Welcome to Health Reform Watch, Sarah Kliff’s regular look at how the Affordable Care Act is changing the American health-care system — and being changed by it. You can reach Sarah with questions, comments and suggestions here. Check back every Monday, Wednesday and Friday afternoon for the latest edition, or sign up here to receive it straight from your inbox. Read previous columns here.



Richard Sherman celebrating the success of the Washington Health Plan Finder, probably. (Photo by Jonathan Ferrey/Getty Images)

The Seahawks certainly have something big to celebrate when they return to Seattle -- that they get to go home to what might arguably be the best-functioning health insurance exchange in the nation, of course.

Yes, there is the Super Bowl victory, as well. But you have enough things to read about that -- and not nearly as much coverage of the Washington Health Plan Finder, which is arguably having one of the best open enrollment seasons in the country.

Washington, alongside Vermont, leads the nation in percentage of eligible population enrolled in its exchange. According to the Kaiser Family Foundation, 33.1 percent of Washingtonians eligible to sign up for coverage through the exchange have gone ahead and done so (in Vermont, it's around 33.4 percent).

To learn what, exactly, sets Washington apart, I got a chance to hear from Washington Health Plan Finder executive Richard Onizuka on Monday at Academy Health's National Health Policy Conference. Aside from the Seahawks, whom Onizuka heartily congratulated, what stood out about Washington wasn't that it had the best preparation or plan going into the exchange. It's that the state has been pretty adaptable, shifting things around as it entered a totally new health care landscape. Here are a few of Onizuka's key observations.

Initial screw-ups don't have to be systemic failures. One thing that makes Washington's current success surprising is that the state actually had one of the worst launches on Oct. 1. People couldn't get into the system to buy coverage for much of the site's first 48 hours online. "To think that we hooked everything up, end to end, for the first time at 4 a.m. on October 1, that's crazy," Onizuka said. Washington made a strategic decision to take the site down and work on fixes, rather than try to muddle through with the site still up. While applicants on other health exchanges saw error messages or endless spinning wheels, Washingtonians got a message to come back later. And, in the interim, the state made some of the key fixes that make Washington's Web site one of the more functional exchanges today.

Call centers were underprepared, but growing. Onizuka said that, when it launched, the Washington Health Plan Finder had 140 call center agents -- who were immediately overwhelmed by floods of tens of thousands of calls. The state doubled the number of call agents and is aiming for a staff of 600 by mid-February, although average wait-times still hover just under 40 minutes. "We had no idea what to expect in the real world environment," Onizuka said. "Monday of last week we had 49,000 calls to the call center. We're getting the volume that California had predicted."

Key to success: limiting the project's scope. This isn't unique to Washington, but it and a handful of other well-functioning exchanges attribute much of their success to narrowing the scope of their project and not trying to put all the bells and whistles on the site at once. "Managing scope has been key," Onizuka said. "We said early on, if you have a goal of October 1, you have to manage the scope of what you can actually do by then." The idea is to add new features into the exchange later in the game, after a more bare-bones version is stable. And, even over the course of open enrollment, Washington has added upgrades through 2013 and into 2014.

Collecting premiums gives better data. Washington is one of the few states that actually collect the first month's premium payment and then send the money to the insurance company. Under Healthcare.gov, and most other state exchanges, the health insurance plans are responsible for tracking down that first check. This means that Washington has really robust data on who has actually paid for their plans. On the other hand, it means more administrative work for the state. When asked if he would do it again, Onizuka said that "the grass is always greener on the other side." But, taken together, this seems to have given Washington a better grasp on how well the exchange is working and who is fully completing the sign-up process.

KLIFF NOTES: Top health policy reads from around the Web.

Healthcare.gov can't handle coverage appeals. "Tens of thousands of people who discovered that HealthCare.gov made mistakes as they were signing up for a health plan are confronting a new roadblock: The government cannot yet fix the errors. Roughly 22,000 Americans have filed appeals with the government to try to get mistakes corrected, according to internal government data obtained by The Washington Post. They contend that the computer system for the new federal online marketplace charged them too much for health insurance, steered them into the wrong insurance program or denied them coverage entirely." Amy Goldstein in The Washington Post.

Here's what happens if the newest Obamacare lawsuit succeeds. "Put simply, destroying the subsidies destroys the mandate, which in turn destroys the possibility of insurance market reforms. An verdict in favor of Halbig would therefore reduce the private health insurance market to what it was before health reform. The end result would be very costly insurance." Harold Pollack in Wonkblog.

Outsiders criticize CMMI's lack of randomized trials. "The idea seemed transformative. The Affordable Care Act would fund a new research outfit evocatively named the Innovation Center to discover how to most effectively deliver health care, with $10 billion to spend over a decade. But now that the center has gotten started, many researchers and economists are disturbed that it is not using randomized clinical trials, the rigorous method that is widely considered the gold standard in medical and social science research. Such trials have long been required to prove the efficacy of medicines, and similarly designed studies have guided efforts to reform welfare-to-work, education and criminal justice programs." Gina Kolata in the New York Times.