How health care law is playing out in 3 key states

Eight weeks into the Affordable Care Act's rocky rollout, California, Texas and West Virginia provide a window into the setbacks and successes of the controversial law.

How well is the Affordable Care Act working?

Depends on where you live.

In August, USA TODAY reporters chronicled how residents of three states - California, Texas and West Virginia - were preparing for the Oct. 1 debut of the health care program, President Obama's signature legislative achievement. Now, eight weeks into its rocky rollout, that trio of states provides a window into the setbacks and successes of the controversial law:

* In California, which is running the biggest of the state-run exchanges, its website launched with far fewer difficulties than the problem-plagued federal HealthCare.gov and saw enrollment ramp up in November. In its first month, over 35,000 residents enrolled, accounting for about a third of those who signed up nationwide.

* In Texas, home to the highest rate of uninsured residents in the nation and a place where state officials opposed the law at every step, the program got off to a bumpy start. Texas, like many other states, did not create its own exchange, so residents are dependent on the balky HealthCare.gov. In the first month, 2,991 residents signed up for a plan through the system, according to federal figures released last week.

* In West Virginia, only 174 people enrolled, according to the Department of Health and Human Services numbers. But state officials have had success on their own, getting their poorest residents to enroll directly in its expanded version of Medicaid, the federal program that provides health care for low-income people. About 54,700 people have enrolled since October, cutting the state's uninsured population by about 25%.

BOOMING CALIFORNIA

SAN FRANCISCO - After weeks of pondering and hours of research, Ron Magnaghi still doesn't know what his health coverage will be.

The self-employed tool salesman was told he'd lose his coverage in January as part of the transition to the Affordable Care Act (ACA). Now, it's not even clear that will happen, given Obama's push to avoid such cancellations.

'It's getting down to the wire,' says the 60-year-old Magnaghi, a resident of Concord, Calif. 'I'd like to keep what I have ... until all this is worked out.'

Magnaghi's other option is more expensive coverage he could purchase via California's state health exchange, he says. Like others, he has until Dec. 15 to sign up for coverage that would begin Jan. 1.

Through mid-November, 59,000 Californians had enrolled in Covered California. Nearly 70% of those surveyed late in October said the application process was easy to complete, the state says.

California's performance is good, but it's 'too early to declare either a victory or a failure,' says Marian Mulkey of the California HealthCare Foundation.

Almost 1 million Californians face policy cancellations in the transition to the new law. If those cancellations are reversed, insurers say, Covered California is likely to get stuck with an older, sicker population than had been expected, because individual policyholders tend to be healthier.

If they stay out, 'we don't have a balanced pool,' says Patrick Johnston, CEO of the California Association of Health Plans. That, he adds, could mean that Covered California premiums will be inadequate for insurers.

He says California's exchange is working well, so extensions for some policyholders aren't needed. About one-third of the 900,000 residents facing cancellation may be eligible for federal subsidies under the new health care law.

After Obama last week asked insurers to let customers whose policies had been canceled keep them for a year, California Insurance Commissioner Dave Jones followed suit. Two large insurers had earlier agreed to temporary extensions for some consumers.

The board of Covered California is expected to take up the issue Thursday. 'California could be a leading indicator of how the exchanges will shake out,' says Steve Wojcik, policy expert at the National Business Group on Health. Depending on timing, Mulkey says, a change may require action by the state Legislature. California, 13 other states and the District of Columbia have created their own exchanges.

While the canceled policies have grabbed headlines, she says, the bigger challenge for California remains getting hundreds of thousands of people enrolled, including the younger, healthier population. 'That'll be the make-or-break issue,' Mulkey says.

TEXAS' LACKLUSTER RESPONSE

AUSTIN - Led by Gov. Rick Perry, Texas Republican leaders have criticized the exchanges and made it difficult for navigators - people dedicated to helping residents with the process - do their work, says David Warner, professor of health and social policy at the University of Texas-Austin, who is studying how the new law is implemented here.

Technical glitches, cautious residents and the state's hostility have contributed to the lackluster response, Warner says. And, he adds, many residents are waiting until next year, when the mandate becomes law, to sign up for a plan. After Jan. 1, people are required to purchase insurance or pay a fine.

'Once it's up and running, you're going to have a lot of people signed up,' he says. 'There was a lot of interest. But even those who got through weren't ready to sign up yet.'

Dealing with the online marketplace was a challenge, says Elizabeth Colvin, a director with Foundation Communities, an Austin-based non-profit that has helped residents cope with the new initiative. Of the 1,600 people the center has counseled, only around 20 have signed up for a plan, though many more are still going through the process, she says.

There are around 80 plans to choose from in Central Texas, giving residents a lot to consider, Colvin says. Once the website is fixed - the Obama administration has vowed that will happen by the end of the month - she says she expects many more people to sign up. 'There are people who were frustrated when their application got stuck, but, overall, people have been patient with the process,' she says. 'The people who are coming in are coming in because they want health insurance.'

Among those needing insurance was Will Love, 27, a self-employed Austin video producer. The first time Love tried to get into the system, it booted him out. The second time, the screen froze.

He's done searching the portal - for now. An insurance broker has contacted him and is researching other options. But Love hasn't given up on the ACA, he says. 'I'll just wait until they get the bugs out.'

MEDICAID SOARS IN W.VA.

Perry Bryant, executive director of West Virginians for Affordable Health Care, says the federal government's health care website 'continues to be a huge problem' in West Virginia, as elsewhere. 'Our numbers are as bad as anybody else's,' he says.

Federal figures released last week showed that fewer than half of the more than 7,000 West Virginians who applied for health coverage on the website found that they were eligible for Medicaid coverage.

The Department of Health and Human Services last week said 7,096 people applied for coverage from Oct. 1 to Nov. 2, but only about 3,100 were deemed eligible, either through Medicaid or the Children's Health Insurance Program. About 3,400 were eligible for private coverage, HHS said.

So state officials have executed an end run, Bryant says: The state Department of Health and Human Resources (DHHR) last month mailed letters to about 118,000 people the agency had identified as eligible for health benefits. The department employees then called each recipient personally to encourage them to enroll in coverage through West Virginia's Medicaid program, which was expanded under the ACA.

DHHR workers are sending second letters to those who didn't respond to the first, he says. 'In all this doom and gloom, West Virginia is a bright, shiny star,' Bryant says. 'They're doing everything they can to get everybody enrolled, which is just tremendous.'

For Catherine Selen, January can't come fast enough.

Catherine Selen, a diabetic who is hoping to qualify again for Medicaid, reads to her daughter, Camillia, while son Isaias does homework at their Princeton, W.Va., home on Aug. 1, 2013.(Photo: Steve Brightwell for USA TODAY)

The 32-year-old waitress has spent most of the past year in a harrowing medical limbo. She had been on Medicaid. But when her hours increased at her job at the Cracker Barrel restaurant near her Princeton, W.Va., home, she discovered she was making too much to qualify for Medicaid and not enough to cover the $500 she needs each month for medicine to treat her type 1 diabetes.

Selen could get insurance through Cracker Barrel, but she says it's unaffordable - it would cost $45 per week just to cover her, not her husband or two young children.

An unreliable supply of insulin has landed Selen in the hospital twice since last spring - the most recent time last week.

She'd been trying to stretch her insulin supply, but after 2½ days without it, she knew she was headed for diabetic shock.

'It was the worst I've ever been,' she says. Selen called a relative to take her to the hospital, where she spent three days, the first two in intensive care.

Like many other Americans hoping to sign up for care through the new law, Selen struggled with HealthCare.gov last month, without success. She called a toll-free number, but that didn't work, either. 'I was just always on hold, forever and ever and ever,' she says.

But thanks to West Virginia's expansion of Medicaid, Selen will be eligible once again come Jan. 1. During her latest hospital stay, a health care navigator came to her hospital bed and helped her fill out an old-school paper application.

In the meantime, her church has offered to cover the costs of her medicine. 'I'll stretch it out and see how it goes,' she says. 'Healthwise, I don't know how much longer I can go on like this. Psychologically, it's just too much.'

She adds, 'I'm just hoping and praying that things come through in January.'

Schmit reported from San Francisco, Jervis from Austin and Toppo from McLean, Va. Contributing: HEALTHYINSURANCENEWS.BLOGSPOT.COM.