The Kaiser Family Foundation poll, taken in December of last year, added another piece of discouraging data to an increasingly daunting pile. “Forty-four percent of exchange policyholders surveyed said it’s somewhat or very difficult to afford their premiums,” the Los Angeles Times reported, “compared with 25 percent of adults who had employer-based or other private health insurance.”

Analysts paid close attention to the figures for two reasons. First, they contributed to the growing perception that Covered California — one of the nation’s biggest, most important and most successful exchanges — is now on a path toward underperformance.

Second, as the Times noted, the numbers will foster an intensified debate between the exchange and the insurance companies on premium rates for the new year. “Many analysts are predicting bigger premium increases for 2016 in California and across the country. Insurers have more details on the medical costs of enrollees, and some federal programs that help protect health plans from unpredictable claims will be winding down.”

Calling audibles

As California’s struggles have reflected the even greater challenges faced by other failed or failing exchanges, policymakers and regulators have turned to consider how to sidestep disaster. One notion that has attracted attention — possibly in Gov. Jerry Brown’s office — is an exchange merger.

“The idea is still only in the infancy stage,” reported The Hill. “It’s unclear whether a California-Oregon or New York-Connecticut health exchange is on the horizon. But a shared marketplace — an option buried in a little-known clause of the Affordable Care Act — has become an increasingly attractive option for states desperate to slash costs. If state exchanges are not financially self-sufficient by 2016, they will be forced to join the federal system, HealthCare.gov.”

The idea would be that a state with a failed marketplace could offer a surge of enrollees and revenue to a state with a struggling marketplace. Intuitively, the arrangement would tend to cluster smaller states around larger ones, effectively extending the insurance regimes of the former to the latter.

In part, The Hill observed, states have turned to the merger idea because federal law requires their exchanges to be financially self-sustaining if they wish to avoid joining the federal exchange. But states have also been pressured by the King v. Burwell case currently pending at the Supreme Court, where the legality of federal subsidies for states without their own exchanges is on the line.

“Most Republican state leaders have avoided talking about how they would respond to a decision against the use of subsidies on the federal exchange,” according to The Hill. “Behind the scenes, however, many are anxiously contacting states that run their own exchanges.”

Expanding coverage

Perhaps paradoxically, legislators in Sacramento have responded to the climate of uncertainty surrounding California’s exchange and the broader exchange system by pushing for expanded coverage, including to unlawful immigrants.

Under the terms of a new bill, SB4, successfully advanced through committee by state Sen. Ricardo Lara, D-Bell Gardens, “the undocumented will be able to buy health insurance on the Covered California exchange, always providing that the federal government authorizes it, but they will not automatically benefit from Medi-Cal, the state medical subsidy, however low their annual incomes,” according to Fox News Latino.

Questioning assessment

As the policy shifts play out, at least some news analysts have raised a key side issue: just how experts and lay readers are supposed to confidently assess just how well or poorly Covered California is doing.

In a recent essay, Trudy Lieberman at the Columbia Journalism Review noted that the exchange has frequently put forth different measures and metrics by which its success might be judged. Sometimes, the standard has been total enrollees or new yearly enrollees. Sometimes, it has been the renewal rate, the number of Californians covered through the exchange itself, or, “simply, the overall rate of uninsured adults across the state[.]”

Coverage of the exchange’s fortunes, Lieberman observed, “has largely followed the lead set by the exchange. The result is coverage that has too often been reactive, short on enterprise, and with missed opportunities to ask some necessary questions. Covered California may ultimately have a success story to tell — but it will need to face some sharper skepticism before we can be sure.”

The White House announced in October that the website would “work smoothly” by Nov. 30. (It was a shrewd decision to choose Nov. 30. If the website didn’t meet the benchmarks imposed by the White House, it would be announced on a Saturday during a holiday weekend.)

Nov. 30 has come and gone. Does healthcare.gov now “work smoothly for the vast majority of users,” as Obama administration official Jeffrey Zients promised? CalWatchdog.com consulted federal technology experts to find out.

Daniel Castro, a senior analyst at the Information Technology & Innovation Foundation, told CalWatchdog.com that it’s difficult to measure success because it “really depends on what the benchmark is.” Castro added that, because the bar has been set so low already, “if the website loads, it feels like a victory.”

There is some clear evidence of improvement. Mike Hettinger of the Software & Information Industry Association pointed to clear signs of progress in the site in the two months since it launched.

“Response time has dropped from eight seconds to one second … and some 400 bugs have been fixed,” he said. “All signs of improvement.”

Castro added that the website was “significantly more stable” and was working 95 percent of the time, up from 43 percent in October.

However, both experts tempered their evaluation of the more positive metrics.

Castro warned that, while the uptime improved, the current amount of time that the system is available “is often considered unacceptable” in the private sector, where anything below 99 percent uptime “would not be very good.”

“And remember, the 95 percent uptime does not include any scheduled maintenance. In addition, the administration did not release how many outstanding bugs remain to be fixed and the severity of these problems.  This is likely a moving target — as one bug is fixed, more might be discovered — but this is something the public should be asking for as it shows how much progress has been made.”

Vulnerable

Hettinger also warned that the website is still vulnerable to problems.

“If it turns out that 50,000 concurrent [users] and 800,000 users per day is a ‘vast majority of users,’ then they have accomplished their goal.  However, if more than 50,000 concurrent and 800,000 per day try to access the site, then we are likely to see additional problems.”

And much of the administration’s focus has been on fixing the “frontend” of the website, where average Americans can see progress. However, there is a whole other aspect to the healthcare.gov website, the “backend.” Insurance companies mainly deal with the backend, where payments are made and the enrollment process is automated. Castro predicted that the backend of the website  “will likely still have bugs that need to be worked out.”

He added, “The administration has more leeway here, since they can deliver this data manually if needed, and it is less of a public relations issue if it is not working properly by their internal deadlines.”

The healthcare.gov site that launched on Oct. 1 was not complete — nor is the one available today. Once error rates decrease and the back end of the website is truly fixed, then the website will be truly complete. However, having a working website is only one component of the law.

Once the website begins working, the question is more simple: Are people using it?

But even with three years to set up the health exchanges and support system, HealthCare.gov has been unavailable to those trying to sign up for government health care since it went live Oct. 1.

The proclamation “The Health Insurance Marketplace is Open!” is falling on deaf ears.

Single-payer system ahead

Since the passage of “Obamacare” as it is usually called, many in America have warned that the real goal all along has really been a single-payer heath system. This explanation goes a long way in explaining the substantial flaws in Obamacare, and why implementation of the massive government health plan system is already a nightmare, and slated for total failure.

This isn't the first attempt at total government  health care; it's just the first plan to have been passed by Congress.

California single-payer system

Even in California, attempts to create a single-payer health system have been attempted. Sen. Mark Leno, D-San Francisco, authored SB 810,  which would have created the California Healthcare System, a single-payer health care system, administered by the California Healthcare Agency, to provide health insurance coverage to all California residents. But Leno could not pass the two-year bill and it died. But that was just the first try. Count on seeing another single-payer health care system bill next year.

Then-Gov. Arnold Schwarzenegger made California the first state to create an insurance exchange after Obamacare was passed. The health exchanges are supposed to be Internet-based places to shop for health benefits, for people who do not get health benefits at work. But Covered California has been as problematic as HeathCare.gov.

Shortly after Schwarzenegger’s creation of the exchange, the Obama administration approved $10 billion for California to begin expanding coverage to its poorest residents, another key part of the new law.

The long road to a Single-payer system

A single-payer health care system would mean the government pays hospitals and doctors directly for every person's health care. Unlike socialized medicine, where the government owns the hospitals, pharmacies and medical clinics, and doctors are government employees, single-payer is more like Medicaid or Medi-Care.

The drumbeat toward single payer health in America has been present in every Democrat Presidential administration since 1912, when then presidential candidate Theodore Roosevelt, campaigned on the Progressive Party ticket and called for establishment of a national health insurance system.

In 1934, President Franklin Roosevelt seriously considered a national health insurance program that would cover every American.

In 1945, President Harry Truman called on Congress to begin a ten-year plan to transform the existing American health care system into compulsory health coverage for all people.

In 1965 President Lyndon Johnson signed legislation creating the government run Medicare and Medicaid programs, to provide health care coverage for people aged 65 and older, and for the poor, and disabled.

In 1971, President Richard Nixon backed a proposal requiring employers to provide a minimum level of health insurance for their workers while also maintaining competition among private insurance companies.

When Jimmy Carter was elected U.S. President in 1976, he immediately called for a national health insurance system with mandatory coverage.

But each of these attempts were scrapped because of nationwide financial crises.

The 1986 Congress passed the Emergency Medical Treatment and Active Labor Act, requiring hospitals to accept all emergency-room patients. It also began the Consolidated Omnibus Budget Reconciliation Act, known as COBRA, which requires employers to allow employees to remain on and pay for their for  group health plan, following termination or resignation.

In 1993 during his first year in office, President Bill Clinton tried to enact HillaryCare. The Clinton health plan would have required all U.S. citizens and permanent resident aliens to enroll in a qualified health plan, and specifically forbade their “disenrollment” [sic] until covered by another plan.

HillaryCare was soundly defeated.

In 2003 when Barack Obama ran for the U.S. Senate, he told the Illinois AFL-CIO, “I happen to be a proponent of a single payer universal health care program.”

“A single payer health care plan, a universal health care plan. And that’s what I’d like to see. But as all of you know, we may not get there immediately,” Obama said. “Because first we have to take back the White House, we have to take back the Senate, and we have to take back the House.”

During the 2008 Presidential election, candidate Obama said during a January 2008 debate, “If I were designing a system from scratch, I would set up a single-payer system.”

President Obama made clear he was determined to see a single-payer system created, but when Democrats couldn’t get the votes needed, health insurance experts say instead they created a law so complex, it would have to fail. Then, the America people would be so angry, they would eventually demand a European style, single payer system.