FORT LAUDERDALE, Fla. (AP) -- Counselors helping people use the federal government's online health exchange are giving mixed reviews to the updated site, with some zipping through the application process while others are facing the same old sputters and even crashes.
The Obama administration had promised a vastly improved shopping experience on healthcare.gov by the end of November, and Monday was the first business day since the date passed.
Brokers and online assisters in Utah say three of every four people successfully signed up for health coverage on the online within an hour of logging in. A state official overseeing North Dakota's navigators said he had noticed improvements in the site, as did organizations helping people sign up in parts of Alabama and Wisconsin.
But staffers at an organization in South Florida and a hospital group with locations in Iowa and Illinois said they have seen no major improvements from the federal website, which 36 states are relying on.
Amanda Crowell, director of revenue cycle for UnityPoint Health-Trinity, which has four hospitals in Iowa and Illinois, said the organization's 15 enrollment counselors did not see a marked improvement on the site.
"We had very high hopes for today, but those hopes were very much quashed," said Crowell. She said out of a dozen attempts online only one person was able to get to the point of plan selection, though the person decided to wait.
The site appeared to generally run smoothly early Monday morning before glitches began slowing people down. By 10 a.m., federal health officials deployed a new queue system that stalls new visitors on a waiting page so that those further along in the process can finish their application with fewer problems.
About 750,000 had visited the site by Monday night - about double the traffic for a typical Monday, according to figures from the Centers for Medicare and Medicaid Services.
Roberta Vann, a certified application counselor at the Hamilton Health Center, in Harrisburg, Pennsylvania, said the site worked well for her Monday morning but she became frustrated later when the site went down.
"You can get to a point, but it does not allow you to select any plans, you can't get eligibility (information). It stops there," she said. "The thought of it working as well as it was didn't last long."
In South Florida, John Foley and his team of navigators were only able to successfully enroll one of a handful of return applicants who came to their office before glitches started, including wonky estimates for subsidy eligibility. He worried about how they would fare with the roughly 50 other appointments scheduled later in the week.
Although frustrated, most were not deterred, he said.
"These are people that have policies going away, who have health problems. These are people that are going to be very persistent," said Foley, an attorney and certified counselor for Legal Aid Society of Palm Beach County.
Despite the Obama administration's team of technicians working around the clock, it's not clear if the site will be able to handle the surge of applicants expected by the Dec. 23 deadline to enroll for coverage starting at the beginning of the year. Many navigators also say they're concerned the bad publicity plaguing the troubled website will prevent people from giving the system another try.
"There's a trust level that we feel like we broke with them. We told them we were here to help them and we can't help them," said Valerie Spencer, an enrollment counselor at Sarah Bush Lincoln Center, a small regional hospital in the central Illinois city of Mattoon.
Federal health officials acknowledged the website is still a work in progress. They've also acknowledged the importance of fixing back-end problems as insurers struggle to process applications because of incomplete or inaccurate data. Even when consumers think they've gone through the whole process, their information may not get to the insurer without problems.
"We do know that things are not perfect with the site. We will continue to make improvements and upgrades," said Julie Bataille, communications director for the Centers for Medicare and Medicaid Services.
In less than an hour Monday, Starla Redmon, 58, of Paris, Ill., was able to successfully get into a health plan with help from an enrollment counselor. Redmon, who juggles two part-time jobs and has been uninsured for four years, said she was surprised the website worked so well after hearing reports about its problems.
"Everything she typed in, it went through," said Redmon, who chose a bronze plan and will pay about $75 a month after a tax credit. "It was the cheapest plan I could go with."
Contributing to this report were Associated Press writers Carla K. Johnson in Chicago; Chris Tomlinson in Austin, Texas; Catherine Lucey in Des Moines, Iowa; Peter Jackson in Harrisburg, Pa.; Scott Bauer in Madison, Wis.; James MacPherson in Bismarck, N.D.; Brady McCombs in Salt Lake City; and Phillip Rawls in Montgomery, Ala.
Follow Kelli Kennedy on Twitter at twitter.com/kkennedyAP.
BOSTON (AP) -- In the five years since the "Octomom" case, big multiple births have gone way down but the twin rate has barely budged. Now fertility experts are pushing a new goal: One.
A growing number of couples are attempting pregnancy with just a single embryo, helped by new ways to pick the ones most likely to succeed. New guidelines urge doctors to stress this approach.
Twins aren't always twice as nice; they have much higher risks of prematurity and serious health problems. Nearly half of all babies born with advanced fertility help are multiple births, new federal numbers show.
Abigail and Ken Ernst of Oldwick, N.J., used the one-embryo approach to conceive Lucy, a daughter born in September. It "just seemed the most normal, the most natural way" to conceive and avoid a high-risk twin pregnancy, the new mom said.
Not all couples feel that way, though. Some can only afford one try with in vitro fertilization, or IVF, so they insist that at least two embryos be used to boost their odds, and view twins as two for the price of one.
Many patients "are telling their physicians `I want twins,'" said Barbara Collura, president of Resolve, a support and advocacy group. "We as a society think twins are healthy and always come out great. There's very little reality" about the increased medical risks for babies and moms, she said.
The 2009 case of a California woman who had octuplets using IVF focused attention on the issue of big multiple births, and the numbers have dropped, except for twins.
The Centers for Disease Control and Prevention's most recent numbers show that 46 percent of IVF babies are multiples- mostly twins -and 37 percent are born premature. By comparison, only 3 percent of babies born without fertility help are twins and about 12 percent are preterm.
It's mostly an American problem - some European countries that pay for fertility treatments require using one embryo at a time.
The American Society for Reproductive Medicine is trying to make it the norm in the U.S., too. Its guidelines, updated earlier this year, say that for women with reasonable medical odds of success, those under 35 should be offered single embryo transfer and no more than two at a time. The number rises with age, to two or three embryos for women up to 40, since older women have more trouble conceiving.
To add heft to the advice, the guidelines say women should be counseled on the risks of multiple births and embryo transfers and that this discussion should be noted in their medical records.
"In 2014, our goal is really to minimize twins," said Dr. Alan Copperman, medical director of Reproductive Medicine Associates of New York, a Manhattan fertility clinic. "This year I'm talking about two versus one. Several years ago I was talking about three versus two" embryos.
The one-at-a-time idea is catching on. Only 4 percent of women under 35 used single embryos in 2007 but nearly 12 percent did in 2011. It's less common among older women, who account for fewer IVF pregnancies, but it is gaining among them, too.
"Patients don't really want multiples. What they want is high delivery rates," said Dr. Richard T. Scott Jr., scientific director for Reproductive Medicine Associates of New Jersey, which has seven clinics in that state.
Better ways to screen embryos can make success rates for single embryos nearly as good as when two or more are used, he contends. The new techniques include maturing the embryos a few days longer. That improves viability and allows cells to be sampled for chromosome screening. Embryos can be frozen to allow test results to come back and more precisely time the transfer to the womb.
Taking these steps with single embryos results in fewer miscarriages and tubal pregnancies, healthier babies with fewer genetic defects and lower hospital bills from birth complications, many fertility specialists say.
Multiple studies back this up. In May, doctors from the New Jersey clinics did the kind of research considered a gold standard. They randomly assigned 175 women to have either a single embryo transferred after chromosome screening or two embryos with no screening, as is done in most IVF attempts now. Delivery rates were roughly equivalent - 61 percent with single embryos and 65 percent with doubles.
More than half of the double transfers produced twins but none of the single ones did. Babies from double transfers were more likely to be premature; more than one-third spent time in a neonatal intensive care unit versus 8 percent of the others.
Chromosome testing and freezing embryos adds about $4,000 to the roughly $14,000 cost for IVF, "but the pregnancy rates go up dramatically," and that saves money because fewer IVF attempts are needed, Scott said. Using two or more embryos carries a much higher risk of twins and much higher rates of cerebral palsy and other disorders.
After explaining the risks, "this is the easiest thing in the world to convince patients to do," Scott said of screening and using single embryos.
But Dr. Fady Sharara of the Virginia Center for Reproductive Medicine in Reston, Va., found otherwise. For a study, he offered 48 couples free medications and embryo freezing if they would agree to transfer one at a time instead of two. Eighteen couples refused, including one-quarter of those whose insurance was covering the treatment. Some who refused said they viewed twins as two for the price of one.
"I tell my patients twins are not twice the fun," Shahara said. "One is hard enough. Two at a time is a killer for some people. Some marriages don't survive this."
The New Jersey couple, who had a daughter using a single embryo, has eight more frozen embryos. When it's time to try again, Abigail Ernst said, "we would do the same thing" and use one at a time.
CDC info on IVF: HTTP://WWW.CDC.GOV/ART/
Infertility info: HTTP://WWW.SART.ORG and HTTP://WWW.ASRM.ORG
Follow Marilynn Marchione on Twitter at HTTP://TWITTER.COM/MMARCHIONEAP
SAN FRANCISCO (AP) -- The St. Louis Rams arrived in San Francisco ready to grab some momentum for the December push with a third straight victory.
They even caught a break when 49ers left tackle Joe Staley went down with a knee injury early, providing a possible opening to get more pressure on quarterback Colin Kaepernick.
Yet Kaepernick shined with a healthy receiving corps at last as Michael Crabtree made his season debut, and San Francisco's stingy defense flustered Kellen Clemens all day in the Rams' 23-13 loss Sunday.
"We went into the ballgame knowing that it was going to be a slug-out kind of physical game up front," coach Jeff Fisher said. "We would have liked to carry on what we've been doing over the last couple of weeks, but for some reason we didn't match up well against these guys."
Crabtree's return opened up the field all the more for Anquan Boldin - not to mention Vernon Davis and his high-hurdle show.
Boldin caught nine passes from Kaepernick, Crabtree made his long-awaited debut six months after Achilles tendon surgery, and the 49ers pressured the Rams defense from every angle.
On the other side of the ball, St. Louis managed only 73 total yards in the first half and regularly thwarted drives with its own mistakes.
Clemens went 19 of 37 for 218 yards with a late TD pass in a dismal afternoon by the Rams (5-7), who were trying for their first three-game winning streak of the season.
"There were some plays out there that we had opportunities to make which would have gotten us into a little bit of a better rhythm offensively," Clemens said. "We didn't make them."
The Rams committed 11 penalties for 105 yards. They settled for a 43-yard field goal by Greg Zuerlein just before halftime in their best drive to that point, then Zuerlein kicked a 34-yarder in the third quarter. St. Louis scored a late touchdown against the second-team defense.
Kaepernick went 19 of 28 for 275 yards and Frank Gore ran for a 3-yard touchdown as the reigning NFC champion Niners (8-4) boosted their position in the playoff picture. Crabtree had a 60-yard catch, while Vernon Davis hurdled into the end zone on a 17-yard touchdown reception.
With Hall of Famer Jerry Rice in the house, Boldin had six receptions in the first half on the way to his second-most productive game of the year behind his 13-catch performance in the season opener against Green Bay.
Crabtree, San Francisco's leading wide receiver during last season's Super Bowl run, had two catches just more than six months after he tore his right Achilles tendon and had surgery. Just having him on the field kept the St. Louis defense from focusing all its attention on Boldin and Davis.
"He's a big physical receiver, and his presence out there is definitely felt," linebacker James Laurinaitis said of Crabtree. "You have to pay attention to him. Whenever you have big receivers, physical guys like Boldin and Crabtree, and you have to worry about the speed of Vernon Davis ... they have a lot of weapons."
Davis displayed his athleticism with a new signature move, and did so not once but twice: a high hurdle over defenders. He led with his right foot while leaping over safety Rodney McLeod in the first half, then again to reach the end zone on his team-leading 10th touchdown catch. Davis also was tackled by T.J. McDonald with a prolonged, painful grab to his crotch. That was a first in his career.
"I was hurting," Davis said.
A year after the teams left Candlestick with a 24-24 tie, the 49ers methodically took care that it didn't happen again. They made it consecutive commanding victories in a short week following a 27-6 win at Washington on Monday night that snapped a two-game skid.
While Kaepernick was sacked four times, Robert Quinn and the opportunistic Rams defense failed to make the game-changing plays it had the past two weeks - even when Staley was lost to a right knee injury early in the game. The St. Louis defensive line had scored touchdowns in each of the previous two games.
The 49ers held the Rams in check before the second-team defense surrendered Brian Quick's 3-yard touchdown catch with 18 seconds remaining.
St. Louis lost left tackle Jake Long late in the third quarter to a concussion after he collided into running back Zac Stacy, who played after dealing with concussion-like symptoms following a win against the Bears.
"He's going to have to undergo the concussion protocol," Fisher said. "He's already started it."
NOTES: Stacy had 72 yards on 19 carries. ... Rams C Scott Wells suffered an ankle injury.