WASHINGTON — States that embraced the Affordable Care Act and created health care exchanges were supposed to lead the way in enrolling their residents in health insurance, but some of them are responsible for the federal government falling behind in its projections.
Only 18 days remain before the March 31 enrollment deadline, and the government is about 1.8 million behind its goal of 6 million new health insurance customers.
That's because states such as Hawaii, Maryland and Oregon, all run by Democratic governors and legislatures supportive of the law, have had their exchanges falter and at times collapse.
Hawaii launched with a lot of fanfare, as well as a lot of technical issues, and sits at 30% of its projected enrollment with 4,661 people. The District of Columbia faced similar issues and is at 28% of its projected enrollment.
Last month, Maryland fired its exchange provider after the website froze on its first day and has had problems ever since. Oregon and Hawaii both began processing enrollment applications by hand because their websites were so problematic. Both states' exchange directors resigned in December.
"Maryland, Nevada, Oregon — I would put them in the disappointments category for state-run exchanges," said Bill Melville, a market analyst at Decision Resources Group, a health care research and consulting group. "They ended up struggling in all three cases."
Other states trailing their original projections say they aren't giving up.
"We've seen a massive uptick just since Monday at our call center," said Debra Hammer, chief communications officer for the New Mexico health insurance exchange, which had 15,012 enrolled in private plans as of Feb. 28. That's far short of initial projections of 40,000 by the end of March. "It had been 200 a day, but now we're up past 600. I think people are starting to feel that urgency."
She expects that to continue as New Mexico — as well as organizations and states throughout the nation — bombard social networks, television and radio stations, online networks such as YouTube and Pandora, and even bars and restaurants with ads, pamphlets, doorknob hangers and one-on-one coffee sessions. New Mexico has 150 events planned in the next 18 days.
"We definitely want our numbers higher by the end of open enrollment," she said. "That is why we're doing a last-minute push to get the word out."
Some states — including largely Republican states where the government has not promoted the exchanges — have surpassed their initial projections, with California at 135% of projections, Florida at 105%, Idaho at 125%, North Carolina at 101% and Washington at 109% by the end of February, according to an analysis by Avalere Health.
But others, again, unexpectedly, have fallen far short of their goals. New Mexico will eventually run its own exchange, but the federal government runs the site now. Hammer said that may have caused some confusion and hurt initial enrollment.
The federal site, HealthCare.gov, has been running properly since at least Nov. 30, officials say.
Avalere projects the total enrollment will be 5.4 million by the end of March, based on the February numbers announced Tuesday, but Avalere Vice President Caroline Pearson said the government could still manage 6 million if there's a big rush at the end.
"I've seen a lot of talk about there being a miracle, but people sign up at the last minute for these things," he said. "I tend to believe there's going to be a big rush at the end."
Some states have had low enrollment rates in part because their governments have not promoted the law.
North Dakota's insurance commissioner focused on the opportunity for fraud and how many people's insurance had not been renewed, rather than promoting the new marketplaces. South Dakota's insurance commissioner page highlights that the state government opposed the law.
"We do not have any special efforts planned during the final three weeks," said Dawn Dovre, director of communications for the South Dakota Department of Labor and Regulation. The office does answer consumer questions as they come in, she said.
But there have also been surprises.
"Idaho's above where their goal was expected to be," Melville said. "But they started with a high number of uninsured."
Although dominated by Republican politicians opposed to the law, Idaho voted to run its own exchange starting in the fall. Private organizations there are promoting enrollment now.
In North Carolina, which has a Republican governor and legislature, "no one expected (the state) to have 200,000 plans at this point," Melville said.
In other states, such as Oklahoma, which is at 45% of enrollment projections, navigators and organizations that had hoped to promote the exchanges faced resistance from state lawmakers who limited their ability to give information to consumers, Melville said.
"I don't think you'll see any of that being lifted before the deadline," he said.
In Delaware, which has 53% of its projected enrollment with 6,500 people, Jim Grant, communications coordinator for the state's marketplace, said they've also ramped up for the last three weeks.
"We've been encouraged that our numbers have been going up," he said. "We're not where we want to be, but there's been steady improvement."
They're targeting 18- to 34-year-olds with Bruno Mars and Lady Antebellum concert ticket contests, emphasizing the penalty people will pay if they don't have insurance in 2014, partnering with African-American churches in Wilmington and Newcastle for enrollment events, and focusing on enrollment in Kent County, where the numbers haven't been as high as they would like.
"We are expecting, and hopeful, that there will be a surge, and we're preparing for that," he said. "We certainly have no reason not to expect it, given human nature and our stepped-up efforts."