On the day that Covered California went live -- the very moment that Executive Director Peter Lee declared the exchange "open for business" -- staff debuted a video celebrating the launch.
The video features photos of cheerful, ethnically diverse people -- spliced between scenes of California -- holding up signs written in English, Farsi, Korean and other languages that all translate to "open." (You can watch Lee unveil the video, beginning at the 10:40 mark.)
One week later, Covered California brought the video back; once again, clips of grinning men and women toting signs that read "Ya abrimos" filled time before a webinar on Tuesday where officials shared updates on the exchange's progress.
The smiling faces and multilingual message illustrate one of California's major challenges in rolling out the ACA: The state is arguably the most geographically and demographically diverse in the union. Expanding health coverage to seven million uninsured residents will take time and a unique strategy.
But you can also forgive Covered California officials for wanting to remind the public that their exchange is live. During much of the first week, the site often sent a different message.
What Went Wrong
Covered California's launch was supposed to be different. The state had spent years gearing up for the exchange's rollout on Oct. 1. It had enlisted dozens of groups to help perform outreach. It had equipped some staffers with "Keep calm and go live" t-shirts.
But a triumphant debut turned out to be an oft-frustrating one. In California, like in most of the nation, most launch day stories didn't center on the people signing up for coverage through the new exchanges, but on all the people who couldn't.
Covered California's website stalled or was down most of the first day, leading officials to take it offline just hours after its launch. The provider directory wasn't ready to go. Consumers dialing into the agency's service centers had to wait up to 40 minutes for their calls to be answered.
"It was an embarrassing start," former San Diego County CIO Harold Tuck told the Los Angeles Times' Chad Terhune. "There ought to have been better beta testing of the systems, and these errors wouldn't have come up," Tuck added, in a separate interview with Terhune and the Times' Noam Levey that focused on the IT problems around the nation.
What Went Right
But there's too much being made of the computer glitches in California and elsewhere, according to Stan Rosenstein, principal adviser at Health Management Associates and a former state official who spent decades working with Medi-Cal, California's Medicaid program, and other public health insurance plans.
"I've watched hundreds of these systems get implemented," Rosenstein told California Healthline. There's "no implementation that's ever been done without computer problems -- that's the nature of the beast."
And when reached on Tuesday afternoon, Rosenstein and several others were gleeful about numbers that Covered California had reported earlier in the day. The exchange got nearly 1 million unique visits between its launch on Oct. 1 and Oct. 5 -- more than any other state's exchange, save New York -- and service centers reported about 59,000 calls. More than 16,300 applications had already been processed through Saturday, with 28,699 Californians being deemed eligible for coverage.
"The numbers are outstanding" as a starting point, Rosenstein said, and "way ahead" of the pace set by California's previous efforts to enroll residents in public insurance programs, like the Medi-Cal expansion in 2000 and the launch of Healthy Families.
"And all of those programs ended up being wildly successful."
Dylan Roby, director of UCLA's health economics and research program, also pointed out one feature that helped users access Covered California.
"With [Covered California], you could still use the 'shop and compare' link that was not connected to CalHEERs" -- the state's Web-based system to determine eligibility and tax credits -- "to see what your options were," Roby explained to California Healthline. That tool kept would-be customers away from the main login page and provided an alternative when the site stalled.
But many other state exchange sites, including the 36 states that relied on the federal government to run their exchanges, didn't allow consumers to window shop. "If you went through healthcare.gov, there was just a placeholder page ... and then the link saying you had to come back later," Roby added. "There was no ability to shop around without logging in, which probably would have satisfied some people that weren't ready to sign up but did want to see pricing and a general idea of their subsidies."
What Others Did Better
California was hardly alone in having start-up problems last Tuesday.
Like the Golden State, Maryland has aspirations of setting the pace on ACA implementation; Gov. Martin O'Malley, perceived as a top candidate for the Democratic nomination for president in 2016, had vowed to be the fastest in the nation when rolling out Obamacare. "Our state is leading the way in implementing this crucial provision of the law," U.S. House Minority Whip Steny Hoyer wrote on Oct. 1, the day that Maryland Health Connection launched -- but that exchange has encountered far more significant problems than Covered California.
Still, a handful of states have seemingly outperformed California. About 20,000 people already have submitted applications through Washington state's exchange, partly because Washington Health Plan Finder has been so easy to use, Sarah Kliff writes at the Washington Post's "Wonkblog." And Kentucky's exchange has reported similar numbers to California -- nearly 15,000 completed applications through Monday -- despite one-fifth as many Web visits and one-tenth as many uninsured. (And unlike California, Kentucky has reported the number of actual enrollees in its exchange: about 7,000.)
Kentucky's secret for success? Servers, simplicity and state agencies' structure, Arian Campos-Flores writes at the Wall Street Journal.
Hold for Judgment
Since launch day, and starting well before, officials across the nation have stuck to a common mantra.
"This is day one of a process" of six months of open enrollment, CMS Administrator Marilyn Tavenner said last Tuesday. "We're in a marathon and not a sprint,"
"It's a marathon, not a sprint," state HHS secretary Diana Dooley echoed last week.
But there's value in getting out of the blocks fast.
"I do think opening day matters," Daniel Zingale of the California Endowment told California Healthline. "The master marketing people in Hollywood know the day the film opens is important. In some ways, I think that's true here too."
That's why Zingale said he's heartened by the early results released on Tuesday, especially the near-1 million unique visits to Covered California across five days.
"That’s a big number," he added.
And there's another big number that no one's talking about, according to Rosenstein -- a story that's more important than news of startup IT glitches and wait times.
"The fact that California is starting with 600,000 people enrolled on the first day of the program" -- thanks to the state's efforts at early Medi-Cal expansion -- "will put California light years ahead of every other state in the nation," Rosenstein said. "That's the story I'd love to see [journalists] writing."
Around the Nation
Here's a quick look at other interesting developments as the health policy community continues to race down the road to reform.
Assessing the exchanges: When will we know whether the exchange rollout is successful? Try 2016, Jordan Rau writes at Kaiser Health News, noting that the marketplaces' effect on premiums can't be measured for years.
'Showdown' in Texas: Writing at Politico, Jennifer Haberkorn examines the fight to implement Obamacare in a state where many local officials are eager for coverage expansion, even as Texas' most prominent leaders publicly fight the law.
Covering the coverage: At the Columbia Journalism Review, Trudy Lieberman reviews how the media has covered the exchanges' launch, finding some distortions and misinformation.