I don’t need to tell anyone about the controversy surrounding the Affordable Care Act (more commonly known as Obamacare). It was the central issue in the game of brinksmanship that led to the U.S. government shutdown last week. But mirroring that mind-blowing dysfunction was the less-than-stellar 1 October rollout of the federal website healthcare.gov. The Obamacare-mandated Web portal lets consumers who don’t have employer-sponsored medical insurance meet the legal requirement to sign up for health coverage through the states where they reside. (To be precise, healthcare.gov is for residents of 36 states whose governments opted not to set up independent healthcare exchanges.) Online exchanges for some of the other 14 states and the District of Columbia also debuted with disappointing results.
So, what happened? Well, it’s no secret that governments are terrible at IT project implementation. Examples abound—as regular readers of The Risk Factor are well aware. (Some of our reporting on recent foul-ups is here, here, and here.) There’s been little evidence so far that these projects are any different.
The Department of Health and Human Services (HHS) reported Wednesday that there were 6.1 million unique visitors to healthcare.gov on the first day and a half after the site opened on Tuesday. By Friday, that number had surpassed the 8 million mark. That’s a good indicator of the level of interest in getting signed up for health coverage. But it’s only part of the picture. What HHS purposely left out (and left to our imagination) is the actual number of enrollments. Officials said they would probably release enrollment numbers next month after tabulating totals from, online, call centers, and paper enrollments. But the picture that’s forming based on anecdotal evidence is not pretty.
Most attempts to reach the federal website resulted in this:
“We have a lot of visitors on our site right now, and we're working to make your experience here better. Please wait here until we send you to the log-in page. Thank you for your patience.”
“Important: Your account couldnt (sic) be created at this time. The system is unavailable."
According to a Los Angeles Times story, community groups aiming to help people sign up have been frustrated in their attempts to do so. Even large insurance companies, which have a vested interest in getting people enrolled in the exchanges, were unsuccessful in the early going. For example, a spokesman for Blue Cross Blue Shield of Louisiana, that state's largest insurer, told the Los Angeles Times that, as of Wednesday, the company hadn't been able to enroll anyone through the federal website. Others who left in frustration included reporters including one for the Huffington Post, who said: “Though officials from the Centers for Medicare and Medicaid Services said they'd made strides correcting the federal exchanges' problems, The Huffington Post made dozens of attempts and still couldn't sign into the website late Tuesday afternoon.”
"We have had a few slowdowns, a few glitches, but it's sort of a great problem to have. It's based on the fact that the volume has been so high and the interest is so high," Health and Human Services Secretary Kathleen Sebelius said on MSNBC Tuesday. "We're working quickly to fix that."
U.S. Chief Technology Officer Todd Park explained further, pointing out that the government expected HealthCare.gov to draw only as many as 60 000 simultaneous users. That estimate was apparently based on a projection from the volume experienced nearly a decade ago on a site for Medicare Part D. But at peak, the Obamacare site was being deluged by up to 250 000 people at a time.
"These bugs were functions of volume,'' Park told USA Today. "Take away the volume and it works.'' Right. Take away widespread interest in signing up for health insurance, and the portal through which people are supposed to sign up for health insurance will work as intended.
The system’s performance invited a swipe from an IT official from the previous administration. “Whoever thought it would draw 60,000 people wasn't reading the administration's press releases,” David Brailer, former national coordinator of health care information technology under George W. Bush, told USA Today. “The Medicare Part D site [launched in 2006] was supposed to have 20,000 simultaneous users and was [built to accommodate] 150,000, and that was back when computing was done on an abacus. It isn't that hard.”
The news wasn’t any better with the state-run exchanges. California residents were stuck in traffic along both routes to enrollment there: computer glitches stymied attempts to sign up online, while hold times at telephone call centers topped 30 minutes. The computer system created to, among other things, log a consumer’s data and determine whether he or she is eligible for government subsidies to cover part of the premiums, responded so poorly that its operators were forced to shut down the online enrollment system twice. According to the L.A. Times story, “Officials were pleased with the strong consumer interest and vowed to fix the problems.”
On the opposite coast, officials in the second most populous state fielding its own exchange reported what could generously be described as an anomaly. State of Health, the healthcare portal serving New York State, which has a population of roughly 18 million, had reportedly received 30 million hits by late Wednesday, prompting some observers to suspect that hackers may plotting a break-in or an out and out takeover. Whether that’s true or not, Donna Frescatore, director of the state’s exchange, confirmed that despite all that activity, only about 12 000 people had managed to enroll by Wednesday evening.
Responding to questions about the extraordinarily high volume, Frescatore told the Wall Street Journal that, “We have no evidence that this is anything but people learning more about [the site].” Furthermore, said Frescatore, state officials are not looking into the possibility that cybercrime was a contributing factor.
Ahhh…the power of positive thinking.
We can all keep our fingers crossed, but the issue of security will likely pop up again. As we recently reported on this blog, privacy safeguards have likely taken a backseat to getting the exchanges open on time. Another IEEE Spectrum post focusing on the exchanges’ security issues is here.
There’s no question that the overwhelming interest caught New York flat footed. Officials took the Web portal offline Tuesday night. Once the smoke cleared, they doubled its capacity and implemented some fixes aimed at keeping it from getting hung up as it did throughout its first day of real-world operation. What happened on day two? The same thing, more or less.
California and New York weren’t alone in their misery. According to a Huffington Post article, at “Maryland Health Connection, Kynect [Kentucky’s exchange], Connect for Health Colorado, Rhode Island's Health Source RI and others, consumers faced obstacles to setting up accounts or comparing plans—or even viewing the websites at various points in the day.” The Chicago Tribune reported that a glitch affecting Illinois’ exchange—missing fields in an online form—left people attempting to enroll in on the first day unable to figure out whether they were eligible for the federal subsidy for premiums. Though that problem was remedied by the middle of the day, sailing still wasn’t smooth, said the Chicago Tribune article. Illinois Gov. Pat Quinn’s advice for those who had trouble accessing the site? "Just keep trying."
Criticism of the portals’ bumpy first week has come from all quarters. But the rollout still has its apologists. In an e-mail sent to the Huffington Post, Jonathan Gruber, a Massachusetts Institute of Technology economist who was an architect of the 2006 Massachusetts health care regime after which Obamacare was modeled, says,
"Hours or even days is not the relevant timeframe for evaluating exchanges. The question is simply whether there are ways that folks can sign up to get insurance by Jan. 1. That is a question for late November, not early October. If things are really buggy in six weeks, that could be more of an issue."
The best “Keep hope alive” message had to be the widely reported one delivered by HHS Secretary Sebelius.
“I clearly have an iPad and I also have an iPhone and about 10 days ago I got the prompt that the operating system had changed,” Sebelius said. Noting that the experience wasn’t great, she added that, “everyone just assumes ‘well there’s a problem, [Apple will] fix it.’” Here’s the good part: “We’re building a complicated piece of technology, and hopefully you’ll give us the same slack you give Apple.”
Matthew Yglesias, writing for Slate, deftly picks the Sebelius comment apart:
“Apple, like any private business, is customer-driven. Apple knows that if it doesn’t provide good products and services, the public will exercise its options, and go to Samsung and Android, or Windows, or even Blackberry…Apple, the world’s most-valuable brand, has a reputation for producing quality products that work. The government has exactly the opposite track record. There is no public confidence in government programs, whether they be in veterans’ affairs, the postal service, the stability of Social Security, containing spending, managing contracts, rooting out fraud, the IRS, the NSA, the EPA, immigration, self-investigating, protecting our Embassies and personnel — you name it.”
As the federal and state governments have repeatedly reminded us, the more than 40 million U.S. residents without employer-sponsored health insurance have until 15 December to enroll in order to get coverage on 1 January, and until 31 March to avoid being assessed a penalty. Will the sites’ managers get their respective acts together in time? I won’t call Sebelius’ and Gruber’s optimistic takes on the situation into question. I’ll simply direct readers’ attention once again to the Risk Factor links in the second paragraph of this post. They’re concrete illustrations of the points Yglesias makes.
Here are links to several other related articles:
Photo: Mike Segar/Reuters