Keeping It Simple

The Private Option

Written by

Bill Karwin

in

There’s a famous case of a fumbled rollout of a website: HealthCare.gov, the federal health insurance exchange used by independent insurance customers in about two-thirds of states in the USA.

These days, the an updated version of HealthCare.gov functions fine, so you’re wondering what the hubbub was about when it was launched.

Poor Debut

Proponents said that a slow rollout is not unexpected. People who managed the health insurance exchange in Massachusetts that served as the model for the Affordable Care Act say that the same initial bugs and slow adoption affected their program too.

The site has performance and scalability problems, has an overly complex user experience, and sometimes calculates wrong answers. The result is that of the 100,000 people who signed up for independent health insurance after October 1 2013, fewer than 27,000 used the federal exchange.

Why Did it Fail?

HealthCare.gov had a major obstacle: they had to handle several times the originally anticipated demand. The original plan was for each US state to implement their own health insurance exchange, to serve people in their respective state, and HealthCare.gov would handle those who couldn’t. It was assumed that only a small minority of states would rely on HealthCare.gov, and these would be the states with smaller populations. As it turned out, a majority of states refused to implement their own exchange web sites. In December 2012, when the states were required to have blueprints describing their solution, reportedly 25 states didn’t meet that deadline. 
By the time of the rollout of the ACA, only 14 states were signing people up using their own state-run exchange, whereas the rest of the states–more than two-thirds–were relying on the federal exchange. These include some of the highest population states like Texas and Florida, and 20 states who had taken federal money to plan their state exchanges, but ultimately also relied on the federal exchange.
The Private Option

A few young programmers created an alternative web site they call HealthSherpa.com in their spare time, after the ACA debut on October 1 2013. Their web site is a prototype effort to make a more streamlined portal for people to find the health insurance plans they’re eligible for. It seems to work, and it’s very fast. It uses raw data that is accessible publicly from the federal government.

It’s a valid question then: why didn’t the federal government—or any of the states—employ a small team of web experts to throw together such a site for a fraction of the cost?

HealthSherpa.com doesn’t have all the functions that HealthCare.gov is supposed to. It doesn’t do credit checks, it doesn’t actually even sign anyone up for health care. It just allows consumers to find the data that pertains to them, and then it links to the websites for the respective insurance carriers. And HealthSherpa.com doesn’t create the data—it might be true that part of the effort behind HealthCare.gov has created the raw data that HealthSherpa.com uses.

Also, HealthSherpa.com isn’t (yet) serving tens of millions of users, as HealthCare.gov is supposed to do. I work for Percona, a company that offers consulting and support for database operations, which is just one aspect of web site scalability. Scalability for a web site is complex, much more difficult than most people appreciate.

But it’s worth noting that even with these limitations, there’s a pretty big difference between a three guys throwing together a working website in a few days, versus major federal IT contractor CGI Federal spending $174 million since they announced winning the contract in December 2011 (i.e. 22 months until their go-live deadline of October 1 2013), but they still failed to implement a site that could handle the demand.

Conclusion

So here’s some hindsight views on the HealthCare.gov project:

  • They should have anticipated the demand from all 50 states. This may have been over-engineering, since the intention was to serve only a minority. But they had no control over which states would agree to create their own exchanges, and every reason to think there would be political resistance to doing so.
  • They should have had a beta test period. No large-scale web site can handle the load of millions of users on its first day, not even sites implemented by major web experts like Google and Amazon. They restrict enrollment to a limited subset of their users, sometimes by invitation only. They leave enough time to work out the problems before going fully public.
  • They should have provided raw data only, not the whole web site. Let other entrepreneurs innovate the best way to search the data. Maybe someone would even create a Facebook game for selecting your insurance.
  • They should have set the deadline after scoping the project.

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