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Maryland's Advice for Fixing and Creating Health Exchanges

The health secretary of Maryland, the only state yet to adopt another state's technology, details the switch that led to a successful second-year launch after an initial glitch-ridden rollout.

Maryland was one of several states last year that enthusiastically embraced the Affordable Care Act but struggled to debug its enrollment operation. But instead of ditching its own technology and using the federal website HealthCare.Gov, like Nevada and Oregon did, Maryland officials decided to borrow technology from a state that had a successful website and enrollment period.

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The state had seven months to make the switch by the new open enrollment period, which started Nov. 15., and so far, it appears the decision has worked out for the best. More than 25,000 people enrolled in the first 10 days, compared with just over 1,000 at that point last year.  

Joshua Sharfstein, Maryland’s health secretary, has overseen both years of rollouts. We spoke with him about why Maryland switched technology, how the state made the switch in time, and what advice he has for states considering creating their own health exchanges. The following transcript has been lightly edited for clarity and length. 

Why did the Maryland Health Benefit Exchange Board decide to adopt Connecticut's technology instead of signing onto the federal IT system?

The main issue with the federal exchange actually had to do with Medicaid, because the Affordable Care Act requires a modern Medicaid system, and we had been relying on our exchange to serve that role. If we just went to the federal exchange for private insurance, we would be stuck modernizing our Medicaid system at the same time. That would be -- we thought -- as expensive or more expensive and more complicated. It was actually easier to adopt another state’s model.

Would another state be able to adopt a platform like Connecticut’s? Is that a viable and perhaps easier option than starting from scratch?

Yeah, I think you’d have to have your head examined if you tried to build this from scratch given that there are several functional models out there. The first year, nobody was really sure which approach would work. We went with an approach that used off-the-shelf software instead of custom-built software. The states that fundamentally relied on large pieces of off-the-shelf software had problems. I would certainly recommend that if states are going to a state-based electronic exchange, they should customize a model that’s already out there.

How much did the switch cost?

The code from Connecticut we got for free, but the adaptation, installation and implementation of the code cost money. The development contract went for about $43 million with Deloitte. What they had to do was more than just deleting the word “Connecticut” and putting in the word “Maryland.” We built an electronic bridge from their system to our Medicaid system. We estimated about 18 percent of Connecticut's system had to change to work in Maryland. We have different Medicaid rules, for one. We also wanted to address some of the gaps that had been identified with the Connecticut system.

You mentioned having to “build a bridge” and modify about 18 percent of Connecticut's system. From an operational standpoint, was that relatively straightforward?

It was much less of an IT lift than the first year, but we did have to change our processes to work with the new IT system. I’ll give you an example. Historically, Medicaid cases have been assigned in Maryland by geography, so local departments of social services would just take care of the people in that area. But the Connecticut system functions on a first-come, first-served basis. It’s a very efficient system, so we adopted the Connecticut model and stopped doing it geographically.

In terms of the differences in preparation, you mentioned the hiring of a new secretary of IT. What were some other changes?

Having effective leadership in the development was essential. The new secretary of IT, Isabel FitzGerald, was a former case worker herself, so she was able to understand what the system needed to do as well as the technical challenges. We also had more time to do very extensive testing prior to launch -- multiple types of end-to-end testing, user testing, system testing, load testing. The Connecticut system can also run 3,000 tests against the system, all automatically. The old system couldn't test things automatically.

The exchange now has more involvement with private insurance brokers to help sell private policies, right?

When we looked around at different state systems, there were several things attractive about Connecticut’s: Brokers get their own dashboard and client notifications and can take over and fill out an application for someone. So it really extends the systems available to brokers in a meaningful way.

The Connecticut system was also very friendly to consumers, provided electronic and paper notices, allowed people to upload things from home, gives everyone an inbox with a copy of their notices stored, and allows anonymous browsing. From day one, it was also available in Spanish. Last year, we couldn’t get that going because there were so many problems, and there was no point extending those problems to Spanish. 

Can you describe how the relationship with Connecticut worked?

Connecticut CEO Kevin Counihan (who's now the CEO of the federal exchange) and his team spoke with us regularly. We had a meeting in the spring, sending about 20 people up to Connecticut. They answered our questions about their IT systems, and we talked about things that worked and didn’t work in our outreach and their outreach. I think all the states realized how difficult this can be, and any way we can help out is appreciated. One thing we’d done that they were interested in hearing about is our physician search functionality -- any specialty, any zip code, you can find out which plans they take. 

Any additional advice to states contemplating building a state exchange to avoid what might happen in the looming Supreme Court decision?

My experience is that it’s possible to adapt one solution from another state, and there’s a collaborative network of states to help with that process. In addition to Connecticut, we’ve been in touch with other states contracting with Deloitte about different issues that have come up. I think Gov. Martin O’Malley set the tone well when he said "if somebody has done it and it’s worked, let’s take that." It totally makes sense to go with what has worked.

Chris covers health care for GOVERNING. An Ohio native with an interest in education, he set out for New Orleans with Teach For America after finishing a degree at Ohio University’s E.W. Scripps School of Journalism. He later covered government and politics at the Savannah Morning News and its South Carolina paper. He most recently covered North Carolina’s 2013 legislative session for the Associated Press.
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