Right after the health insurance marketplaces opened for enrollment on October 1, a wave of problems crashed down on consumers and physicians.

Consumers are still faced with everything from registration website malfunctions to narrow networks and many physicians are crying foul over what they believe will be low reimbursements from insurance companies. President Obama acknowledged that there would be glitches in the ongoing rollout of the exchange, but the question remains as to whether these are just glitches or lasting problems.

The push to boost enrollment
Since open enrollment began, it has been the primary goal of many hospitals to get people on board. Each exchange must have two organizations that are certified as navigators and one must be notfor- profit. In August, Health and Human Services Secretary Kathleen Sebelius announced that 105 groups, including a number of hospitals, had been chosen to be navigators and would get a piece of the $67 million federal grant.

About twelve of the hospitals that are a part of the American Hospital Association received funding, but many of the others have become navigators voluntarily. “Hospitals are community-based organizations who are focused on providing service to the community,” says Ellen Pryga, director of policy development at the AHA.”For years, they have dealt with some of the tragedies that can come from people being uninsured, so when there is an opportunity to help people get insured there’s a very strong incentive to up the level of support for the community.”

Hospitals will often undertake community outreach efforts at local meetings and fairs, provide information on their websites and utilize contractors to help get people enrolled. “It’s to connect people to both information and the processes to enroll in coverage if they are uninsured,” says Pryga.

The AHA is unsure of the exact number of people who have enrolled in the exchanges as a result of their outreach, but they describe it as a “fluid situation.” What is known is that by the end of 2013, there were 2.1 million Americans who signed up for health coverage on the health exchange.

Too many glitches
Health insurance exchanges were included in the Affordable Care Act as a place where consumers could go to shop for affordable health insurance, or to see if they qualify for subsidies to purchase a plan.

Every state had the opportunity to create a fully state-based marketplace, enter into a state-federal partnership marketplace, or be a part of the federally-facilitated marketplace. The Kaiser Family Foundation found that 17 states created a state-based marketplace, seven went with a partnership marketplace, and 27 are a part of the federally facilitated marketplace.

For many people, the enrollment process was fraught with frustration. Many who enrolled through the online federal insurance marketplace could not access the website but those who could log on and create an account ran into issues when the glitches caused them to sign up for more than one insurance plan or send incomplete data to the insurance companies.

“When patients went on, excited to try to get insurance, to not have it work for the first month and a half, I think was disconcerting to some people,” says Reid Blackwelder, president of the American Academy of Family Physicians.

Even if people made it through the enrollment process without any issues, the New Year brought in new problems. When they purchased their health plans, many files were corrupted or misplaced on the way from the government website to the insurance company’s database.

The insurance companies refer to the people who don’t appear in the insurer’s database but whose enrollment the government has records of as “orphans,” and “ghosts” are those who show up in the insurer’s database, but aren’t on the government’s list of people who enrolled. Because of this, physicians and pharmacists are unable to verify that these people are insured.

Despite all of the setback over the past few months, the public seems to be split about the new law. A Rasmussen Reports survey released on January 13 included 1,000 likely U.S. voters and found that 56 percent have an unfavorable opinion of the new law.

But even more problems could await individuals seeking bargain insurance if they purchase one of the less expensive insurance plans, according to Richard Duszak, the chief medical officer at the American College of Radiology.

“A lot of folks are just going for the cheap amount not necessarily understanding that there are deductibles associated with this,” says Duszak.

Those who choose bronze plans, for example, might have lower insurance premiums but high deductibles and some plans will not pay for a doctor visit until they pay that deductible. “There is a concern that patients who choose to have high deductibles are still going to need to have their medical problems addressed so the challenges of people still having to come in and work with their physicians is real,” says Blackwelder.

Blackwelder hopes that patients will find a way to prioritize their health issues even in the setting of high deductible plans that will cause them to pay out-of-pocket for their health needs. He adds that at least they will have some coverage under the new health reform law that they didn’t have before.

The other downside of buying the cheaper plans is the limited access to providers. Research done by McKinsey & Co. found that the majority of the lowest-priced insurance plans sold through the marketplaces have very narrow networks of hospitals.

“These are narrow network products so a lot of physicians are not included in the network and to the extent that they’re not, it’s a problem,” says Dan Mendelson, CEO of Avalere Health, a health care consulting firm.

These narrow networks are a product of insurance companies competing on premiums. “They can’t compete, as they historically have done, through risk selection and cherry picking, they can’t exclude unhealthy people and sell only to healthy people, they can’t compete very much on benefits, they all have to cover a comprehensive benefit package,” says Timothy Jost, a professor at Washington and Lee University School of Law. “One of the few places they can compete is on premiums, which they all do, by offering a narrower network.”

Where’s my money?
These narrow networks are also affecting physicians because they can no longer negotiate a price with insurance companies, when it comes to reimbursement, they must accept what they are given. If the physician doesn’t like the amount, then they won’t be a part of their network.

“One of the ways that insurance companies are reducing their costs is to deliberately cut out expensive practitioners from their networks,” says Frank Lexa, professor of radiology at Drexel University College of Medicine. “Certainly, some of the best hospitals and doctors in the state are not going to come cheap so they may be cut.”

A Medical Group Management Association survey found that 55.5 percent of physicians in more than 1,000 group practices have an “unfavorable” or “very unfavorable” view of the impact the health exchanges have on them.

“There’s no inherent price that is the value of the physician’s services determined by markets, so I’m sure some physicians are unhappy because they’re not getting as much as they’d like,” says Jost.

But this is the only way that insurance companies can make it work to make the exchange profitable. “Basically what’s going on is we are moving toward a more competitive market, a market that looks more like markets for other products, the way markets are supposed to look where you have your supply and demand curve,” says Jost.

The reimbursement rates might be low, but Mendelson doesn’t think it’s all that bad. The law will aid physicians who treated uncompensated care in the past because most people will have insurance now. “If someone comes in and needs services and you take care of them and get nothing, that’s worse than if they come in and you get something,” says Mendelson.

On the bright side
Despite the problems, most consumers and physicians are pleased with other aspects of the Affordable Care Act. According to the U.S. Department of Health & Human Services, 41.3 million uninsured Americans have new opportunities for health insurance coverage and six out of 10 of them will be able to get it for 100 dollars or less.

Even though the cheaper plans don’t offer as much coverage, the new law requires every insurance plan to cover preventative care. “The new insurance, whether it’s through the state or the federal exchanges are set up to recognize the importance of primary care,” says Blackwelder. “Any primary care preventive services, so things like flu shots, pap smears, colonoscopy, things that are appropriate for sex and age, will have no copay.”

The other benefits are that health plans can no longer limit or deny benefits to children with pre-existing conditions, young adults under 26 are eligible to be covered under their parents health plan, there are caps on annual out-of-pocket medical and drug expenses, and insurers cannot drop your coverage or raise your premiums if you get sick.

Both Lexa and Blackwelder say they are hopeful that the problems with the law will eventually be ironed out.

“Any new system needs some adjustment and we need to continue to find the parts of the act that work great and we need to find the parts that need some attention and address them and that’s what I’m hopeful will start to happen,” says Blackwelder.