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A Tale of Two Obamacares: Which Is Right?

Critics of the Affordable Care Act rollout say its technology problems are overwhelming. Defenders point to the states, where the health insurance marketplaces seem to be working.

Critics of the Affordable Care Act rollout say its technology problems are overwhelming. Defenders point to the states, where the health insurance marketplaces seem to be working. (Karen Bleier/AFP/Getty Images)

This weekend, I read two very different takes on the three-week-old Healthcare.gov health insurance marketplace. One was hopeful; the other decidedly not. Both are worth your time.

Writing for the National Review, Yuval Levin explains that he spoke to several longtime sources at the Centers for Medicare and Medicaid Services as he tried to understand why things have gone so wrong. This is what he discovered:

The reaction of these individuals to what has happened in the last two weeks is the reaction of people who are coming to realize that their expectations and understanding of web development were mistaken. They believed (as I did too, I admit) that whatever technical problems the exchange sites encountered at first could be cleared up quickly and simply once things got going — that the contractors developing the websites could just respond to problems on the fly, as they became apparent. It is now increasingly obvious to them that this is simply not how things work, that building a website like this is a matter of exceedingly complex programming and not “design,” and that the problems that plague the federal exchanges (and some state exchanges) are much more severe and fundamental than anything they imagined possible.

Levin acknowledges that he is an opponent of the Affordable Care Act, but it would be wrong to dismiss his observations and insights.

One key worry is based on the fact that what they’re facing is not a situation where it is impossible to buy coverage but one where it is possible but very difficult to buy coverage. That’s much worse from their point of view, because it means that only highly motivated consumers are getting coverage. People who are highly motivated to get coverage in a community-rated insurance system are very likely to be in bad health. The healthy young man who sees an ad for his state exchange during a baseball game and loads up the site to get coverage — the dream consumer so essential to the design of the exchange system — will not keep trying 25 times over a week if the site is not working.

The second piece, by the New Republic’s Jonathan Cohn, takes a glass half-full approach. While Cohn does not defend the problems plaguing the federal website, which handles enrollment for residents of 36 states, he praises the way the process is working in the remaining states, which have designed their own enrollment websites and do not rely on the feds.

But if these past two weeks appear to reflect poorly on the federal bureaucracy and the Administration managing it, they shouldn’t reflect poorly on health care reform itself — which, after all, has worked in Massachusetts and seems to be working in the states running their own operations. The success of states like Kentucky and New York and Connecticut and California are important for their own sake: By my count, they constitute about a fourth of the national population. But they are also important for what they show about how the law can work, once the technology piece is in place.

Cohn also thinks time is on the side of those signing up. After all, the open enrollment period extends to March 31 (although folks have to sign up by Feb. 15 to avoid a penalty).

The Obama administration leaked figures to the Associated Press on Saturday night that suggest nearly 500,000 people have created accounts in the state and federal exchanges. But the selective release of data — site visitors and applications created — continues to keep under wraps information on those who actually enrolled in a health plan. This data, not visits or applications, will determine the success or failure of this venture. Dan Diamond has the best roundup of applications vs. enrollments around.

Lost in much of the dissection of the technology - is the political climate in which Healthcare.gov had to be built.

Keep in mind - Healthcare.gov wasn’t (originally) expected to be THE exchange for any single state - let alone 36.

Many of the States (for obvious political reasons) waited until the last *possible* moment to announce their decision to punt and have HHS run their exchange.

By having HHS run the State Exchanges - CMS effectively became the lead contractor on a system with 55 separate (and big) technology contractors. Technology challenges aside - CMS was massively underfunded AND understaffed to handle this mission-critical lead role.

State Governors were all well aware of this before casting their decision and all of them are jockeying for their own political advantage. The Governorship is a well worn path to the Presidency itself. About 40% of our Presidents were State Governor’s.

Joseph Fleischman

Oct. 21, 2013, 2:57 p.m.

All good points Dan. Of course, the fact that the websites programming was poorly done sheds no light on the legislation.  The programming will be fixed even it means a complete reconstruction, and there’s plenty of time.  The legislation was smart to allow people 4 1/2 months to sign up before incurring penalties.  And to account for the down-time, Obama can extend the February 15 penalty deadline for this first year.

On top of what Dan says—which is absolutely on-target, by the way—we’re also not talking about a simple website.  This wasn’t going to happen by installing Drupal on a server and pulling the comically-large switch to turn everything on.

We’re talking about traffic numbers on the order of YouTube, which ain’t cheap or easy to handle.  We’re also talking about an environment where a lot of people have motivation (either politically- or privacy-oriented) to feed the system bad information.  There are also glitches in the run-time environment (Oracle’s Java) that were only discovered after launch, and may not be fixed on the servers, yet.  And that’s servers, plural, meaning you need to worry about freshness of data and potential conflicts.

And on top of everything else, frankly, it’s looking like the team that built the system…may not have been very good.  They used DataTables (.net, if anybody wants to investigate), an Open Source package that’s permissible, but only with credit to SpryMedia.  Nothing on the sign-up site acknowledges this.

In itself, that’s not an indictment.  However, when the company you contract with misses something like “make sure the licensing agreement is upheld,” it’s a safe bet the code isn’t exactly pristine.  Imagine buying a used car and the previous owner left their baby seat in the back as you drive off.  How much confidence do you have in their maintenance…?

I wonder how much this all cost.

Oh, and don’t forget that this isn’t an insurance system.  It only directs you to the insurer, who needs to validate the data and take the customer that last mile.  I don’t understand the anger over not having real numbers, when a good percentage of registrants almost certainly called themselves I.P. Freely and Thomas Paine.

Give them time.  They have more than two months to actually insure people.  And as Dan points out, the states running their own exchanges are probably a lot further along.

Brandon Adams

Oct. 21, 2013, 4:25 p.m.

I don’t understand the repeated assertions that this is a complex project.

There are a known number of insurers on the exchange with a more or less known number of permutations of items that need to be submitted to the insurers for an insurance quote. Age, smoker status, location, etc.

Put the onus on the insurers to maintain API endpoints that can deliver quotes back to the exchange 24/7. If they can’t deliver a quote, then there is no guarantee that a user will see their offering in the exchange listing. This is a good incentive on them to craft their systems well – if they fail to provide quotes, they fail to get customers.

To reduce load and make the system more resilient to brief outages on the insurer end, cache the results returned for each permutation (age + location + smoker status + etc.) for some period of time that makes sense. I’m not in this industry, but I imagine that a quote is good for some longish period of time, more than just a few hours.

Everything else is just registration and login bits that are already solved problems.

I imagine this is basically how bankrate.com and other quote aggregator sites work.

If the requirements are vastly more complex than what I’ve described, I’d love to see a more in-depth article on what the requirements are.

This isn’t rocket science. They can make a more complex secure login site for buying insurance. Any fool can set up a Wordpress site to post insurance prices. And yeh, you could do a slightly more complex site in Drupal, pull the comically small switch and we would know how much insurance is going to cost compared to the comically large 2.5 percent tax we’ll have to pay if we don’t buy.

The penalty is not 2.5%, it’s $95.00 or 1%, which ever is larger the first year due, Tuesday, April 15, 2014.

It’s the HIPAA confidentiality, the security against hackers trying to prove there are faults, and the DDOS attackers. Give it time, and go after the attackers, follow the money.

The website didn’t kill anybody yet.

Thanks for the article, thanks for not including the “fire Kathleen Sebelius” solution, and thanks to Dan and John for further helping us understand the complexity in plugging in so many moving variables in order to provide us with a properly working site.

There are a few in this thread who don’t understand (or at least aren’t taking into account) two critical variables:

1) Alignment. In the commercial world - alignment is assumed based on $‘s paid (or received). In the Government IT world - that key assumption doesn’t apply - because the only real gain are the contractors - who are often competitors and working against each other. All the more reason the “lead” contractor is literally “mission critical” (to keep all the subs in line. In this case - the lead was CMS - an underfunded and understaffed Government bureaucracy. CMS isn’t like a startup (where everyone’s shoulder is to the same wheel for the benefit of all), and healthcare.gov isn’t their only IT project!

2) Three added complexities. 1) Security (HIPAA tight). 2) Verification - not just against fraudulent use - but for Federally applied TAX subsidies. 3) A wall clock that never moved (October 1) with an unknown number of States committed to Healthcare.gov (until the last possible minute - for obvious political reasons).

All of which was against a huge headwind of political forces that actively want/wanted this all to fail - spectacularly!

am i the only former civil servant snickering at this fabulous contracting out success story? the private sector does it better and cheaper, right?

Mr. SHAHISLAM

Oct. 22, 2013, 5:06 a.m.

Never rule out the secret involvement of a magic-black-wand via easily possible furtive actions of an old invisible or elusive Party in North-America from the other side of the Atlantic for additional but subtle sabotaging “electronic tools of Mischiefs” -factors, very cleverly done (and more can be added anytime) by remote digital means that are ‘Protected by outdated & outlandish laws’ (e.g. Users of all laptops connected to the Internet can be disturbed with jamming signals or identified or even tracked down by the apparently inactive-looking, attached tiny but alive cameras).

I’m writing these from direct experiences. In Canada, the above mentioned secret Party’s operation is continuing unchallenged for the last half of a decade at least.
Example: If a beautiful 20 year old girl sends an e-mail to someone and a ‘guy with a royal link’ doesn’t approve or like that, the sent e-mail will vanish from the system for forever.
And since further mischievous manipulations are happening so strongly that traces of digital signatures of undelivered e-mails can disappear from the local servers or system devices too without any explanations from anyone in the Canadian Corporation levels, although unlike the ones of USA. 

(Digital evidences have been preserved personally but none in the Canadian Government Operation is powerful enough to address accordingly these issues of electronic mischiefs by ‘faceless current actual business bosses’ of Today’s Internet Technology.)

James M. Fitzsimmons

Oct. 22, 2013, 8:31 a.m.

The New Republic and other ideological supporters of Obama and therefore Obamacare have observed that the system works well where states run the exchanges. That might provide a clue as to how to proceed not only on healthcare but other important issues as well. Shun grandiosity and partisan exercises of power and encourage incremental changes consistent with appropriate field testing and consideration of unintended consequences.

Steven Sagala

Oct. 22, 2013, 9:47 a.m.

Somebody explain to me how the current administration expects to expand its support base. Look at the photo. I voted for Obama, but he wouldn’t vote for me - I’m an older hetero white guy with a mortgage and few employment prospects. The focus on twenty-something immigrant females doesn’t win my support.

Tom, good start on a list of requirements—HIPAA alone is something like two hundred pages of requirements (or was, ten years ago), for those who aren’t familiar with it.  On top of that, the scale is also a huge deal; the term used through much of the Internet is the “Slashdot Effect.”

Steven, there has yet to be a case in history where giving another group a helping hand has diminished the established group.  We’ve allowed immigrants into this country.  We’ve abolished slavery.  We gave non-whites citizenship.  We gave women the right to vote.  In a lot of the country, we’re letting gay people get married.

At every step of the way, people (largely older white men like ourselves) railed against it, swearing that this development made their lives inherently worse.  It’s time to give up on that rhetoric, because we’re far worse off for tax breaks to the wealthy, anti-laundering laws that only seem to “catch” poor people, and ubiquitous surveillance.

James, the state-run exchanges (a) aren’t better run because the states are running them, but rather because they don’t have half a million people hammering the site per day and (b) were what the ACA required, but the anti-ACA states refused to do it, leaving the Federal government to pick up the slack.  As much as I don’t like the law, blaming it for states refusing to put up their own exchange is a little extreme.

Adding bodies and money to this won’t fix it.  That’s not how these things work.. Adding a time delay to correctly fix it *may* work, but only if the underlying incorrect assumptions are examined.  That’s a big ‘if’ with this administration..

Sorry for the unintentional misinformation above about the penalty, the penalty is not 2.5%, at least not the first year, it’s $95.00 or 1%, which ever is larger the first year, the penalty (tax) is due, Tuesday, April 15, 2015, that’s twenty fifteen, it does grow from there, when it gets cheaper to buy insurance rather than pay the penalty then it’s time to join. Of course, those of you who don’t join expect the rest of us to pick up the tab if you get sick or injured and can’t pay, by going to the emergence room without any ability to pay yet seeking services sticking the hospital with the bill, and this will continue in the states that have not expand their Medicaid services under Obamacare.

I’ve been reading through HIPAA and I don’t actually think that the healthcare.gov site qualifies as a covered entity.

There are three types of entities that are covered—health care providers, insurers, and clearinghouse. As far as I can tell, a clearinghouse is just a medical transcription and data entry outfit. All the definitions talk about converting nonstandard data into a standard format.

Additionally, the information collected isn’t particularly related to a patient’s health history.

A lot of blaming the victim amongst these comments.  Do not tell me I HAVE to purchase a private product approved by a political party with whom I do not agree and then blame ME (or my State which may more accurately reflect my principles) for not doing everything I can to get the mechanism designed to make this undesired purchase to work.  “For obvious political reason” sounds quite belittling of the concepts of both democracy and republicanism.  Robert Allen

This is all beside the point:  the Health Insurance Exchange will not work because the market assumptions and economics of the scheme are critically flawed.  The best we can say about the entire Obamacare hype is that we will hopefully realize we need a single payer system before the health care insurance system implodes.

I have spent time at the NY exchange. It is not good. At first there were access issues. Now there are navigation issues but you can get it and find your way around (as annoying as it is). But the real problem (and I imagine this is true in other states as well) is not with the technology but with the content. The plans are not cheap. The information is limited. There are many, at different price points, that offer exactly the same benefits based on the criteria listed. The concept of the marketplace requires complete and accurate information about the products. Gold, silver, bronze and platinum doesn’t mean anything. The details matter and they are scarce. I am tired of all the discussion about the technological issues. It’s the ACA that is the problem.

Seth, quit your whinning, if you don’t want insurance don’t buy it and pay the tax. You apparently don’t want to do any work, well, that’s the lazy way out, if it’s anything like Medicare, and I’m not saying that it is because I don’t know, then the different plans, by precious metal designation, provide the same coverages from each insure represented, it’s the prices that vary by insurer for the same plan, this is the same for Medicare, though Medicare uses different designations, do your work if you want the cheapest plan, if not pay the tax, in either event quit whinning.

This article is part of an ongoing investigation:
Obamacare and You

Obamacare and You

The Rollout of the Affordable Care Act has been marred by glitches and political opposition.

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