Finding a cure for what is ailing Healthcare.gov and the Affordable Care Act

Kathleen Sebelius testifing before the House Energy and Commerce Committee
10-30-13

Last week, both Kathleen Sebelius, Secretary of the U.S. Department of Health and Human Services (HHS) and Marilyn Tavenner, Administrator of the Center for Medicare and Medicaid Services (CMS), testified before Congressional Committees as representatives of the Obama Administration giving their side of the story regarding the failed Open Enrollment launch of the Affordability Care Act (ACA). Just when we were hoping that Healthcare.gov was on the mend because of the announcement that Optum/QSSI was taking the role of system integrator and additional help was coming from Silicon Valley and Jeffrey Zients, Director of the National Economic Council and founder/former CEO of Portfolio Logic, Healthcare.gov suffered another setback. This time Verizon was reported to be responsible for a system outage that occurred the weekend before Secretary Sebelius and Administrator Tavenner testified before Congress.

On Wednesday, October 31, Secretary Sebelius faced a tough crowd of Republicans with a series of questions about not only the website’s maladies, but also privacy and security issues/breaches and health insurance cancellation notices received by two millions[i] Americans from insurers who blamed the cancellation on ACA’s requirements.  They also peppered her with questions about whether the President intentionally deceived or misled the American public when he repeatedly said that people could keep their existing insurance plans if they liked it, and the 50% or higher rate increases for new plans insurer are offering those whose plans have been cancelled. Insurers are justifying the rate increases by saying the ACA law is forcing the change. Although Democrats were generally supportive, they too wanted substantive answers on why the website continues to be plagued by problems.

Ms. Sebelius apologized in her opening statement for the inexcusable: a failed launch of Healthcare.gov. She committed to fixing the website, and earning back the confidence of the American public.  But even as she tried to move the conversation away from the website by talking about the goals and other successes of the ACA, such as:

     * The promise of significantly lower premiums via the
         ACA Marketplace (both federal and state health     
         exchanges);

     *  Some insurance companies finalizing rates for the
         marketplace that are even lower than they initially
         proposed which will result in significant cost savings to
         individuals;     
     *  Discounts via tax credits and subsidies that could
         amount to 35% off of the undiscounted marketplace
         rates for those who qualify; [ii]

it was reported that Healthcare.gov was down and it remained down for duration of the Hearing making it difficult to change the subject. 

And when the Republicans did change the subject, they went to another hotspot for the Obama Administration:  millions of Americans receiving health insurance cancellation notices and President Obama’s words that “if you like your health care plan, you can keep your health care plan”.  In two days of testimony by both Secretary Sebelius and Administrator Tavenner, there was no easy and simple response to the challenge that the President was not truthful about the effects of the ACA law on the insurance market place and its current customers. Talk of grandfathered clauses and the hope that individuals who recently received cancellation notices will shop for new plans via the federal and state health exchanges did not fully address the anxiety some Americans are feeling about having what’s familiar to them taken away when they were told otherwise.  A concise and succinct message that explains what has happened and what affected consumers should do next is needed. Not just anecdotes about the experiences of a few people who have been able to overcome all of the challenges of the website and enroll in a plan.

Marilyn Tavenner, CMS Adminstrator

The premise of creating competition by aggregating noninsured young and old, sick and healthy Americans into large groups similar to the groups that large employers benefit from is admirable.  Administrator Tavenner testified on Tuesday, October 29th, before the House of Representatives’ Ways and Means Committee  that 80% of those who apply for coverage through the “Marketplace” will qualify for some type of assistance[iii].  That’s great news for those who will eventually get the expected tax credit and subsidies. 

The problem is the website’s issues have been going on for over a month now, and instead of “our patient” being downgraded to stable condition, news reports of more outages and system problems have kept it in intensive care.  Also, news of cancellation notices consumers are receiving from well-known insurers like Kaiser Permanente of California, Blue Cross Blue Shield of Florida, Highmark Health Services of Pennsylvania and Carefirst Blue Cross Blue Shield of Maryland continue to undermined the recovery process.  The millions of people who are visiting Healthcare.gov looking for a solution to their health insurance needs want to know that the ACA law is going to deliver the help it promised.  Although the ACA law is not just the website, right now the other good benefits of the law have taken a back seat because of a lack of information that would normally be accessible through the website.  This has caused people to fear that they will be left in a lurch paying higher prices for health insurance, left without coverage and/or penalized because they do not have coverage by the deadline.  Saying that the cancellations are happening because those policies are “substandard” is not enough.

The bottom line is until Healthcare.gov is fixed so that consumers have a shopping experience that is acceptable, all the Obama Administration’s messaging about the benefits of the ACA law sound like a broken record.  People want to know, ‘what have you done for me lately’?  The fact that the Marketplace rates are finalized and stable for 2014 is newsworthy but this message is being eclipsed by the other stories about the website’s ills and cancelled health plans, etc.  November 30 is the deadline to find a cure or people are going to really start wondering if this program can be cured.

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[i] Obamacare: More than 2 million people getting booted from existing health insurance plans, October 29, 2013, http://www.cbsnews.com/8301-505263_162-57609737/obamacare-more-than-2-million-people-getting-booted-from-existing-health-insurance-plans
{ii] Prepared testimony on the Affordable Care Act Implementation by Kathleen Sebelius, Secretary, U.S. Department of Health and Human Services, before the U. S. House Committee On Energy and Commerce Committee, October 30, 2013, 
http://docs.house.gov/meetings/IF/IF00/20131030/101446/HHRG-113-IF00-Wstate-SebeliusK-20131030.pdf
[iii] Prepared testimony on the Affordable Care Act Implementation by Marilyn Tavenner, Administrator, Center for Medicare and Medicaid Services, U.S. Department of Health and Human Services, before the U. S. House on Ways and Means, October 29, 2013,
http://waysandmeans.house.gov/uploadedfiles/102913_tavenner_testimony.pdf

Healthcare.gov: Usability Not Blame

Figure 1-- Comscore’s data regarding daily visitors to Healthcare.gov

According to a recent U.S. Census Report, 48 million Americans need health insurance. President Obama commented from the Rose Garden of the White House on October 21^st that there had been 20 million total visits to the Healthcare.gov website indicating that despite the difficulties encountered when trying to register via the website, there is still a lot of individuals who are interested in checking out what the Affordable Care Act has to offer in terms of its affordable health insurance rates. The Center for Medicare and Medicaid Services (CMS) said in a briefing on Thursday, October 24^th that 700,000 people have begun the enrollment process via the federal or a state-based exchange[i] Although the unique visitors to Healthcare.gov has declined significantly since October 1^st as shown in Figure 1, a considerable amount of new individuals are still visiting the site to shop for health insurance. The question is will the site work as intended enabling Americans to view realistic health insurance rates and make purchase decisions?

In the first Congressional Hearing held by the Energy and Commerce Committee in the House of Representatives on Thursday, October 24, there was hope that committee chairman Fred Upton’s (R-MI) remarks before the testimony of the four companies primarily responsible for building the Healthcare.gov website, marketplace and data services hub would set a tone similar to what you would expect in an “After-Action” Review or a Lessons Learned/fact-finding session.  He said, “This is not about blame – this is about accountability…”   CGI Federal Inc., Optum/QSSI, Equifax Workforce Solutions, and Serco, had recently appeared before the Energy Committee on September 10th and said that their testing of the system had not revealed any major problems.  They assured the Committee that the Federal Exchange and Data Services Hub would be ready for Open Enrollment on October 1.  This did not turned out to be true.

And the hope for a hearing focused on identifying the implementation failures of Healthcare.gov (e.g., system, procurement, and/or program management issues, etc.), which was what the CGI Federal Inc., Optum/QSSI, Equifax Workforce Solutions, and Serco witnesses were there to testify to, was dashed when the discourse among congressional members descended too often into partisan “back and forth” sparring. 

Citing some of the popular benefits of the Affordable Care Act which include prescription drug savings, coverage for young people up to age 26 under their parents’ plan, rebates from health insurers who spend more than 20% of insurance premiums on overhead costs, and free preventative care, etc., Representative Henry Waxman of California, the ranking Democrat on the committee, in his opening remarks endeavored to separate the law from the troubled website. He went on to state that “[Democrats} want to know want is wrong with the website and how we can help fix it.” Representative Pallone (D-NJ) coined the phrase “fix it, not nix it”.

Figure 2--Pictured L-R: Cheryl Campbell of CGI Federal, Andy Slavitt
of Uptom/QSSI, Lynn Spellecy of Equifax, and John Lau of Serco

Healthcare.gov Contractors:
CGI Federal Inc., Optum/QSSI, Equifax Workforce Solutions, and Serco testified that their responsibilities in the implementation of federal marketplace and data services were as follows:

·         CGI Federal Inc.—was awarded a $293 million contract by The CMS in 2011, after a two-step competitive process, to develop the Federal Marketplace. The Federal Marketplace and associated “health insurance exchanges” is a “website and a complex transaction processor that must simultaneously help millions of Americans determine their eligibility for insurance and federal subsidies, shop for health plans, and enroll in a qualified health plan.”[ii] CGI Federal was represented by Senior Vice President Cheryl Campbell.

·         Optum/QSSI—is responsible for the Data Services Hub, the “pipeline that transfers data – routing queries and responses between a given marketplace and various trusted data sources.[iii] The Data Services Hub takes the personal identification information input by consumers and directs queries to information government databases for verification and sends the responses back to the federal or state, whichever initiated the query, marketplace. The Data Services Hub does not determine eligibility, it facilitates the process.  QSSI also developed the enterprise identity management or EIDM software that allows consumers to create and use a secure account during the registration phase. Their contract is valued at ~$85 million. Optum/QSSI was represented by Group Executive Vice President Andrew Slavitt.

·         Equifax Workforce Solutions—was awarded a contract in March 2013 “to provide real time verification of income and employment to the Data Hub to facilitate the verification of eligibility for Medicaid and Children’s Health Insurance Program (CHIP), as well as for eligibility for premium tax credits and reduced cost sharing.”[iv] In 2014, they expect to increase their scope of services by verifying that individuals who apply for the tax credit or cost-sharing reductions are eligible to receive them. Equifax Workforce Solutions was represented by Senior Director and Corporate Counsel Lynn Spellecy.

·         Serco Inc. was awarded a one year contract with up to four one-year renewable options valued at $1.2 billion “to provide routing, automated processing, reviewing, and troubleshooting of applications submitted for enrollment into a Qualified Health Plan.”[v]  Serco will also provide records management.”[vi] Serco is also responsible for opening and managing 4 processing centers in Kentucky, Arkansas, Missouri and Oklahoma with approximately 1500 staff people. Serco was represented by Program Director John Lau.

Most Americans are not aware and do not understand the complexity of the system needed for the marketplaces and exchanges to work. Although Representative Anna Eshoo (D-CA) made an informative comparison to the e-commerce capabilities of Amazon, ebay and ProFlowers.com in her remarks and questioning, the Healthcare.gov system differs from an Amazon website in that the purchasers’ identity, not their form of payment, must be authenticated before they can view any products. Further, the consumer’s eligibility for tax credits and subsidies must be verified before final purchase.  This process is similar to Amazon saying that they have to qualify you for a credit card at a certain limit before they can allow you to shop for products on their site.

Amazon allows you to browse for products, determine what products meet your feature and price requirements and then you are permitted to make your purchase.  At the point of purchase you can add a discount coupon or code if you have one that lowers the overall price paid.  With the Federal Marketplace, a person’s identity through their social security number (SSN) and date of birth (DOB) must be verified before they can even view the products available.  What further added to the system’s complexity is all of these transactions and look-ups in various disparate government and private companies’ databases must take place in real-time and this is the real problem.

Cheryl Campbell of CGI Federal characterized the enormity of the problem when she stated that the federal marketplace and health exchanges were not a standard consumer website and was “…by far for our country one of the most complicated large-scale systems”.

Andy Slavitt of Uptom/QSSI said that a major problem was a CMS decision that came in late September to require individuals to register and be authenticated before they were allowed to browse and shop for insurance products via Healthcare.gov.  Clearly this major change negatively impacted the system’s readiness for October 1.  Some Republicans committee members felt this change may have been politically motivated and intended to hide the real prices of the insurance products offered.

The testimony of Lynn Spellecy of Equifax Workplace Solutions and John Lau of Serco suggested that their companies’ involvement was not directly related to the interminable problems that have plagued Healthcare.gov since October 1.  It was apparent from Campbell and Slavitt’s testimonies that Healthcare.gov was not sized properly for the volume of traffic it received and the EIDM functionality that authenticated each user did not work properly and caused the problems that consumers faced when trying to register via the website.

Campbell and Slavitt also testified that end-to-end testing did not occur until a few days before October 1.  From a program management standpoint, these two issues were enough to signal doom for the Open Enrollment launch.  Campbell also stated CMS took on the role of system integrator. A system integrator is the Single Point of Contact (SPOC) and they are responsible for assembling all parts of a system ensuring that the parts work together as intended. It is questionable whether CMS should have taken on this responsibility.  This is not part of the agency’s mission or core competencies. 

Congress would do well to try and ascertain why CMS took on this responsibility. Was it that CMS felt hampered by the procurement options they had at their disposal? Was the budget allocated inadequate to procure the type or all of services needed or was the timeline established to begin Open Enrollment too aggressive? There is a real opportunity for Congress to examine whether the government’s existing procurement vehicles and laws allow or enable the government’s agencies to meet their mission. 

If assigning blame was an objective of Thursday’s hearing, there is certainly enough to go around starting with:

·         The procurement approach CMS took to acquire this system.

·         CMS’s decision to act as the system integrator

·         Lack of time allocated for end-to-end testing

·         The government’s late September request that individuals be required to register and their identity be validated before they are allowed to browse the insurance products via Healthcare.gov

·         CGI and Uptom/QSSI ‘s products failed to meet expectation

At the end of the day, this is about empowering everyday Americans and enabling them to purchase affordable health insurance. As Rep. John Dingell (D-MI) said, “Healthcare is a matter of right and not privilege.”  For most of those everyday Americans, especially the young and healthy ones the program is trying to attract in order to keep the health insurance rates affordable, the website is how they will get the information they need to make informed purchases. 

In order to make the website more useable and viable, Healthcare.gov needs to make the user and shopping experience more like what Americans experience when shopping for other products via the web.  Consumers need to:

•  Be able to browse and  view the available health insurance products
• View a side by side comparison of the basic features and options of each plan
•  Be quoted a reasonable and realistic price quote that’s based on their individual characteristics not the characteristics of a group so broad that the quote is 30-50% higher than the actual rate
• Be told how the tax credits and subsidies could affect their final rate. For example, individuals should be told what the requirements are for the tax credits and subsidies and the value of these discounts 

As part of my follow-up from Thursday’s Congressional Hearing, I tried to sign in and register via the Maryland exchange on Thursday. I had purposely waited to view what was available via the health exchange website because of all of the reported problems. I went to Healthcare.gov to sign in and was directed to the Maryland Exchange because Maryland, the state where I reside, has its own health exchange.  I quickly entered the requested personally information. This process did not take long at all.  However, I immediately received the message shown in Figure 3.  I tried this process twice and was unsuccessful both times.

On Friday, I tried again and received the same message. When I called the number listed on the website to find out what the problem was, I was told that the website application process was unavailable and that I would be notified when it was fixed.  

Figure 3--Message received from Maryland Exchange when trying to
register on October 24 and 25.

Final Thoughts: Opportunities For Change

The Obama Administration should re-consider the requirement for identity authentication before an individual can view the insurance products. This is not in line with comparable commercial e-commerce sites and there does not seem to be an operational need for this requirement. I would never enter my SSN and DOB in a website just to shop. My fears about this were only curtailed because I was using Healthcare.gov. If this was not a dot.gov site, I would never have considered entering this information to view the website’s products. It’s kind of like being asked for your credit or bank card before you have decided to buy something.

Healthcare.gov’s challenges have undercut confidence in the law. Although the Obama Administration has given some regard to this in that they have extended the deadline for signing up for health insurance from February 15th to March 31th, they should focus on building confidence in the website’s ability to function as previously promised and assure the public that they will not be unfairly penalized because of the website’s early problems. The administration has not done enough in this area. To do this they will have to address the penalties associated with the Individual Mandate.

Also, Congress should not miss an opportunity to understand how the government’s procurement laws affected and added to the problems with building Healthcare.gov. Questioning Health and Human Services Secretary (HHS) Kathleen Sebelius will not totally reveal these issues in enough detail to uncover the underlying problems that may continue to hinder the government’s effectiveness in building state of the ark computer systems. In order for this to happen they need to create an environment that is similar to what is experienced in an After Action or Lessons Learned meeting and definitely interview top management officials at CMS.

Lastly, the fact that no one at HHS or CMS stopped the Open Enrollment launch given that  days before the October 1 deadline they knew there were significant problems with the website may indicate a deeper problem within the employee culture at the agency. Do employees feel safe in truthfully communicating unpopular news to top officials? At this point, it’s impossible for outsiders to know whether this is the case, but it may be something the agencies should take a seriously look into.

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[i] “No time to test: Feds admit they rushed the insurance website”, Maggie Fox,  NBC News Health, http://www.nbcnews.com/health/no-time-test-feds-admit-they-rushed-insurance-website-8C11457475

[ii] Testimony of Cheryl Campbell before the House Energy and Commerce Committee on 10-24-13, Senior Vice President, CGI Federal Inc., http://docs.house.gov/meetings/IF/IF00/20131024/101424/HHRG-113-IF00-Wstate-CambellC-20131024.pdf

[iii] Testimony of Andrew Slavitt before the House Energy and Commerce Committee on 10-24-13, Group Executive Vice President of Optum which owns Quality Software Services, Inc. (QSSI). Optum is a business united of UnitedHealth Group. http://docs.house.gov/meetings/IF/IF00/20131024/101424/HHRG-113-IF00-Wstate-SlavittA-20131024.pdf

[iv] Testimony of Lynn Spellecy before the House Energy and Commerce Committee on 10-24-13, Senior Director and Corporate Counsel for Equifax Workforce Solutions, a subsidiary of Equifax. http://docs.house.gov/meetings/IF/IF00/20131024/101424/HHRG-113-IF00-Wstate-SpellecyL-20131024.pdf

[v] Serco Press Release: Serco Awarded $1.2 Billion Center for Medicare and Medicaid Contract Supporting Health Benefit Exchanges, July 11, 2013, http://www.serco-na.com/news-article/2013/07/11/serco-awarded-$1.2-billion-center-for-medicare-and-medicaid-contract-supporting-health-benefit-exchanges

[vi] Testimony of John Lau before the House Energy and Commerce Committee on 10-24-13, Program Director of Serco Inc. 

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Leadership Tuesdays: Healthcare...A Conversation with Karen Dale of AmerihealthDC

Do you have questions about choosing a health insurance provider? Listen as Karen Dale, Executive Director of Amerihealth District of Columbia, explains what to look for in a provider and the impact of the Affordable Care Act in the Washington, D.C. area. 

The goal of Leadership Tuesdays is to provide a platform for a variety of voices and resources to develop, encourage, and strengthen women leaders. Dr. Myles Munroe put it best in his book, Becoming A Leader (2009), "...there is a leader in everyone waiting to serve his or her generation." Women, get ready... get set...let's lead!!