These first two weeks have been rocky for the state health insurance exchanges. The online marketplaces opened across the country Oct. 1, with computer glitches and staffing shortages.
Even the states that have agreed to run their own exchanges are having a hard time. In states that have not embraced the Affordable Care Act, the federal government is struggling to fill in the gap.
As Alexandra Dixon threads her way among the people waiting to see a doctor at the Community Clinic, Inc., in Silver Spring, Md., she introduces herself with a bright smile and an outstretched hand.
"I'm one of the new health care navigators. Have you heard of the Affordable Care Act?" she asks.
While some folks mumble, "Um, no, I don't think so," Dixon is nonetheless booked up with appointments. She's one of 350 people in Maryland who have been hired and certified to help people enroll in the federal health care law's insurance options.
"Sure, I've had a couple of people go, 'Ooooh, Obamacare, I don't want that,' " Dixon says. "But for the most part, people have been really excited and really happy and know what this is."
Dixon sits down with Maria Hernandez, a construction worker who's been uninsured for the past five years. Hernandez says sometimes she gets sick, but without insurance, it's better just to take some medicine and stay home. With Dixon's help, she's started an application for insurance.
Despite Dixon's assistance, no one at the clinic where she works has actually enrolled on the exchange: The Maryland website freezes almost every time.
But whenever Dixon hits a roadblock, she sets up an appointment for the patient to come back, "because the portal is a lot better this week than it was last week," she says. "I have every expectation that next week it will be working better than this week."
And she has her state behind her: Maryland has embraced the health law. It's one of the 16 states, plus the District of Columbia, that are running their own exchanges. The rest are being run by the federal government, which has been stretched thin, according to Caroline Pearson of Avalere Health, a consulting company that's been tracking the insurance marketplaces.
"The states that are operating their own exchanges just have a lot more funding available to do outreach and enrollment," Pearson says. "The federal government just had limited funding left to do that, and it was spread across a large number of states."
The entire state of Ohio, for example, received just $3 million in grants to reach out to those who might need the insurance compared to $24 million in Maryland, which has half as many uninsured residents.
That frustrates Lisa Hamler-Fugitt, who runs the Ohio Association of Foodbanks, the state's main consumer-outreach group for the exchange.
"We have too few boots on the ground," she says. "We need hundreds if not thousands of individuals to assist us."
Instead, she'll have about 40. Ohio has laws putting additional restrictions on navigators, such as requiring them to go through a longer certification process. Hamler-Fugitt believes that's caused a three-week delay in getting her navigators to work.
These early differences between states could hamper the goal of the Affordable Care Act, which is to get as many people insured as possible, according to Pearson of Avalere Health.
"Recent polling shows that only about 12 percent of the uninsured population who could benefit from exchanges understand that they are launching and began on Oct. 1," she says.
The effort that's needed to ramp up awareness won't be there in states that aren't proactive, Pearson says.
But, she adds, this is only the beginning of the enrollment process; launching an initiative of this size is always a huge lift, she says.
Consumers have until the end of March to sign up for coverage in 2014.