges starting Saturday as sign-ups resume for year two of the federal health overhaul.
The state needs to help 1.2 million existing policyholders renew their coverage within the next month and persuade hundreds of thousands more people to sign up by Feb. 15. That's when the enrollment window closes again.
Much of the outcome in California will hinge on willing consumers, a retooled ad campaign, and whether the state has done enough to fix persistent service problems and technical glitches that continue to stymie many customers and enrollment workers.
This three-month sign-up period is half the time of the first open enrollment.
"The first year of enrollment was big and rocky, and this next open enrollment will be even harder," said Peter Lee, executive director of the Covered California exchange. "It's a short time frame with high volume."
Friday, Lee and other state officials stopped at Grand Park in downtown Los Angeles as part of a statewide bus tour to celebrate a dramatic reduction in the rate of uninsured Californians and promote the launch of open enrollment Saturday. The exchange wants to reach 1.7 million enrolled by February.
The percentage of Californians without health insurance has been cut in half to 11% through an expansion of private coverage and Medi-Cal, the state's low-income health plan.
More than 2 million Californians have joined the Medi-Cal program since January for a total of 11.3 million people statewide. That program has been plagued by a severe backlog of pending applications, which has left about 134,000 people still stranded in limbo.
Covered California made a strong debut last fall and avoided the disastrous launch that defined the federal HealthCare.gov website and some other state marketplaces.
But the state's operation was far from flawless. California's website and the exchange's ability to perform basic functions began to buckle as enrollment surged during the spring.
The website went down or slowed to a crawl, wait times on the phone often hit an hour and some consumers had coverage canceled unexpectedly. In one survey, 39% of exchange customers said the enrollment process was difficult.
At a hearing last month in Sacramento, state lawmakers supporting the health law recounted the high number of complaints they heard from constituents upset about delays in coverage or their inability to find a doctor who accepts their new health plan under the Affordable Care Act.
"Clearly there were some bumps in the road," said state Sen. Bill Monning (D-Carmel). "The sheer size and scope of this in California is mind-boggling and further complicates it. But Covered California will be held accountable for its performance."
In response, the state exchange has spent $36 million to improve its online enrollment system and nearly double the size of its call center to about 1,300 workers. It has added an online payment feature for several insurers so consumers aren't left waiting for a bill in the mail, and extended its service center hours.
The state relaunched its website Wednesday, several days behind schedule.
Long Beach resident Malinda Rohweller, 31, tried the revamped site and quickly encountered error messages. She was trying to update her account information since getting married. She said she couldn't get through by phone or using the exchange's online chat function.
Rohweller said her Blue Shield of California premium is going up by about $25 a month and she would like to shop around. But she's thinking of letting her policy automatically renew because of the technical headaches.
"They have had a year to make adjustments and there are a lot of people in our state who need to go through this," Rohweller said. "It's horribly frustrating."
Pasadena resident Lynne Bateson said she called the exchange this week about a confusing notice she received and got a recording telling people to call back this weekend for renewal questions.
"I'm sure they are trying, but they don't know how to write in plain English," she said.
Lee said the exchange has learned from its mistakes and knows it must do better at answering consumers' questions and solving their problems. The state expects 15% of existing enrollees to find coverage elsewhere or drop out altogether, putting pressure on to find new people.
"If we make people wait 30 minutes on the phone, they will walk away," Lee said. "If we don't do better this year, we are toast."
Trent Cumming, 45, said he would have missed out on coverage if an enrollment counselor hadn't come to his apartment on a Saturday morning. He couldn't get through the website on his own at the deadline in March.
The Studio City consultant was uninsured when he was diagnosed with skin cancer on his cheek last fall. He said he didn't have $5,000 for the surgery and put it off.
Using his Silver policy, he paid a few hundred dollars and had a successful surgery on his basal cell carcinoma in June.
"This coverage changed my life and I got the surgery I needed," he said.
Cumming is now featured in the state's $95-million marketing and outreach campaign showcasing personal stories of the newly insured. The state is also investing heavily in ads targeting Latinos, who make up nearly half of the state's uninsured population eligible for subsidized coverage.
In California's marketplace, rates have remained fairly stable for the second year. The average rate increase statewide is 4.2%, according to the exchange. Some people will pay more — 13% of exchange customers face an increase of 8% or more.
There are also ongoing complaints about the narrow provider networks insurers have deployed to hold down premiums.
The uninsured people left to reach in California are disproportionately male, Latino and eligible for less federal financial help with their premiums because of slightly higher incomes.
Many of the people who signed up initially were closer to the federal poverty line and often paid just a few dollars a month for health insurance thanks to generous federal subsidies. The remaining uninsured are closer to the cutoff for those federal dollars, meaning they will pay more of the premium themselves.
Mollyann Brodie, a senior vice president at the Kaiser Family Foundation, said "this second enrollment period, almost by definition, ends up being tougher because there's a tougher group left to enroll."