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Belmont Club

The Plight of the Navigator

October 1st, 2013 - 8:43 pm

The rollout of Obamacare — the proximate cause of the of “shutdown” — has become a headline in itself. The touted health care exchanges were experiencing highly publicized difficulties all over the country. A rollout of this size was never going to be easy in the best of circumstances, but in this case many of the problems experienced were the direct consequence of the length of the law and its attendant regulatory complexity.

These regulations are often called “business rules,” and they have to be implemented in software. The Obamacare ruleset is now reportedly eight times the length of the Bible and still growing. This has had unavoidable results. How the IT personnel at Oregon approached the problem, as described by InformationWeek, gives a sense of the hurdle. Chris Murphy writes:

To understand the challenge, I spoke with Aaron Karjala, CIO of Cover Oregon, which runs Oregon’s health insurance marketplace, and Carolyn Lawson, CIO of Oregon Health Authority and Department of Human Services, which started the exchange project before state lawmakers created Cover Oregon. Here’s a look inside some of the challenges facing Oregon’s more than two-year effort.

Presenting a product — an insurance policy — isn’t the hard part. The hard part is figuring out which federal and state programs and tax credits a person or family is eligible for. Getting that part right takes creating an extremely complex rules engine.

About 1,700 individual rules affect eligibility for health insurance subsidies in Oregon. Children might qualify under different rules from their parents, or half-siblings might have different eligibility based on their parents’ income. In Oregon, writing the eligibility rules engine took 12 people nine months. Confirming eligibility requires integration with multiple outside data sources, such as confirming income and citizenship with federal sources, and that process is what separates it from ecommerce sites.

“The policies and rules came to us a little at a time,” Karjala says. “It was constantly emerging requirements.” For example, the Federal hub that state exchanges connect to for verifying income and citizenship was completed this summer. That timing helps explain why exchanges are doing so much testing down to the deadline.

The solution, says Lawson, was “ruthless incrementalism. We had to build in an agile fashion and build what we know, and then put the pieces together like Legos.”

And that’s just Oregon. It was a difficult, possibly insuperable job under the best of circumstances, but the problem was compounded by the incompetence described by Scott Gottlieb and Michael Astrue in the Wall Street Journal:

There are two key technological flaws in ObamaCare. First is the “hub” — the software to link servers at the Treasury Department, the Internal Revenue Service, Homeland Security and state agencies to verify the income and health-insurance status of enrollees and ensure that they are eligible for subsidies. The other flaw is the “portal” — the federally run IT platform that is supposed to let consumers compare health plans and select one that best suits their needs.

In planning ObamaCare’s IT infrastructure, the Centers for Medicare and Medicaid Services (CMS) dawdled for more than a year under Administrator Donald Berwick until Marilyn Tavenner took over in December 2011. Even then the agency was slow to outsource key contracts and turned to what insiders say were not top-quality programmers. CMS did not sign a contract for a backstop system to process paper verifications and do paper verifications of online applications until July.

The Health and Human Services Department did not begin testing the chief pieces of this IT system until August. The testing found that states couldn’t consistently link to the federal portal (a problem that persists in some states), and that the hub couldn’t reliably verify if a person is eligible for a subsidy, or accurately calculate how much the applicant is eligible to receive.

But Gottlieb and Astrue mention the biggest problem last — the consequence of the architecture of the system:

The biggest risk involves data security. The Obama administration created unnecessary opportunities for fraud with the White House’s pork-minded insistence on funding favored community groups to employ “navigators” to solicit applicants and help them input their personal information, such as income and Social Security numbers.

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Top Rated Comments   
Deja Vu all over again.

In 1993-1994, I was a hired as a consultant to a deliberately unidentified major blue-state Medicare/Medicaid rewrite. They spent about 9 months of a 1 year schedule designing and redesigning the data model. There were about 80 data modelers, about six or eight programmers, one DBA, and the rest (rounding out the team to about 100) subject matter experts. They designed the office with the programmer-analysts in open desks pushed together in the middle, and the managers and SME's in outer desks around the programmers. The data modelers were out in conference rooms interviewing in teams.

This was supposed to be an "iterative" process, i.e. design... redesign.... redesign until the model was perfect, then had the specifications to the programmers to "generate" the code using a CASE tool from their brilliant, perfect design, and then a week or two at the end for testing. The programmers were rebuffed whenever we pressed for details and inputs to the design. We were told to sit in the middle of the office, and study the vendor's CASE materials - for months. We were allowed to eventually sit in on some of the JAD (joint application design) sessions as long as we agreed to keep silent.

Richard, and any other experienced programmer out there, is probably chuckling. The project was doomed to failure from the start. By the 10th month, they had fired the data modelers, handed the results to the programmers, and asked us to make something out of the mess. We THEN began the iterative process of actually interviewing SME's and end users, presenting prototype software, defining the business rules, data flows, and data transformations necessary to bring the ERD (entity relationship diagram, i.e. a mapping of information of a system and relationships, the result of data modeling) to life.

It was at that point that we started making real progress. This was not my first government project; unfortunately, it was one of many and quite typical. The first thing I learned when writing and implementing business rules for government is that many situations will occur where they are illogical. I mean "illogical" in a classic sense, not as a pejorative statement, in that there would be rules that say "If A+ B, then C", and later, If "A-B, then C", and then, "If A+B+C, then C, and so forth. Because LEGISLATORS and their staffs are not wizards of logic, and because laws are passed in conflict with many preexisting laws, it can be impossible to make sense of when the law actually mandates, in terms of business rules. Programmers cannot program an action, unless the business rules are clear AND Boolean.

In any case, I left the project after the first year, but kept tabs with some on the team that remained. I believe that they implemented key portions of the system after 2 or 3 years, but it was probably 25% of the original target.

So, I knew (as any decent developer would) that implementing Obamacare rules into an IT system would be challenging, if not impossible. I've heard from some folks looking for help, and I believe at least some of the states are using a Service Orientated Architecture (SOA) for the rules engine, connecting via a SOA interface to the Federal rules engine. I just spent 2 years tuning a system for a major medical insurer, which worked out well, but one of the key choke points were insurance rules verification to external (and internal) entities. That system was a massive, four-plus year project and which was relatively successful. However, it's but a tick compared to the Elephant called Obamacare.

One more thing: The Medicare/Medicaid rules were relatively consistent, if not uniform, across the fifty US states. I used to work for a guy named Ross Perot very early in my career, and I learned at that time that he grew Electronic Data Systems (EDS) into the giant it later became by getting the first Medicare/Medicaid contract with the first state, and then "reselling" the same software to the other 49 states, slightly modified as a new instance of the software, reaping 49x the rewards. Certainly EDS put a lot of work into each implementation and incurred huge risks as they were "fix price, fixed date" deliverables. However, it speaks to the uniformity of the rules that this was indeed possible back then. The fact that they cannot do this now, speaks volumes about the ACA implementation across the fifty disorganized states of America. It looks like there's little if any synergy between states.

And of course, the specifications have been changing throughout the development of the Federal rules engines, as well as the individual states participating. The result will be "jello", not stability.

Good luck with that, Mr. President.
28 weeks ago
28 weeks ago Link To Comment
Great Minds Think Alike.
On the last thread I posted:
"The Democrats want Obamacare to fail because they want a single payer British NHS system. They want a government shutdown because they want to replay the assault on Gingrich of 1996. The contents of the Bill or the quality of the web engine were always unimportant.

One thing meant to survive are the taxes, which will be eternal. The other important part of the plan is the jobs for the Navigators. Acorn is back big time. This is more money for them by the most expensive and complex route possible."

Anyone registered with the VA is exempt from Obamacare, that is they are already compliant. If America just instituted universal military conscription and registered every citizen and permanent Resident with the VA then who would be left? Perhaps the law would have to be renamed the "Care for the Courts Martialed Act."

Can someone exhume the ridicule the Democrats heaped on Reagan's Strategic Defense Initiative aka Star Wars. They said it was unworkable and to complex while needing millions of lines of code.
28 weeks ago
28 weeks ago Link To Comment
Is this a government version of "Grand Theft Auto?"

If they had contracted the whole thing out to Amazon or Turbo Tax, they might have had a chance at success. However, "success" is relative to whatever is the actual goal. This fiasco will work out fine for the government.

Here's how: The Exchange will be essentially a beta version that generates crap quotations and bookings for insurance that will collapse after verification and adjustments. The end product for the would-be client will end up as inappropriate coverage with coverage lapses, and miles from what was quoted. In a year or two of frustrated customers and confusion, all pretense of "insurance" will be lost after a flurry of corrections, stopgap measures, and waivers for "humanitarian" reasons, for "the children," and the "poor and needy." Then it will be welcome to the American version of the National Health Service. Brought to you by the friendly folks who provide you your daily ration of barnyard-fresh fertilizer.
28 weeks ago
28 weeks ago Link To Comment
All Comments   (84)
All Comments   (84)
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The glitches were, in her words, “a great problem to have.” They are proof of the overwhelming demand for Obamacare.
What a boneheaded comment by Sebelius. That's like saying being laid off gives me more time to catch up on my reading. My doctor already quit seeing patients 6 months ago - he saw this nightmare coming and wanted no part of it. He opted for "Healthcare administration" at a local hospital as opposed to be bullied into taking whatever fees this mess imposes.
28 weeks ago
28 weeks ago Link To Comment
I doubt Sebelius actually believes that, but this is government. She has to lie.
27 weeks ago
27 weeks ago Link To Comment
Our Canadian newspapers keep saying that there are 4.1 million people employed by the U.S. Federal Government and that 80% of them are expected to show up at work during the "shutdown". So 20% of the Federal civil serpents not showing up at work is a "shutdown"?

Let's hope that the 800,000 (20%) aren't getting paid so that the wealth sucked out of the economy by civil serpents is temporarily reduced.

Just 20% less of Nanny and President Princess Numb Nuts is shouting that the sky is falling?
28 weeks ago
28 weeks ago Link To Comment
On another thought, some of you might have heard that Tom Clancy has passed away. RIP. I have an interesting anecdote about his "Red Storm Rising" book vis-a-vis my military service at that time, but I'll hold off. Wretchard may be coming forth with a thread on Clancy, since as a similarly successful author, well, I'm just sure he'll have some sort of observations.

An interesting writer, by most accounts a pretty good man, died too young at 66 yrs, but that time will come eventually for all of us.
28 weeks ago
28 weeks ago Link To Comment
I hope you do post that anecdote. And I hope that Wretchard does do a threat on him, both for my own selfish reasons. I knew him for 31 years, and yes he was a pretty good man indeed.

Subotai Bahadur
28 weeks ago
28 weeks ago Link To Comment
Yes, please post it.
28 weeks ago
28 weeks ago Link To Comment
C**p. "threat" should = "thread". Been a long day.

Subotai Bahadur
28 weeks ago
28 weeks ago Link To Comment

drbatman and ,
Thank you for your replies. DB I would like to hear a professional opinion of just how loose BHOs screws are and whether any are likely to come off and start rolling around in public.

Possibly being the least qualified person in the room, and seeing that this is the Internet, I want to follow up on one of my points. Let us compare Obamacare to the SDI.

SDI was attacked by the Democrats for being an insolubly complex problem that would need millions of lines of code. Obamacare is touted with religious fervor as the answer that is out there.

SDI called for solving a basic two body problem in physics. A potential threat had to be spotted, analyzed and determined to be a threat, IMHO the hard part since false positives would be unacceptable, and then the location trajectory and speed of the threat had to be calculated fast enough that an intercept, missile pebbles or laser, could occur. The core problem of the intercept though was a simple two body problem in Physics. While the initial threat assessment is difficult and the engineering problems to attain the demanded level of reliability were formidable the basic concept was comprehensible.

The success rate had to nearly 100% for it to work, also a hard part. That was a much higher standard than traditional BMD which was only expected to degrade the reliability of a threat so as to induce uncertainty. SDI or Star Wars was intended to render the threat obsolete.

Obamacare relies on hundreds or thousands of constantly changing variables to deal with a potentially infinite number of conditions. The good news is that perfection is not demanded. If some people save something, even at ruinous cost to society, and others get jobs as bureaucrats, even if the economic costs destroy hundreds of thousands of other jobs, then it will be declared a success. In the long run we are all dead anyway.
28 weeks ago
28 weeks ago Link To Comment
yurself,
My apologies. It ate your name. We have found another flaw in the software.
28 weeks ago
28 weeks ago Link To Comment
The main thing the Govt Shutdown will achieve is make very sure that EVERYONE not seriously afflicted with dementia will KNOW FOR CERTAIN that the Republicans DO NOT LIKE Obamacare.

When it crashes, no one will be able to say that "What difference does it make now? Both parties are the same!"

The biggest worry is that Obamcare will not fail. It will just needed to be "tweaked" and be given just a little more time to work, just a little more effort to get the software working, just few more special favors and exemptions for deserving groups - and just a little more money.

After all, for a $ trillion program, another $ billion won't hurt if that is all it takes to fix it. And just another $ billion, and another and another.

And a few extra taxes on medical equipment. By the way, are not cars medical equipment, since you drive in them to the doctor? And don't hospitals use TV sets and computers and printers and staplers and refrigerators and microwave ovens and AR-15 rifles? All are medical equipment that should be taxed!

A mere 4 years before the first Space Shuttle flew, NASA said confidently that each Shuttle launch would cost $14M. The actual cost was 114 times that. Even the government's abject failures die hard, take a long time to do it, and are celebrated and mourned when they go.
28 weeks ago
28 weeks ago Link To Comment
buddy, Very interesting comment. It sure fits Buraq's methods.

I guess it comes down to whether enough of us have reached psychological level of the New Soviet Man.

I sure hope not.
28 weeks ago
28 weeks ago Link To Comment
Unsk, this is the Beria Doctrine. The stage where the Party reveals that it is indeed causing the people's misery after all, and if the people want relief, there is therefore no one to come to but the Party.
28 weeks ago
28 weeks ago Link To Comment

Intriguing comment about your daughter and her pals. Why are they upset over the shutdown? Do most of those under 30 feel that way?
28 weeks ago
28 weeks ago Link To Comment
--near as i can tell, in a sample of about 15 or 20 kids she stays in close with, the split is about as it is in the general population, and --not that i judge their politics deliberately, but impressions form autonomically --the big bell curve recapitulates --on the interest in and understanding of politics and policy.

The interested are fully aware of the mess in DC, the less interested are i think trying to compensate for their lack of study, by lapsing into what until recently was a safely 'good citizen' attitude which attaches them to officeholders by the fact of being officeholders, and against insurgents, which continuum has al-shebab on one end and tea party on the other --IOW just as they are being told by the overwhelming preponderance of the usual suspects.

The less interest or understanding they have, the more demonstration they make if or when an issue discussion arises. I'd say three quarters of word counts and nine tenths of sound volume come from the left slope of the cognition curve.

The principle-aware and ethos-developing conservatives don't say much --they don't proselytize. Alas. And tho i flatter myself that i would sniff it out, truth is my presence may be skewing the sample behavior by creating the Eddie Haskell Effect. "Hi, Mr. Larsen, boy is that Obama ever annoying, huh?"

All in all, they're way too passive for the situation. I'm usually torn between giving a blood sweat & tears speech, and just letting them enjoy the Sitzkrieg while they can.
28 weeks ago
28 weeks ago Link To Comment
PS, i forgot to mention, the pro-admin kids lard it on the others in the social media --instagram especially --while the anti-admins don't.
28 weeks ago
28 weeks ago Link To Comment
Damn I- thingy-

Sentence should read as follows:

the administration ordered the cancellation of the Air Force/Navy football. the navy athletic director was ordered to cancel the game by his superiors to show the right "optics".
28 weeks ago
28 weeks ago Link To Comment
Me thinks our Dear Leader's shutdown strategy is starting to go to sh*t.

The optics sure are starting to show just who is the "anarchist/extremist".
these stories are starting to paint a very slimy picture of Buraq Hussein:

- the Dems have shutdown the N.I.H., and in the process shut down potentially life saving trial treatments for children enrolled. guess this shutdown is not for the children after all.

- the Dems have gone to extraordinary efforts to barricade the Veterans WWII monument in DC that was always accessible and wide open to the public.

- the Dems have shut down Williamsburg, and sent home the staff even though the park was financially self supporting..

- the administration ordered the Air Force/Navy college football. the commander in charge was ordered to do it for the "optics".

these slimy antics by Dear Leader are starting to pile up, and I can't help think that the public is going to notice soon.

meanwhile, the pubs may have found a strategist - Senator Mike Lee. He is proposing that the Pubs fund popular essential services in individual bills so the Dems will either be forced to fund or take the heat for shutting down popular services. (Lee was also behind the Cruz filibuster.)

if this strategy starts to take hold, the Tea Partiers will look like the sensible ones and the Dems will be the ones who will look like the anarchists and obstructionists.
28 weeks ago
28 weeks ago Link To Comment
They have to shut the parks and monuments down now and get ready, where else are the 800,000 federal employees going to set up their tents after they are evicted for not paying rent? It just shows how great a heart Obambus has, he does it all out of kindness.
28 weeks ago
28 weeks ago Link To Comment
(excerpt)

Later in his remarks, Perry highlighted some of the positive effects that have manifested because of the reforms passed 10 years ago:

“Since Proposition 12 passed 10 years ago, Texas has added more than 30,000 doctors, with significant gains in communities that had been traditionally medically under-served.

“Over 3,000 new medical licenses have been issued each year for the past seven years, and more than 3,500 over the last two fiscal years.

“We also set a record for applications, with more than 4,600 applications filed in Fiscal Year 2013.

I’m continually surprised some people still want to argue the case that tort reform hasn’t worked; they’re swimming upstream against a flood of hard data.

“Many of the same lawsuit reforms we passed also freed entrepreneurs and employers across our state to worry less about lawsuit abuse and invest fewer resources in defending them.”

http://watchdogwire.com/texas/2013/09/11/perry-celebrates-tort-reform-anniversary/
28 weeks ago
28 weeks ago Link To Comment
That wasn't gratuitous --my youngest telling me last night of her cohort waxing wroth over the Tea Party's shut down of the government, we all need to remember the quick & dirty rebut, that what was wrong with the best healthcare ststem in world history was that it cost too much, and it cost too much because a few easy reforms were impossible to get past the Democrat Party. Tort reform, no go due to nearly 100% Democrat plaintiff's bar, insurance portability no go due to local monopoly-loving Democrat lobby lock, and the HSA model that would overturn every efficiency disincentive (most egregiously the three party transaction) also a Democrat no-go due to danger of the Enlightenment crashing into the Inquisition.

First, they infect you with the sore throat and runny nose, then they cure the infection by chopping off your head.

Don't believe it? Look at the results of a few light modifications to the three uglies, the blooming of pretty flowers on state levels here and there, and always only after bitter struggles with the Democrat party, and there's the proof of the pudding.

So when the Democrats defend ACA the only way they can, that is by screaming that the system before was terrible and Obamacare is simply an attempt to do so, the proper answer is to toll like a liberty bell, 'wrong ...wrrrong ...wrrronnnnng ....
28 weeks ago
28 weeks ago Link To Comment
"...was terrible and needed fixing and Obamacare is ...."
28 weeks ago
28 weeks ago Link To Comment
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