With confidence growing in the ability of the online state insurance exchanges to be up and running in all 50 states when sign-up under the Affordable Care Act begins, the big question for the Obama administrative now rests on its biggest test of all: how many uninsured Americans will actually enroll?
Rebecca Pearce, the executive director of Maryland Health Connection, who oversaw the build-out of her state's online marketplace, is confident the exchanges will be ready on Oct. 1.
"People are going to flood our gates. They're going to want to know what this is about," she told her staff at a recent meeting to go over enrollment plans.
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The real challenge, she said, will come after that first flurry of curiosity—actually getting people to sign up for coverage, which won't start until Jan. 1.
"They may not buy right away," she explained to her staff. "I expect another spike in December, when people are actually coming back in and purchasing."
Relying on the brokers
Maryland's goal is to enroll at least 250,000 of the state's estimated 800,000 uninsured residents in the first year through the online marketplace. To reach its target numbers for enrollment, the state is reaching out to insurance brokers and agents for help.
"We were looking to supplement the market and not replace the market," Pearce said. "We understand that there are people in the state who have been doing this for a very long time, and we're relying on the expertise of brokers."
Kelly Smith, of New York State of Health, said for small businesses especially, brokers will serve as an important link in the Empire State. New York is one of 16 states along with Maryland and the District of Columbia building its own exchange.
"I think small-biz owners that have historically relied on brokers to help them make a decision related to a health insurance purchase ... if anything, they're going to be relying more on the them." she said, citing the new insurance requirements under the ACA for the increased dependence.
Brokers await federal information
In New Jersey, one of 34 states that have opted for a federally built exchange, brokers have been told they'll play a role in enrollment, as well. But so far, federal officials have not given them the one thing they need to help their clients: information on what plans and pricing they'll find on the exchange.
"Already our phones are ringing off the hook. There are so many questions that are being asked," said Frank Petrulla of Richard Oscar & Associates, an insurance brokerage in West Caldwell, N.J.
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Petrulla organized a conference of the New Jersey Association of Health Underwriters on Sept. 12, expecting regional representatives of the Department of Health and Human Services would be able to provide more details on the new insurance plans.
Instead, they learned that they won't be able to get specifics on plans much before the start of open enrollment on Oct. 1.
"I don't have a doubt that we'll get it straight and once we get past that little bit of unknown, all the anxiousness will be gone," said Reginald Slaten, associate regional administrator of the Centers for Medicare and Medicaid Services, at the meeting.
Brokers are generally paid by commissions from insurers. For 2014, Citi analyst Carl McDonald said carriers are generally cutting commissions.
"The worst news we've seen for brokers is that some plans intend to pay a first-year commission of just 4 percent," he wrote in a note to clients. "It varies widely, but today, most plans tend to pay a commission of 10-12 percent, with the commission rate generally cut in half upon renewal."
Hitting the target
It's important politically for the Obama administration that large numbers of people sign up. The White House has targeted enrollment of 7 million uninsured Americans by the end of March 2014.
"Seven million people in the first six months is a very aggressive number," said Gary Lauer, CEO of online brokerage eHealth. "It's not easy to do."
For insurers, it's especially important that healthy young people sign up in sizable numbers, to help offset the expected demand for health insurance from older Americans. As a result, insurers may want to keep brokers in the mix.
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"We have the expertise and knowledge that no one else in the industry has, even people that are assisting as navigators," he said, referring to facilitators being hired by exchanges to help with in-person enrollment.
"We have the personal relationships with the small-business owners," he said. Those relationships may help people feel more comfortable with the new plans and convince them to enroll earlier than they would on their own.
When Massachusetts launched its online marketplace in 2006, some residents engaged with the call center a dozen times before actually buying a plan, said Maryland's Pearce.
"This isn't just buying a pair of shoes online," she said. "This is an important decision that people are going to be making for themselves and their families."
—By Bertha Coombs. Follow her on Twitter: @berthacoombs.