Obamacare: Fundamentally Bad Design, Website Included

The technical problems with the implementation of the (Abdominable) Affordable Care Act are becoming the stuff of legend. The entire thing should be rebuilt. But that will not save the ACA, because the underlying policies and political pressures that have caused the problems are even worse than the systems so far created to deliver it.

As Twitchy notes, the ACA continues to reap a bitter harvest. But the real problems of the law may come later. Even if the technical issues can eventually be worked out, because the policy errors and economic misconceptions driving it can never be worked out.

There are two areas of abject failure in the ACA system implementation: the “front end” and the “back end.” Sharp readers will note there is nothing else left to fail.

The front end is the web site and systems used to communicate with the user. The back end consists of dozens of interlocking computer and communications systems among government agencies and their crony industry partners, reaching even into the examination room. Both the front and back ends are disasters, and both disasters are driven by the structure of the ACA itself.

The Front End

The front end has drawn much of the attention so far, and is not ready even though Health and Human Services officials said it would be:

Initially, users were forced to create accounts before doing any shopping. HHS released a tool to let people see the prices in their area, but to see subsidy qualification they still have to create an account. 

The account creation process is filled with problems all of its own.

This is Not How It’s Done. Users of amazon.com or travelocity.com do not have to do that. Those sites know that account creation drives away users while slowing down the system, especially the part of the system used to register new users. 

Healthcare.gov seems to be more optimized for collecting Social Security numbers than in connecting people with the right insurance products. And the accounts appear to be permanent, with no facility in place to let users delete them.

Industry observers say, and the compressed timelines attest, that nobody tested it. Because of the political need to open October 1 (resulting from the partisan nature of the law’s origin), testing was not done.  

Experts said the decision to require that consumers create online accounts before they can browse available health plans appears to have led to many of the program’s technical problems. Consumers trying to create their accounts multiplied the volume of online transactions that have overwhelmed the website.

The White House suggested they simply needed to improved the consumer experience. The incredible departure from best practices of the omission of testing can’t be overstated.

The Back End

Health insurance expert Bob Laszewski says that only 5,000 people have signed up for insurance through the federal exchange. While the numbers are bad, the behind-the-scenes picture may be worse:

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.

Read that whole thing.

The bureaucracy is ill-equipped to solve these systemic problems, particularly when the bureaucracy itself may be part of the problem. HHS is treating these fundamental problems as help desk issues (emphasis added):

Federal health officials declined to discuss the problem with the enrollment reports. “As individual problems are raised by insurers, we work aggressively to address them,” said Brian Cook, a spokesman for the Centers for Medicare and Medicaid Services, the branch of HHS that is overseeing the insurance exchange.

That kind of approach is unlikely to solve the problem. Perhaps they really are trying to get to the root of each problem they encounter, but passively waiting for insurers to report problems in a system that is massively failing will lead to duplication of effort and a great deal of waste. Individual symptoms may or may not be seen as part of the same underlying problem.

It would be easy to pass off the technical failures as “glitches” or to blame the contractors and federal employees who have created the systems. There are clearly issues with data exchange, system design, plain errors in the coding, and a lack of testing.

But even in design, according to the Medicaid-CHIP Program Information document (pdf), the system designers should have known they were overreaching:

We envision a streamlined, secure, and interactive customer experience that will maximize automation and real-time adjudication while protecting privacy and personally identifiable information. Individuals will answer a defined and limited set of questions to begin the process, supported by navigation tools and windows that open to provide or seek additional information based on individual preferences or answers. The application will allow an individual to accept or decline screening for financial assistance, and tailor the rest of the eligibility and enrollment process accordingly. The required verifications that will be necessary to validate the accuracy of information supplied by applicants will be managed in a standardized fashion, supported by a common, federally managed data services hub that will supply information regarding citizenship, immigration status, and federal tax information.

In the backend of Obamacare, this complex set of systems for insurers, the IRS, Health and Human Services, and other federal and state agencies connect via a “hub,” responsible for collecting information about an applicant and indicating what kind of insurance the poor sap should get. As late as June of this year, the code for the hub had not yet been written.

Insurers may not put up with the situation for long.

“They’re doing testing this week because they haven’t got the bugs out. They still aren’t sending clean files,” said Laszewski. “The insurance industry is scared to death.”

Driven By Bad Policy

All of the technical problems can be traced back to the toxic political origins of the law, however.

Were it not for the partisan way in which the original bill was crafted, and the even more partisan means by which the thing was passed,

  • There would have been input from Republicans as to what would be acceptable to their voters and in their state legislatures
  • The bill could have gone to conference, instead of being passed in its unworkable condition, so many of the errors could have been taken out
  • Republican states would not have been so sure to avoid implementing their own exchanges
  • There may not have been quite so many Republican governors and state legislatures in the first place
  • The structure of the law led to an overemphasis of creating user accounts
  • As mentioned above, the political need to open October 1 (because delay of the law was so politically difficult) has led to a lack of testing, and doubtless contributed to the overall poor quality of the entire system

The law is having unintended — or at least unadvertised — consequences, generating real-world pain for ordinary people. 

The ACA ought to be repealed, and this stupid episode in disrupting the American Experience put behind us. Failing that, the entire thing should be put on hold for a year. Even simply dropping or delaying the individual mandate would take enormous pressure off of everyone and give time for a true public beta test.

Republicans, as those wisely opposing this debacle, must stand firm if the public is to be protected from the calamity of the Abominable Care Act. 


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