Politicians love to blame contractors when things go wrong. It’s so much easier than accepting responsibility for government mistakes. So we shouldn’t be surprised that companies involved in building the HealthCare.gov web-site supporting Obamacare have been raked over the coals in congressional hearings. However, political leaders need to look deeper for explanations if they want to make the Patient Protection and Affordable Care Act work. Of course, many politicians don’t want it to work. But for those who do, here are four key facts worth pondering that have already emerged from hearings.
1. The site is complicated because healthcare is complicated. Obamacare is the most far-reaching reform of federal healthcare programs since Medicare and Medicaid were created half a century ago. It implements a series of mandates, mechanisms and subsidies that further complicate an already baroque tangle of federal programs and private-sector efforts. So it is easy to see why a user of HealthCare.gov might have to negotiate 75 different screens in order to finally nail down a desired solution — there are over a thousand screens in the system. But that’s because healthcare is complicated, not because contractors didn’t know what they were doing. It often takes days to review coverage options and eligibility standards with private insurance agents.
2. Contractors didn’t design the site, the government did. The IT companies hired to implement HealthCare.gov collectively have hundreds of years of experience in supplying federal information technology and services. They were competitively selected on the basis of their past track records and demonstrated capabilities in supporting programs such as Medicare. However, it wasn’t the companies that called the shots on how the web-site functioned, it was the government. When the government designates itself the lead architect and integrator for projects with many moving pieces, things often go wrong. That was true of the B-1 bomber 30 years ago, and it’s true of HealthCare.gov today. Washington is run by lawyers, not tech experts.
3. The government did not organize effectively for the task. The federal agency responsible for implementing the web-site is the Centers for Medicare & Medicaid Services (CMS), a component of the Department of Health and Human Services. CMS should have created a streamlined structure for managing HealthCare.gov, but instead there was continuous infighting about web-site features that caused long delays and resulted in subpar specifications. For instance, CMS decided that users of the system should enroll as individuals rather than as families, greatly complicating use of the web-site. It decided to mandate use of obscure technology rather than industry-standard systems. And it required a sequencing of functions that confused users.
4. The government ignored warnings from contractors. CMS continued to make changes in HealthCare.gov until days before it was scheduled to go live on October 1. As a result, much of the testing that should have been done before the site debuted was not conducted. Software glitches and user-experience problems that could have been identified in advance only became apparent after the site was up and running. Normal industry practice when launching complex projects is to conduct detailed end-to-end testing before users gain access, but in this case there was no time for an end-to-end assessment. Contractors repeatedly warned CMS in the days leading up to October 1 that more testing was needed, but the agency chose to proceed.
The government violated many well-established management principles in the way it implemented HealthCare.gov. It has probably compounded its problems by committing to an early deadline for resolving issues. If you visit the web-site itself, it is not the nightmarish experience depicted in some media accounts. But it could have been better from day one, and for that the government has only itself to blame. HealthCare.gov is a case study in how it is possible to tap world-class talent and technology only to get mediocre results because the customer was distracted and disorganized.
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