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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.'"
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.
we can't even launch a damn website.
The Republicans in Congress had exactly ZERO involvement with the implementation of the website. Once approved by Congress, and then upheld by the SCOTUS, it was on the Executive branch to hire the firms to build the website. This is 110% on the Executive Branch of the government.
I think that most Americans can be found in the middle of the two extremes (far-left/far-right) but our political system is set up to reward those who pander to the extremes (Gerrymandering + closed primaries in most states), so we wind up with this system that swings back and forth between the two, rarely settling in the middle where most of the electorate lies. Divided Government used to bring outcomes in the middle (Reagan/O'Neil, and Clinton/Gingrich) but now it just seems to bring grandstanding and stalling (Bush/Pelosi, Obama/Boehner), as each side waits to beat the other in the next election, while kicking the serious issues of the day down the road, to be dealt with after they have a "mandate" from the voters. Each side misreads the smallest win as a "mandate" for their platform, ignoring the fact that 49.9% of the country voted the other way. BHO's "mandate" in 2008 can be boiled down to three words: "Don't be GWB", not "Dust off every Progressive idea that's been on the bookshelf since the 60s." Similarly, John Boehner's "mandate" in 2010 was "Don't be Nancy Pelosi", not "Give the keys to the Tea Party."
There are some benefits to the two party system in the United States, compare the (relative) stability of our system to some Parliamentary Democracies, but we're in pretty big trouble if we can't take the two parties back from their respective extremes. I'm not sure how this happens, when each party keeps bleeding elder statesmen, House primaries are dominated by rabid partisans living in echo chambers, and even the Senate (where gerrymandering is a non-issue) looks to be on a downward spiral wherein statesmen are out and partisan hacks are in.
I want peace on earth and goodwill toward man.
We are the United States Government! We don't do that sort of thing.
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.
Wait, so you're blaming bi-partisanship on the fact that the DHHS mismanaged a project. A project which: A) They had more than sufficient funds available. B) A Mandate in terms of legislative action. C) An executive branch lead by the guy who pushed this shit through?
I'm sorry but if somebody gave me over $300 million to develop a website with the requirements that these guys had, it would be done and our contract would have had penalties for failure to deliver. None of these contractors who put this mess together have yet to be held accountable for their own mismanagement and that is at the heart of why government projects like this fail, the contractors always have weasel clauses that the government allows, ultimately releasing them from blame when things go Tango Uniform. There's ample fees and revenue to be made for change orders which do nothing but encourage the project management team to encourage them to the stakeholders, causing delays and increasing the overall cost of the project. Healthcare.gov has had over $300 million spent on it and it's still doesn't work. Now they've extended dates and shifted delays and I'll bet you within 3 to 6 months they'll try to scrap it and start over. In the meantime you'll get a friendly letter from the IRS saying you owe a penalty because you haven't signed up because now there's thousands of new public servants at that vaunted institution just looking to fuck you over because the T wasn't crossed or some other problem that the government created but now it's your problem. "Oh you couldn't sign up? not our problem, we're the IRS and we're always right and you're wrong."
This whole piece of shit legislation was thrown together by a bunch of morons who wanted to look good. I won't quote that retard Pelosi but the fact that nobody read the legislation. It was over 2000 pages long and more than anything else, shows how truly fucked we are in this country because at that point when legislation gets railroaded through like this because "Teddy is dying and we need to show we still lick the Kennedy's nutsacks in DC" Is no reason the rest of us have to take it up the ass. So while you blame gridlock let's not forget that for two years the Democrats pushed all this shit down our throats, not reading the legislation and trusting that it would all work out; Glinda the Witch of the North will wave her wand and make it all better.
Don't believe me? In 2009 after the ARRA was passed I had the privilege of flying from DC to Raleigh Durham, sitting behind two Congressmen heading back home, one newly elected on Obama's coattails. They were high fiveing the crew when they came on-board "We passed it!" one exclaimed. During the brief flight they kept handing pieces of the ARRA legislation back and forth with one saying "I didn't know that was in there!?" The other being so myopic that even with glasses he held the pages about 2 inches from his nose to read them.
Harrison's Postulate - "For every action there is an equal and opposite criticism"
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.
would rightfully get them primaried in the next election?
And therein lies the problem. Primary elections are the "true" election in most Congressional districts (Democrat and Republican), thanks to gerrymandering. Primary elections are universally low turnout affairs that are dominated by the true believers, the types that get all of their news from MSNBC or Fox, who are least inclined to seek accommodation with the other side. The consequence of this is that we end up with hyper-partisan hacks that don't even represent the mainstream of their gerrymandered district, much less the country as a whole.
I'm not blaming the GOP, the exact same thing happens in gerrymandered blue districts. Nancy Pelosi doesn't represent the mainstream of the Democratic party, much less the United States, yet she is the voice of the Democrats in the house.
I don't know what the solution is. Some will argue that we need a third party, but that's no guarantee of a different result. Indeed, it makes it possible for the same hyper-partisan hacks to win as before, only now they'll have won with 40% of the vote instead of 50.1%. My hometown (Binghamton, NY) ended up with a left-wing asshole as Mayor, who won two three-way elections, and pushed his asinine left-wing agenda despite 60% of the city voting against him. (Hint for Matthew Ryan if your egotistical self finds this post with a Google search: People don't vote for Mayor to make statements about the Iraq War, they vote for him to fix the fucking potholes, keep the parks clean, and to try and attract employers to the area)
I want peace on earth and goodwill toward man.
We are the United States Government! We don't do that sort of thing.
Yet Obama's response was not "By executive order, if the website is not fully functional by December 1st, all executive departments are hereby forbidden to award future contracts to CGI or its successor entities."
What a putz.
Guess you're not the CEO of the Fortune 500 I used to work for. I see this frequently the time in corporate structure as well - the bigger the structure, the worse it is.
Underling: "That's impossible. We might get it done in N days, and C isn't actually possible without a complete rewrite."
Low-Boss: "Great. The time frame is tight but we can do it with some extra elbow grease! Let's meet about the specs."
Mid-Boss: "Timeline is great and we'll iron out the details."
Upper-Boss: "It's all on track."
BIG Boss: "Great job."
The developer has to do the work, and is the most accurate about time constraints and difficulty of the project. At each level of reporting, though, the prognosis get's a little better because nobody wants to deliver bad news. Low management says it will be tough and there are some problems. Middle management says things are looking good and they're working out the kinks. Upper management says everything is great. The Boss has no idea. The more levels there are, the more dilute the bad news becomes.
Your
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.