Tim Worstall Contributor 
Matthew Herper Forbes Staff Tim Worstall Contributor 
Save The Knives For ObamaCare: Four Ways To Actually Defund The ACA 
Michael F. Cannon Contributor The more we hear about the Federal health care exchange necessary under the ACA (aka “Obamacare”) the worse it is looking for the idea of technocratic government. This isn’t a comment in any manner upon the economics of health care insurance, the need for reform or anything of that nature. It’s about the skill and aptitude with which this particular reform has been implemented: somewhere between little and none that is.
The more information comes out about that exchange the more the professionals in the field are biting their lips over how bad the implementation has been:
The website failed Mrs. Sebelius, the Health and Human Services secretary, during her appearance to tout it last week in Pittsburgh. Uninsured residents, including 41-year-old LaKesha Lowry, tried to sign up on laptops brought in for the special event. But the system was down, Ms. Lowry said, with instructions to “Try again later.”
I will admit to finding that darkly amusing. This is something of a hostage to fortune:
The “bugs” that have plagued the rollout of U.S. health-insurance exchanges will be fixed by Dec. 15, said Senate Finance Committee Chairman Max Baucus, the lead author of the 2010 health-care law.
For there’s no particular indication that the problems will be resolved by then. Rather, the more the professionals look at the current system the more the thought is that there’s going to have to be a rewrite, not just a tinkering with the system. Here’s one series of chats with those on the inside of the system:
This latter point turns out to be quite important. 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. That doesn’t mean they can’t be fixed, of course, and perhaps even fixed relatively quickly, but it means that at the very least the opening weeks (and quite possibly months) of the Obamacare exchanges will be very different from what either the administration or its critics expected.
Actually, this diagnosis is really the wrong way around. There’s nothing particularly complex about the programming necessary for a site like this. It’s not just Java for the script kiddies, for sure, but the complexity is actually in the design, not the programming. That design should have been nailed down two years ago, the code written and then tested for a good 6 months. Rather than what actually happened, which was that the design itself was still changeable into September of this year. That those insiders are still misdiagnosing the problem shows quite how far out of a technical understanding they are. Then there’s this:
For some reason the system is enrolling, unenrolling, enrolling again, and so forth the same person. This has been going on for a few days for many of the enrollments being sent to the health plans. It has got on to the point that the health plans worry some of these very few enrollments really don’t exist.
The reconciliation system, that reconciles enrollment between the feds and the health plans, is not working and hasn’t even been tested yet.
OK, so that’s from 8 days ago: but seriously? Someone sent a major system live without having tested a component of it? What? Even the helath policy wonks’ health policy wonk, Ezra Klein, is getting worried:
We’re now negative 14 days until the Affordable Care Act and most people still can’t purchase insurance. The magnitude of this failure is stunning. Yes, the federal health-care law is a complicated project, government IT rules are a mess, and the scrutiny has been overwhelming. But the Obama administration knew all that going in. They should’ve been able to build an online portal that works.
Early on, President Obama like to compare the launch of the Affordable Care Act to Apple launching a new product. Can you imagine how many people Steve Jobs would’ve fired by now if he’d launched a new product like this?
So is anybody going to be held accountable? Is anybody going to be fired? Will anyone new be brought in to run the cleanup effort? Does the Obama administration know what went wrong, and are therr real plans to find out?
What’s abundantly clear to anyone who reported on the run-up to the federal health-care law’s launch is that the White House had no idea how badly the Web site would perform. They expected problems. But the full extent of the disaster was either obscured or ignored. Heads should roll for that. Changes should be made because of that.
Where the blame lies, well, further up the management tree rather than a long way down it:
As others have noted, the failure of healthcare.gov is not unique in the annals of government technology projects. But it is surprising that the Obama administration—which has tried to build a reputation for competence—did so spectacularly badly on its flagship project. Most likely, there were just not enough people in the chain of command who had enough understanding of technology to realize that things were going horribly wrong, which is a pretty clear management failure on the part of the administration.
The idea of a shutdown and restart is gaining currency:
The chorus of voices calling for postponements will grow louder every day with healthcare.gov’s continued — and very visible — woes, experts agreed. And some say the site should be taken offline until it’s more serviceable.
“The problem with the Obama administration keeping this open is [it's] five times harder to fix something like this on the run,” industry analyst Bob Laszewski told The Washington Post’s Klein. “If it would’ve taken a month to fix it during the shutdown, it’ll take three or four or five months to fix it while it was running.”
The site is even deleting passwords of those who have managed to open accounts:
The Obamacare website, which launched October 1, deleted some users’ passwords, according to multiple call center representatives for the site.
Five call center agents told CNN on Wednesday that because of an upgrade to the beleaguered website, many passwords were deleted if they were created in the first week or so after the launch. More recently created user names and passwords don’t seem to have the same problems.
If the representatives have it right, some users will continue having trouble logging in, no matter how many times they try.
“They did maintenance on the website recently and deleted all the passwords, so they needed resetting,” one agent wrote in a live online chat with a CNN reporter who has been attempting to go through the process of using the site.
Even those who managed to get all the way through to booking coverage aren’t faring all that well:
Emerging errors include duplicate enrollments, spouses reported as children, missing data fields and suspect eligibility determinations, say executives at more than a dozen health plans. Blue Cross & Blue Shield of Nebraska said it had to hire temporary workers to contact new customers directly to resolve inaccuracies in submissions. Medical Mutual of Ohio said one customer had successfully signed up for three of its plans.
The flaws could do lasting damage to the law if customers are deterred from signing up or mistakenly believe they have obtained coverage.
And it’s entirely possible that the problems could lead to the death spiral as the healthy fail to sign up while the unhealthy keep at their attempts to do so:
As consumers struggle to navigate healthcare.gov, some health-plan executives worry that only the sickest—those who most expect to need insurance—will persist in seeking coverage. If younger consumers who are on the fence about buying coverage find the process too onerous, insurers may end up with too few healthier members to offset the costs of less-healthy enrollees.
Tara Seidenberg, a 48-year-old paralegal from suburban Houston with multiple sclerosis, says she is likely to put up with all kinds of hurdles to buy coverage. After days of failed attempts to sign up on healthcare.gov, she is taking a break to wait for the glitches to resolve. She takes medications that cost $4,600 a month and her current coverage won’t be available next year. “I’m pretty much guaranteed to try it again,” Ms. Seidenberg said.
And from the technical world, an analysis of what has really gone wrong:
Sebelius, incidentally, is the first daughter of a governor to be elected governor in American history. She has a liberal arts BA and a master’s in Public Administration. The CMS Chief Operating Officer is Michelle Snyder who holds advanced degrees in Clinical Psychology and Legal Studies and Administration. She has been a manager in the HHS budget office and had assignments with the Office of Management and Budget, Congress, the Social Security Administration, and as a management consultant in the private sector.
I’m sure liberal arts majors and management consultants have an important role to play in modern society. That role does not, apparently, include being in charge of a major IT project. Not only are they incompetent to run it, it seems that they are incompetent to appoint someone competent to run it. Personally, I’d have started with Richard Granger,, ex-head of the UK NHS Connecting for Health program that pissed £10-15 billion down the drain for no result. Yes, his track record is beyond absymal – on the other hand, a) he now knows first-hand all the mistakes you shouldn’t make and b) when you announce his appointment the expectations on your project will plunge so low that even delivering a badly-working underperforming system will impress people.
The people responsible for the technical management simply were not competent to be in charge of the technical management.
At some point there’s going to be an autopsy on this health care exchange. And other than the part of it that we already know, this isn’t how to run a major technology project, the details of who failed to do what by when are going to be fascinating.
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