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Lessons From the Healthcare.gov Fiasco
Nerval's Lobster writes "In theory, the federal government's Health Insurance Marketplace was supposed to make things easy for anyone in the market for health insurance. But fourteen days after the Website made its debut, the online initiative—an integral part of the Obama administration's Affordable Care Act—has metastasized into a disaster. Despite costing $400 million (so far) and employing an army of experienced IT contractors (such as Booz Allen Hamilton and CGI Group), the Website is prone to glitches and frequent crashes, frustrating many of those seeking to sign up for a health-insurance policy. Unless you're the head of a major federal agency or a huge company launching an online initiative targeted at millions of users, it's unlikely you'll be the one responsible for a project (and problems) on the scale of the Health Insurance Marketplace. Nonetheless, the debacle offers some handy lessons in project management for Websites and portals of any size: know your IT specifications (federal contractors reportedly didn't receive theirs until a few months ago), choose management capable of recognizing the problems that arise (management of Healthcare.gov was entrusted to the Medicare and Medicaid agency, which didn't have the technical chops), roll out small if possible, and test, test, test. The Health Insurance Marketplace fiasco speaks to an unfortunate truth about Web development: even when an entity (whether public or private, corporation or federal government) has keen minds and millions of dollars at its disposal, forgetting or mishandling the basics of successful Web construction can lead to embarrassing problems."
And you have to realize that not everyone on the team has the same goals.
How much do the contractor companies get paid for overtime or change requests?
When I'm a contractor I will tell you what problems there could be that I can see. But if you tell me to do it your way I'll do it your way and collect my check.
Part of the problem is the usual problems with large-scale IT projects: it's not until you're well into it that you really get a grasp of what's involved. Nothing government-specific there, that plagues all large IT projects in private industry. Part of the problem, though, lies exactly in the fact that contractors were used. Contractors are mercenaries. They're here to deliver this project, and once they get their paycheck they're on to other work. They won't be around to deal with the fall-out and maintenance headaches from their work, and they don't have any vested interest in the quality of their work as long as it's good enough to pass review and get their payment check cut. In fact, poor quality is actually an opportunity to get paid twice since fixing the problems is a new project. Full-time permanent employees may not be as efficient as contractors, but on the other hand they've got a vested interest in making sure the system doesn't create any more problems than necessary because they know they're the ones who're going to have to clean up the messes. Long-term employees also have a better grasp of what's already involved in the current system, which translates directly into a better grasp of what the new system will need to do. They're less likely to miss major complications because they already have to deal with them.
Part of the problem with contractors is also the fact that large organizations like governments limit themselves to Tier 1 contractors. And there aren't a lot of those. So it rapidly becomes a situation where the Tier 1 contractors aren't really concerned about quality and results, because they know their customers will by policy refuse to consider any alternatives outside a small set and those others aren't any better about quality. If the government switches from contractor A to B, that means B can't take on another customer who takes their business to A (because A and B are the only Tier 1 firms and the customer can't consider anyone who isn't a Tier 1 firm) and it's a net wash for A.
This
made me laugh.
I've been in the unfortunate situation of working for a government agency when Booze Allen Hamilton came in to help make changes and improve things. They did much of the former and none of the latter.
Typically, dealing with whoever was going to actually use the process they were changing was something the Boozers did just to check off an item on a list. They did not listen to users because they assumed government employees were all idiots and could tell them nothing they really needed to know about the processes they were about to change.
Personally, if I were going to change business processes that had been in place for decades I'd want to talk to the people who work the current processes and find out how they work before I started trying to think up better ways of doing things. BAH never did that. They brought in workers for planning sessions, listened for a couple of days, then distilled the results of those discussions into a document of findings that was obviously written before the research ever started and contained exactly zero input from the field workers who truly understood job requirements.
Boozers, in my organization, were almost universally so convinced that their shit didn't stink that they were worse than useless. In the course of years of contacts with them, I met exactly ONE who listened, learned, and improved things.
Based on those past experiences, I can only surmise that the folks responsible for this current fiasco simply said "Oh, we don't need to talk to anyone from the government about how they run web sites that stand up to incredible traffic swings. We know what we're doing."
And some idiot government executives trusted them.
I don't know who to be more disgusted with.
The reason for the mandate (and for the original single-payer system) is that currently the cost of health care for the uninsured is hidden in the "uncollectable debt" category in the hospital's accounts receivable. It's all the bills for ER visits and emergency care for people who can't pay. I was taught a basic rule back in high school business classes: you can't manage costs until you've got them laid out where you can see them. The idea was to get all health care being paid for and accounted for so we can see where the money's going and do something about the areas where it's costing more than it should. It was also to help with shifting the costs from expensive emergency care to much cheaper preventative care, the idea being that when people know they're covered by insurance they're more likely to go to the doctor before things get critical instead of putting it off and hoping they get better so they don't get nailed with a doctor's bill and ending up at the ER in critical condition. If you have no insurance the bill's going to be a killer either way so it makes sense to go for the chance to avoid it, whereas if you do have insurance the bill won't kill you either way so why wait and suffer more than you have to?
"...but I seriously had no idea it would be this bad."
How would you design a Healthcare Extortion Racket?
"New York State's healthcare plans range from Fidelis Care's 'Bronze' plan at $810.84 per month to $2554.71 per month for something I didn't bother to look up because if I had $2500+ a month to spend on doctors, I'd buy a doctor and have him/her live with me and dole out pills like I was Michael Jackson. The deductibles - the amount you pay out of pocket every year before you the insurer has to give you anything at all - are outrageously high. Fidelis Care Bronze has a $3000/year deductible per person. I'm in pretty good health; it's a rare year I spend that much on doctors. After the $3000/year deductible, they pay 50% of your bills. So if you rack up $5000/year in medical bills, you pay $4000 and they pay $1000. Pretty damned crappy."
Repeat, from my JE.
"Flyin' in just a sweet place,
Never been known to fail..."
The point is that states implemented their own systems and none of them have been declared a disaster. You don't hear about any of them because they are working as intended.
Sadly, this is simply not true.
Oregon had been running ads for CoverOregon for months prior to Oct. 1. Cute ads, catchy music, but no indication of exactly what "Cover Oregon" was. Unicorns and pixie dust.
Come Oct. 1, the website went live. Unfortunately, they hadn't yet implemented the details of how to sign up, ignoring the basics of "how much will you have to pay" based on income, etc. That part of the website is, to this day "Coming Soon".
You can sign up, but you have to contact a "Community Partner" (new name for "Insurance Agent") on your own. They'll point you at one, but interestingly, the law doesn't require that "partner" to tell you about anything other than the plans his company sells. Lowest rate? Well, look here at my glossy brochure, ...
And no, this isn't how it was intended to be. It just wasn't finished, and still isn't. It did make the news, but only in Oregon media. Who cares about failures of the health care exchanges in someone else's state? BTW, Gov. Kitzhaber is a Democrat and a physician who is fully behind taxpayer-funded health care for all.