But if the stick is small, the carrot can be large. A family of four earning as much as four times the poverty rate, or $94,200, would still be eligible for some federal help. The target is for households to pay between 2.5 percent and 9 percent of their income on premiums. For example, a single parent with two children who earns $40,000 a year might pay 6 percent of his or her income, or about $200 a month — while federal credits cover most of the cost.
"We should make a good dent this year in the uninsured," Madrak said. But he added, "This is really a two- or three-year implementation."
No one thinks Access Health CT will sign up anything close to the estimated 344,000 Connecticut residents who don't have insurance this year. The goal is less than half that, including 100,000 in private plans, some individual, some through small business plans; and 30,000 new Medicaid enrollees.
That seems modest, considering that Medicaid eligibility is expanding dramatically for low-income adults with no children. Gov. Dannel P. Malloy proposed to tighten eligibility for working poor parents, sending them to subsidized private plans on the exchange. That would have saved state taxpayers, but advocates won that battle, and the budget for the coming year leaves parents at up to 185 percent of the federal poverty rate on Medicaid.
The goal also seems modest considering that companies with at least 50 employees working at least 30 hours a week must offer health insurance. But, Counihan said, based on federal estimates of likely enrollment, "I think it's an aggressive goal."
Aggressive or modest, Connecticut has some advantages. "We're a small state — we know where the uninsured are," Madrak said.
And, as one of just 14 states running their own exchanges — the rest are relying on the federal government to do the job — Connecticut was able to tailor its own program and received far more money to make it happen.
Behind The Scenes
As the core of health care reform, the exchange system is, by all accounts, a work in progress.
"There are so many dynamics that are happening at the same time, it's going to take a few years for carriers to price plans, come into the market," said Sam Gibbs, president of the government systems unit at the brokerage eHealth Inc., the largest online private exchange.
As the firm that pioneered online exchanges and has signed up 3 million people, about 40 percent of whom had been uninsured, eHealth is trying to take an active role in Obamacare. Private brokers, who receive commissions from insurers, must charge the same rates and must offer every plan on a state exchange, or they can't enroll people.
Private brokers will be especially helpful in working with small businesses, Counihan and Madrak said. Meanwhile, eHealth is trying to take it a step further by lobbying for the right to sign up clients directly on its own website.
"Just because Connecticut has a website and a call center, that doesn't mean people are going to go there," Gibbs said.
"We are very pro-broker," Counihan said. "We view them as trusted advisers."
In another issue, advocacy groups such as the Universal Health Care Foundation of Connecticut lobbied for a bill in the recent legislative session that would have required Access Health CT to actively negotiate with insurers to lower prices. The bill passed in the Senate but died in the House.
Counihan, a veteran of the Massachusetts reform on which the exchange system was modeled, says the debate over active negotiating is based on a misunderstanding. "There is not one state negotiating," he said. At a recent conference of state exchange heads, he asked for a show of hands of how many actively negotiate.
"Nobody raised their hands," he said. "Actuaries don't negotiate, they review."
Access Health CT has hired a consultant to review the prices offered by insurers, and the firm is due to report back on June 26.
The state's network of 14 community health centers, some with more than one location, has a total of 80,000 uninsured people as patients — obviously a key avenue for enrollment. But because the health centers receive money to enroll people in Medicaid, they were not allowed to seek grants to assist Obamacare enrollees in the exchange.
"We were disappointed when we were excluded from the assister applications," said Deb Polun, the government affairs and media relations director for the Community Health Center Association of Connecticut.