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.
The navigators mentioned don’t find their way around the surface of the Earth. They find their way through the bowels of Obamacare. The role of these “navigators” was described by Politico:
More than 100 groups will split $67 million to help people “navigate” the new Obamacare health insurance exchanges — more money than the administration initially said would be available but short of what advocates say will be needed to help people sign up, especially in states where the governors are hostile.
The grants announced Thursday will go to 105 organizations, including community groups, health care providers, business groups and a handful of Planned Parenthood affiliates. The program, which got an extra $13 million from the health law prevention fund, is for those states that refused to set up their own health insurance exchanges, and the federal government is stepping in.
The “navigators” will have to fill in the outreach gaps in Obamacare-resistant states that are doing little to raise awareness of the law. With just 46 days until Obamacare health insurance exchanges open for enrollment, the timeline is also extremely tight for the groups receiving the grant awards to hire navigators and have them undergo mandatory federal training.
This stampede of mediocrity has created a hasty toxic pudding, a jerry-built monstrosity of such complexity that possibly no living human being understands it, and whose general effect is to create a jungle in which tigers, tarantulas, and giant reptiles can lurk at will. For her own part, Kathleen Sebelius dismissed any such charges of incompetence. She believes the technical problems in the program’s rollout are due principally to the overwhelming enthusiasm which has caused droves of insurance seekers to crash the health care exchanges. The glitches were, in her words, “a great problem to have.” They are proof of the overwhelming demand for Obamacare.
Obamacare care has often been referred to as “insurance,” as if it reflected some relationship between premium, payout, and risk. But it should be abundantly clear from this peek under the hood that the “insurance” purchased on its exchanges is a product of the “rule engine,” which is fed literally thousands of tax regulations, subsidies, fines, transfer payments, and fees as fast as the programmers can code them. These somehow spit out a number. That number is what you pay.
What it means, what it may include? Who knows? As the Oregon people put it: “it was constantly emerging requirements.”
There is now some preliminary data on how well the system has been working. The Daily Mail reports:
Less than 1 per cent of Web visitors are signing up for Obamacare on some state health exchange websites
California’s program registered an estimated 0.58 per cent of website visitors in its first day
A Connecticut congressman boasted that his state took 167 applications for Obamacare services on day one, a rate of 0.59 per cent
Obama administration won’t say how many Americans signed up on the central website that covered insurance exchanges for 36 states
Kentucky’s 5.3 per cent application rate seems to be the nation’s highest
Other states wouldn’t provide statistics, or tracked only the creation of new online accounts, not numbers of completed applications
It’s anecdotal data but if there were good news the press would be trumpeting it already. This has been a disastrous rollout.
While there have been some dark hints that New York’s system jammed up because of suspiciously high traffic — denial of service attacks? — the most probable cause for these “glitches” is straightforward. We are watching a complex system, insufficiently tested, perhaps poorly executed and hastily rolled out, basically fail. This happens because neither Murphy nor the Gremlins ever take a day off.
Murphy belongs to no political party. He and his partner the Grem are willing to gum up anything half-assed on an equal opportunity basis.
There is nothing shameful in watching your rocket crash to the ground just so long as you realize the payload isn’t launched. What is shameful is pretending to receive signals from orbit when Telstar is smoking on the launch pad.
A reasonable manager would delay the rollout until more testing can be done and the problems are understood because the chances are the more the debugger looks the more he finds. Fixing something this big isn’t as easy as the movies make it look.
But then a reasonable manager would have tested the system before turning it loose. Many of you will doubtless know that even the “unexpectedly high traffic excuse” cited by the press is hardly credible. There are services which simulate test traffic and hit test sites with however many zillion hits you desire that you may configure capacity accordingly.
This miserable rollout cannot be plausibly explained by IT incompetence. A disaster of this magnitude can only be the result of politics; by the imposition unrealistic deadlines; by a refusal by managers to understand that if a system isn’t ready then it ain’t ready. That circumstance is sometimes difficult to explain to “political” people; to leaders who live their mental lives sweeping across the panorama of history.
Nobody ever beat arithmetic.
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