As the nation prepared for the launch of federal health reforms, Maryland was lauded as a leader in adopting the president's signature program. Obama used a community college in Maryland as a backdrop to promote his plan -- and to praise Maryland as a model.
But nearly two weeks after Maryland's online marketplace opened to the uninsured, the state program remains plagued by technical problems, and officials say it could be six weeks before the system is running smoothly. The Maryland Health Connection enrolled just more than 1,120 people in the first 10 days -- compared with more than 9,000 in Kentucky, which has fewer uninsured, and tens of thousands in California and New York.
Other states have had similar problems, and the federal site, which serves 36 states, has been bogged down. But Maryland is now being targeted for criticism by conservatives on Capitol Hill and publications such as the Weekly Standard, which highlighted the fact that consumers could not search Maryland Health Connection to see if their doctors participate in the program.
Some Obamacare supporters are also expressing frustration about the balky website.
"Once you get beyond the slick-looking front page, it looks like something a college kid may have put together in an afternoon. It's rife with weird programming, verification errors and dead ends," said Jim Fortney of Silver Spring, who has built some small websites himself and says he supports the health care program. He has been trying to enroll himself and his 12-year-old son on the Maryland site.
Maryland officials have downplayed the troubles related to the Maryland Health Connection's online portal. They say initial problems -- some created by high demand -- are fixed and others, such as slow movement between pages on the site, are being addressed.
Still, Gov. Martin O'Malley said some problems are likely to continue in Maryland, which has about 800,000 uninsured residents. "My sense of it is, probably for the next month or so, month and a half, we will be working out glitches in the portal," he told reporters Friday.
Joshua Sharfstein, secretary of the state Department of Health and Mental Hygiene, said a planned upgrade is in the works and noted that the pace of enrollment in the health exchange is picking up. In the first six days, the state signed up 326 people; four days later there were 1,121.
Still, computer experts are trying to figure out why some state exchanges worked and others -- like Maryland's -- lagged as a key element of the Affordable Care Act took effect.
Sharfstein wasn't specific about the problems that Maryland has encountered, and Noridian Healthcare Solutions LLC, the company contracted to build the software, said it could not comment.
When Obama spoke before a crowd of nearly 2,000 students at Prince George's Community College on Sept. 26, he predicted that signing up for health insurance would be as easy as shopping for "a TV on Amazon."
He acknowledged that some computer problems could emerge around the nation, but praised Maryland's efforts.
"Like any law, like any big product launch, there are going to be some glitches as this thing unfolds," the president said. "Folks in different parts of the country will have different experiences. It's going to be smoother in places like Maryland where governors are working to implement it rather than fight it."
Many states reported they had trouble initially because there was far more interest than expected and servers were overwhelmed. Experts said the sites that worked smoothly -- once computer capacity was increased -- were those that allowed consumers to shop without creating an account. Maryland and the federal site both require registration to see the details of insurance plans, and bottlenecks developed as information was relayed among computers for user verification.
Kentucky officials say the simplicity of their system and strong oversight brought success. They used few graphics and limited text on the website so it wouldn't get bogged down and consumers wouldn't be overwhelmed, said Gwenda Bond, a spokeswoman for Kentucky's Cabinet for Health and Family Services, where the exchange is housed. They thought anonymous browsing would be popular, and as it turns out, that approach avoided the bottleneck plaguing other states.
Most importantly, Bond said, the state used its own technical people, who also oversee Medicaid and other social service systems, to create the overriding architecture of their exchange. They also "stayed in the room" with contractors -- some of the same ones who are running the troubled federal site -- to keep close tabs on the operation.
"We had some glitches," Bond said. "But we were able to correct them quickly."
New York and California also are enrolling thousands of residents. Peter Lee, executive director of Covered California, said enrollment was "going strong," with 16,311 applications completed to cover 28,699 people as of Oct. 5.
The website for the New York State Department of Health experienced some slowness upon opening, with 2 million hits in an hour on its first day, but officials added servers in the following days to handle the load and said they haven't experienced any interruption in service. As of Friday, nearly 80,000 residents had enrolled.
But problems with the federal exchange's website means consumers face delays in obtaining coverage in 36 states, including Delaware, Pennsylvania and Virginia. Delaware officials don't expect to have any estimate of enrollment until mid-November, said Jill Fredel, spokeswoman for that state's health department.
Other state-run exchanges have faced serious problems. In Oregon, for example, technical difficulties have prevented residents from completing enrollment, though about 4,000 people have filled out initial paperwork either online or in print.
"We're working through the problems," Cover Oregon spokeswoman Ariane Holm said. Officials hope to open the enrollment website to the public by the end of the month. "We want to make sure we get it right, not just get it out there."
Software experts question the approach that the federal government and some states took in creating the online marketplace.
Alexander Howard, a fellow at Harvard University's Ash Center for Democratic Governance and Innovation and Columbia University's Tow Center for Digital Journalism, said the federal government has a procurement problem, and some states may have fallen into the same trap. Governments often contract out large, complex systems to companies that may not be innovative and nimble enough to envision them, write code, communicate and anticipate user needs, he said.
"Maybe [the companies are] not the best at building systems, they're the best at getting government contracts," he said. "There is a thicket of rules and regulations that governs how government can buy and maintain technology."
Paul Smith, chief technology officer at Public Good Software, agreed. He headed software engineering efforts for Obama's 2012 re-election campaign while at the Democratic National Committee, and embraced cutting-edge technology more common to a Silicon Valley start-up to effectively raise donations and organize. He said rigid procurement rules limit such innovation among federal agencies.
Another issue is that the federal website and Maryland's are hitting bottlenecks because they depend on computer links to agencies, including the Social Security Administration and the Internal Revenue Service, to verify consumer information. The systems at such agencies weren't meant to handle high web-based traffic, the experts said.
The problems can be overcome with good computer code writers, enough servers, proper testing and lots of oversight, Smith and Howard said. But that takes time, and many health exchanges weren't ready by the Oct. 1 deadline for the start of enrollment.
Smith pointed out that the Medicare Part D prescription drug plan also had a rough roll out, though he suspects most people don't remember that because the program is hugely popular.
"I've been developing software for decades and it's buggy," he said. "The first time you always encounter challenges and everyone expects that with any product. ... Going forward I expect the sites to stabilize and be more responsive, and enrolling people in health care and the experience not to be a frustrating one."
If the kinks are not worked out soon, some say authorities may need to ease enrollment deadlines. The uninsured need to buy coverage by March. For coverage to begin in January, consumers must sign up by mid-December.
"There is still time," said Sabrina Corlette, a senior research fellow at Georgetown University's Center on Health Insurance Reforms. "Maryland had been seen as ahead of the pack. But now we're pointing to Kentucky as one of the only states moving smoothly. If this goes on another month, some policy decisions on open enrollment will need to be made."
Maryland officials said 1,121 people have enrolled for insurance through the state's health exchange. Here are samples from some other states:
New York: nearly 80,000
Federal system, serving 36 states including Delaware, Pennsylvania and Virginia: Statistics not available