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Healthcare.gov and the Gulf Between Planning and Reality
An anonymous reader writes in with this excerpt from Shirky.com. "The idea that 'failure is not an option' is a fantasy version of how non-engineers should motivate engineers. That sentiment was invented by a screenwriter, riffing on an after-the-fact observation about Apollo 13; no one said it at the time. (If you ever say it, wash your mouth out with soap. If anyone ever says it to you, run.) Even NASA's vaunted moonshot, so often referred to as the best of government innovation, tested with dozens of unmanned missions first, several of which failed outright. Failure is always an option. Engineers work as hard as they do because they understand the risk of failure. And for anything it might have meant in its screenplay version, here that sentiment means the opposite; the unnamed executives were saying 'Addressing the possibility of failure is not an option.' ... Healthcare.gov was unable to complete even a thousand enrollments a day at launch, and for weeks afterwards. As we now know, programmers, stakeholders, and testers all expressed reservations about Healthcare.gov's ability to do what it was supposed to do. Yet no one who understood the problems was able to tell the President. Worse, every senior political figure—every one—who could have bridged the gap between knowledgeable employees and the President decided not to. And so it was that, even on launch day, the President was allowed to make things worse for himself and his signature program by bragging about the already-failing site and inviting people to log in and use something that mostly wouldn't work. Whatever happens to government procurement or hiring (and we should all hope those things get better) a culture that prefers deluding the boss over delivering bad news isn't well equipped to try new things.'"
>> a culture that prefers deluding the boss over delivering bad news
I'm pretty sure the guy at the top was in on the ruse too.
>> no one who understood the problems was able to tell the President
Isn't there a petition system for that? :)
When both parties work together toward a common goal, we can put a man on the moon.
When both parties work against each other, and try to stop each other every step of the way purely for their own political agenda, we can't even launch a damn website.
The Internet King? I wonder if he could provide faster nudity.
Just ask Pelosi: they had to launch the website so they could find out what would crash it.
In the end they will lay their freedom at our feet and say to us, Make us your slaves, but feed us. - Fyodor Dostoyevsky
While there is plenty of blame to go around, I am still left wondering where the investigative journalism was regarding the true progress of ACA implementation as the 3 years progressed up to this point.
So, while the press is justifiably having a field day with the sheer incompetence displayed here, where were they while all this was developing?
"If you want to improve, be content to be thought foolish and stupid." - Epictetus
So the *signature* piece of Obama's second term agenda -- the legislation he's harped on loudly and constantly -- launches with an epic fail. The contractors working the site were sounding alarms well in advance of the launch. And yet Obama is somehow utterly unaware that the launch could be anything but a total success? I call bullshit. Either Obama is the most disconnected president in recent history when it comes to the success of his *core legislative agenda* or he's just bullshitting about not knowing there were issues on launch day.
In the end they will lay their freedom at our feet and say to us, Make us your slaves, but feed us. - Fyodor Dostoyevsky
I think the most interesting thought in the article was about the author's observation of contempt between modern managers (in the example in the publishing business) and the engineers who actually create and manage systems. I'm also drawn to how articles written with sources inside the Administration refer to the technical people as 'Technicians' instead of what they probably were 'Senior Software Engineers' or appropriate equivalent title. I certainly don't think of myself as a technician, and I find the term somewhat demeaning somehow.
CGI was selected in part because they were one of only a handful of companies that got on the task order from DHHS that covered this and many other big CMS contracts. This system is designed to make it extremely difficult to just start a business and put out a bid. The justifications for it are very flimsy and center around things like making sure that some fly-by-night company doesn't get the contract/screening out junk bids. Poblem is, they don't actually work. In many cases, they just let the "primes" that win the slots act as funnels for the actual work done by subcontracts which just adds to the cost of the contract.
Another thing, if the reddit thread on this was correct, CMS needs to do what the DoD increasingly does with overtime which is to scrutinize or reject invoices with more than 80 hours per two weeks per employee unless the overtime was either authorized or can be explained in reasonable terms. Overworked government contractors don't get rich; their employers do at the expense of the employee and government. One thing often left unappreciated by the general public is that unpaid overtime is literally stealing employment from the employee because a salaried employee is only authorized to bill so many hours to a contract during a period of performance.
If only there was this much scrutiny and post-mortem analysis over other government failures such as, oh, I don't know, the multi-BILLION dollar failure joint strike force fighter that nobody wants (other than private contractors who are making billions).
Thank gawd, however, that we have this eagle eyed scrutiny over a website that's a few months over deadline and a few million over budget.
I think that the Members of the House who were newly elected in 2010 after the ACA, resulting in the GOP retaking the House, and re-elected in 2012 are rightfully following what the people in their districts want them to do: oppose the ACA. There are a handful of districts which voted for both Obama and a Republican Member of Congress, but there aren't many, and those few are pretty squishy about what to do. My own Congressman came back into Congress in 2010 (he had been unseated in 2008) and then defeated in 2012 by a Democrat; he wasn't following the will of the voters who showed up on election day 2012, other places, the story is different.
when non-engineers that dont understand technology but make engineering decisions, shit like this happens.
shocker.
Anons need not reply. Questions end with a question mark.
The task was simple. Make a friggin website that takes user input and spits out insurance options. If this happened where I work, they'd fire the whole lot without question. Probably enact some kind of legal investigation as to where all the money went too.
If Congress can't handle a simple friggin website project, it's time to clean house and Enact term limits. Restructure the entire congressional seating process, and give people more control over who's buying the laws for us. It's time to change that whole mess.
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Next time try being a little more subtle - not even Obama himself thinks this mess will be fixed in six months.
If you want to pretend to be a left wing loony, "keep the gov't out of my medicare/obamacare" is a little too stupid.
Try "keep the evil businesses out of my business".
the worst fears of the GOP will be realized - people will be getting better healthcare at lower cost.
The GOP by and large isnt bothered if your costs get lower (though, in reality, it is not actually possible for the majority's costs to get lower when we are now covering higher risk people); the concern is that we are going down a path of surrendering every area of life to government control. The idea that the government has the right to tell you to buy X product in order to live in this country is problematic; and its problematic that the government is OK with saying "it doesnt matter what bad choices you make in life, we (that is America at large) has your back".
Theres a term called "enablement" when dealing with someone who has an addiction / other problem; it refers to feeding their bad choices by taking away all consequences. What do you suppose happens when everyone is paying into insurance to cover the terrible choices others make? Or, I suppose, we could fix that by legislating exactly how people can live everyday life, but Im not seeing that as much better.
Seems to be a clasic case of the Themocline of Truth. http://brucefwebster.com/2008/04/15/the-wetware-crisis-the-themocline-of-truth/
The Affordable Care Act : AKA ObamaCare
Well, the website had 4 major functions:
1) Comparison shopping. In retrospect, it could have been handled by a private company that Travelocity like didn't sell insurance, but instead helped you shop.
2) Subsidy. According to the law, you only get a subsidy through a state-run exchange (the Administration has chosen to ignore the actual wording of the law to include the Federally run exchange two.)
3) Seeing if people should be shuttled off to the mediocre but cheap care of Medicaid.
4) As a showcase for the law. This was to be something concrete to show what great things progressive government is capable of.
Bureaucrats are comfortable generating reality. To a large extent this becomes their job; if you are in charge of an environmental clean up you will move the goalposts around to match what you can do, and if you can't even meet these mutable goals you figure out a way to measure it so that the result are met. Plus you take any reports that indicate failure and "massage" them until they look good; and if the underlings who create these horrible truths won't shut up you punish them or just get rid of them.
This works well when the facts are a bit fuzzy and you are able to control the flow of information to your superiors and ideally the public. The problem is that the skillset that enables these people to survive and thrive in a bureaucracy aren't the skills required to deliver a functioning and realistic test passing product. So you have a product such as healthcare.gov which is going to be wildly exposed to the public and the scrutiny of people you can't control (the press and political opposition) and oddly enough it blows up.
People look at the hard numbers and say this is a pile of crap that doesn't work. Yet I am willing to bet two key things are happening:
One is that there are reports flowing up to the top people (who don't understand technology) that are a combination of saying that it works far better than the "detractors" are claiming while simultaniously blaming some other party with lesser abilities to communicate with said superiors.
And two that the company that won this contract is awesome at participating in this reality distorting circlejerk. I bet that the reports and other paperwork was Washington gold; the product of top-of-the-class-MBAs. People for whom facts are not only to be ignored but to be looked at with suspicion and hostility.
So the question of which development style should have been used or which technology was best are nearly moot; in that every choice would have been made based upon the criteria of "It must look good in a report"
I suspect that the only lesson learned from this in Washington is that if you love your career that you should not get involved in a project that involves a measurable end product that is delivered to the public.
The various opposition groups will probably try to score various points based upon actual facts such as cronyism and poor testing but the reality is that 5 minutes into getting power they would hand a similar project over to their insider friends and primarily demand good paperwork over an actual product.
So to prevent this type of disaster you can't look at say agile practices in software but maybe agile type practices within government itself.
Way to take that line out of context. "Failure is not an option." wasn't about general day to day stuff, it was about saving the lives of 3 astronauts during an emergency situation. In fact, the mission (LANDING ON THE FREEKIN MOON) was indeed a failure.... They DIDN'T do it!
The whole "failure is not an option" thing is fine when you have lives in danger and the whole world is watching, but you don't get to use it about your website, no matter how many jobs are at stake. The message to take away here is "Even a million jobs are not worth 1 human life." If you understand and live by that, you will be a better person. Otherwise, you're just another scumbag millionaire who doesn't care about people.
As soon as we decided that hospitals were legally required to give you health care if you walked into the emergency room we decided that health care is a human right. That debate is over. So now what do we do about it? You can either have the blood suckers feed off a system they're not paying into, or you can require they pay into it like every responsible adult has been doing for generations. The government is not requiring me to do ANYTHING really. They've created a new income tax (you're exempt if you have no income) and a corresponding tax break if you happen to buy health insurance. While it may be slimey it's perfectly within the normal business of government to enact income taxes and tax breaks. IMHO single payer or Medicare-for-all would've been a preferable option, but it wasn't politically viable, so we got this. It's not great, it's basically a big handout to the insurance companies. Have you watched their stock prices? They've shot up over the last few years. But at least the bums who were living off me in the form of higher premiums I was having to pay each year will now be paying in. And if someone was really sick and was unable to get health insurance at any price before now gets health coverage.. isn't that GOOD? My ex-wife couldn't get private health insurance. I know, because we tried. She had a clotting disorder but was generally a healthy and able-bodied person. But nope, can't buy health insurance. So unless her provider got her on a group plan, she was completely SOL. If more people like her, and even people who are not able-bodied can get some insurance now then that's awesome.
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In my group there is a person with that specific responsibility. They communicate the possibility of not meeting a deadline and make contingency plans to get the best result given the circumstances.
That person should be fired, and IIRC they have already resigned.
Now find senior advisors who weren't responsible for communicating the risks but knew about them anyways. Ask them why they didn't communicate the risks to the President and based on their answer either fire them or reprimand them.
Send the message that there will be accountability. Why is that important? Unfortunately, be it in Government or the private sector, there is a culture of "that wasn't my job". Everyone knows the project will fail, every single fucking person from the junior engineer to the senior project director know. But everyone winks at each other across the table at meetings and agrees that "failure is not an option, it will be done on time". And inside their heads and within their small groups everyone is saying "well it's not my job to sound the alarm". There is no incentive to take that political hit and say "Boss, we might have told you several times that everything is OK but honestly there are some severe risks to launching by the deadline and we need to start planning for a delay or reduction in features". Instead, when shit hits the fan it's like a mexican gunfight, everyone points a finger at someone else and says "well he knew too" or "that wasn't my job to bring up that this would never work."
Engineering is hard, failure happens. It really shouldn't be punished (except where people just failed to do their jobs), instead it should be learned from so that the same mistakes are not made again.
One day, when software engineering management is a real discipline, they will pound it into the heads of MBAs and PMPs that failure is not only an option, its the most common result so make sure the lines of communication are open, that people feel comfortable communicating risks and saying no, and that all the stakeholders know that the engineers cannot travel through time, so if you start a 1 year project 9 months before you want it to launch then you are SOL and have to pick what features are most important.
I hate "you have more than one number one priority" more than "failure is not an option" and I feel people who say one usually say the other.
In a former life I did a lot of gov contracting. For any project, you couldn't get your GPM (gov program manager) to sign off on anything. Why? Because they had to go to their boss to get approval. Who also had to go to their boss to get approval and so on.
Why? Because they didn't want to be the one to blame if something went wrong. If anything, they were very apt to go up the flag pole for anything, but the issue was you never got an answer for anything.
This seems to be the case for healthcare.gov, no one made actionable decisions.
The more you hear about how he supposedly didn't know this or that, the more you have to wonder if he isn't a simple community organizer.
When Fascism comes to America, it will call itself Anti-Fascism, and tell you to give up your guns.
....The idea that the government has the right to tell you to buy X product in order to live in this country is problematic...
There's more than one way of looking at it, and I'll try to explain it in a way that even the most neo-liberal, free-market capitalist would understand. Before Obama Care, back when Barack Obama was probably the name of somebody living in a cave in Afghanistan, the government was requiring those who sold a "product" (medical care) to give it away for free to those who could not or would not pay for it (the uninsured). Forcing "retailers" (hospitals) to give away their "product" (medical care) for free is not a sustainable business model, especially when in some "markets" (states), such as Texas, 20% of the population "cannot pay for the product" (is uninsured). But rather than go out of business, the "retailers" (hospitals) divided the cost of giving away their "product" (medical care) to "unpaying customers" (uninsured patients) and added it to the overhead payed by their paying customers (insured patients). The insurance companies turned around and increased the "price" (insurance premiums) they charged for "X product" (health insurance); thus making "product X" (health insurance) more expensive; thus resulting in more "unpaying customers" (uninsured patients) demanding "free products" (health care) from "retailers" (hospitals), thus further increasing the "price" (insurance premiums) charged for "X product" (health insurance) etc. etc. etc.
But comparing an inelastic market to a normal consumer product with elastic demand, is really as nonsensical as my post.
I think what Richard Feynman said at then end of the appendix to the report on the Space Shuttle Challenger failure may also apply in this situation.
For a successful technology, reality must take precedence over public relations, for Nature cannot be fooled. --Richard Feynman
Planning? What planning? Hoping. Commanding. Directing. Praying. Lying. Concealing. Misdirecting. Deceiving. But no "planning" of the type that experienced project managers would recognize.
>> If Congress can't handle a simple friggin website project, it's time to clean house
Replace "Congress" with "the current president" (you know, the one in charge of IMPLEMENTING the law - http://www.archives.gov/exhibits/charters/constitution_transcript.html) and I'll agree with you,
How about some other perspective: in 1941, the US entered into a total war, the last such war we have seen. Essentially the entire output and focus of the country was directed towards the task of winning the war. I'm not sure getting healthcare.gov up and running was really quite the same priority.
There is a common myth that the high cost of health care is due to uncompensated obligatory emergency room care. Like many myths, it provides comfort to the general public, who are always looking for easy explanations for the complex problems of the world. But like all myths, it has the downside of being false.
In particular, the percentage of a hospital's expenses spent on uncompensated care is about 6% (in 2011, 5.9%)
http://www.aha.org/content/13/1-2013-uncompensated-care-fs.pdf
The mandate to provide emergency care to all those that show up in the ER was part of the Emergency Medical Treatment and Active Labor Act of 1986.
http://en.wikipedia.org/wiki/Emergency_Medical_Treatment_and_Active_Labor_Act
Turning back to the first link: what was the percentage of uncompensated care in 1985, before the Act? 5.8% So as a result of the treatment mandate, the percentage of hospital's uncompensated care went up all of 0.1%. (From then to today; there was a spike up to 6.4% the year after the Act was passed).
Undoubtedly, uncompensated care is a problem. It's just a rather small problem. Far bigger is the lack of market forces that removes any incentives to inefficiency.
As a side matter; I'm very sorry to hear that about your wife -- there is definitely a significant need for improvement in the system for helping people with pre-existing conditions.
One of the most helpful things I ever realized is that Design and Management think in terms of yes / no and Engineers think in terms of shades of gray. It will work vs it will work to "x" sigma are very different things and you have to have some skill to translate.
There is a common myth that the high cost of health care is due to uncompensated obligatory emergency room care.
The high cost of health care - as seen for by those without insurance - is the inability of the common man to receive services at the negotiated rate of insurers. An X-ray for a major insurer is $27. Double it and add a zero if I walk into the emergency room without insurance. Pills for your condition? $4 co-pay at the in-network provider for the insured. $40 a pill if you're on your own. Don't pretend the insurer is paying $40 a pill, that's just the price the uninsured pay.
If I could pay the negotiated rates for day-to-day services, I'd have the highest deductible plan someone would sell me - saving my insurance for something actually worth insuring against - catastrophe. Unfortunately, that's not an option.
Well, it is true that gerrymandering leads to extremists, but gerrymandering really only is that bad in large states. I live in New Hampshire, I'd like to see you try and draw a district map in New Hampshire which was more than 55% Democratic, as we only have 2 districts and both are always competitive. On the other hand, Massachusetts has no Republicans in Congress; and even then Barney Frank quit in a huff when his Newton district was redrawn to be even a little bit competitive and he'd have to spend time debating some hopeless Republican; how humiliating for him.
I used to live in California, and the gerrymandering there was horrible and resulted in the legislature being filled with morons and parasites. It'd be nice if you could mandate a computer algorithm to draw the lines based solely on population, city boundaries and a minimum number of polygons.
Who concedes decision-making power of the most important item on one's list? It's more than a conundrum, it's a full-blown mystery.
It baffles me, but the President surrendered leadership on his signature legislation at the beginning. One of his first moves was to let partisan Nancy Pelosi take the lead and also take the process into the back rooms with lobbyists in tow. He surrendered his promises of an open and transparent legislative process with seats at the table for all.
While it may be the Republican's view that government does not work and should be reduced, it's the Democrats who are proving out the validity of that view.
Since the Democrats do not seem to have that view, it seems then a totally valid view to have given those most opposed to it are providing the evidence.
"There is more worth loving than we have strength to love." - Brian Jay Stanley
False. 26 Republican States refused to create their own website by the December 31st 2012 deadline, forcing the Federal government to create 26 websites in less than a year.
So you are arguing that some big social programs are best handled at the state level, that they should not be done at the federal level? That they can not be done right at the federal level?
According to Wikipedia, "In left-right politics, right-wing describes an outlook or specific position that accepts or supports social hierarchy or social inequality."
Rand Paul is all about small government--which pretty much by definition means right-wing according to the definition above.
Rand Paul calls himself a "constitutional conservative" and a "libertarian conservative." He opposes federal government involvement in health care, thinks it should be entirely privatized. He thinks the 14th Amendment shouldn't apply to kids of illegal immigrants. He shares some of the views of the religious right--he is against abortion even in cases of rape or incest, and he is opposed to same sex marriage.
False. 26 Republican States refused to create their own website by the December 31st 2012 deadline, forcing the Federal government to create 26 websites in less than a year.
You are ill informed at multiple levels. (1) The federal government only needed a single website. There is only one federal exchange. (2) The federal government knew it needed this website as soon as the legislation was passed. They have had over three years to implement it.
Read some news from that time WMD were found just not the quanties the intelligence offices from almost the countries of the world said there were, Cuba and North Korea being some of the that said there were none.
It is always easy to spot the breitbart.com fans in the office:
1) They all subscribe to the "Nancy Pelosi as ultimate evil librul WITCH" theory - despite Pelosi being an ordinary centrist Democrat. Which is to say, a bit to the left of the DLC/Third Way, a bit more to the left of the neoliberals: just about at the median of US voters.
2) They have no understanding of how a legislature that intends to endure for many years and which uses parliamentary rules of procedure, actually works
3) They have no understanding of what the Speaker of the House's job actually is.
sPh
Pelosi is, to be sure, a very good political manager (and therefore a very effective Speaker of the House). Perhaps that is what makes her unforgivable compared to Boehner and - particularly - Cruz.