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Figure 1-- Comscore’s data regarding daily visitors to
Healthcare.gov
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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 21st 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 24th
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 1st
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”.
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Figure 2--Pictured L-R: Cheryl
Campbell of CGI Federal, Andy Slavitt
of Uptom/QSSI, Lynn Spellecy of Equifax, and John Lau of Serco
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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.
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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.
[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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