Affordable Care Act (ACA) Rollout: State of Failure, January 5, 2014

Unmet Needs, Organizational Neglect, and International Piracy

The Affordable Care Act (ACA) rollout is in a state of failure. Driven by over-politicized decision making throughout, the ACA web page project (Healthcare.gov) has been a Supply Chain failure. Quashed by heavy-handed senior management both Government and its Canadian contractor, the voices of the technical staff went unheard. It is no wonder that technical staff members are getting sick and fainting at meetings. Even a woman on the podium behind President Obama in his October 21, 2013 speech defending the ACA web page project (Healthcare.gov) rollout also began to faint as she dutifully fulfilled her role as a prop in the charade. Perhaps she had just learned that the President's promise, "You can keep your plan if you like your plan", was not true after all even it does appear 102,000 times on the White House web page or that erroneous applicant data is being transmitted to insurers. Could this be related to the fact that the ACA web site received only a preliminary security authorization to operate? All that, and the flagrant act of software piracy in removing the copyright notice and credit attributions from the Open Source code used.

Software projects that launch this poorly with so much commotion do not end well. This project, like other failed projects before it, can not be rescued simply by working as hard as they can 24/7 to detect and correct bugs as they appear and completing a punch list of a couple of hundred issues without doing end to end testing. Instead, its deep rooted problems must be ferreted out, identified, acknowledged, findings assessed, and recommendations framed and acted upon. A 60-day effort to do this should begin immediately. 

ACA Website Intended Function 

The ACA website is a software-based facility intended to bring customers and health care providers together. The purpose of this software is to ensure harmonious cooperation between people and machines in enrolling customers in affordable health care plans that meet their needs. The ACA website rollout has demonstrated that it is incapable of achieving this primary purpose, that is, bringing customers and health care providers together in a harmonious and satisfactory relationship. For the past month the ACA web site has been operating in a state of failure. The ACA web site has not met the standard of excellence, either expected or promised, of best industry practices. It is not complete, it is not correct, it is not consistent, and it does not follow the rules of construction for an industrial-strength health care web application architecture. 

ACA Supply Chain Flow

Operating as a Supply Chain, the mission of the ACA website is to permit customers to apply for and purchase affordable health care; to comparison shop; to enter profile data, personal data, and decision data; and to facilitate health care providers to promote their offerings, provide product pricing, and accept and confirm customer decisions including changes in decisions. 

There have been reported problems at every step in the ACA Supply Chain flow. We know this because the first three weeks saw 19,000,000 ACA web page hits and only 476,000 applications, that is, customer entered profiles and personal data. Just how many of these were paper applications, the recommended approach by navigators when customers desperate for insurance are faced with persistent web page difficulties?

Not much Supply Chain flow going on in Delaware which recorded just 4 enrollments in health care plans and just 31 enrollment applications by by November 6, 2013. Yes there are kinks in the ACA web page, but there are also kinks in the Supply Chain which must be trusted. But is it?

Now what about the trustworthiness of the health care enrollments that have taken place? I understand there were 6 on the first day and 248 on the second day. Was this flawed system able to perform each of these correctly? All results to date should be viewed with suspicion until the web site has been renovated and the end to end testing completed not just for the purpose of finding more bugs but for the actual intended purpose of demonstrating a trustworthy, correct, and secure operation.

No small task, Supply Chains are risky and complex operations. With 55 companies delivering products, components, services, and relationships, the ACA web site connects to a variety of other Government systems including Social Security Administration, IRS, Veterans Administration, and the Office of Personnel Management. Not just English, the ACA web site is intended to support Spanish; however, this feature is currently on hold.

Root Cause Problem: Over-Politicized Decision Making

Over-politicized decision making appears to be the root of the problem. First there was  the decision to select a Canadian contractor who encountered similar difficulties in a failed health care project in Ottawa. Then there was the decision to finesse the potential for public problems prior to the 2012 election by postponing the start of the ACA website development effort, with specifications appearing only in early 2013 followed by the start of belated code development. In an effort to retain control and contain problems, the Government decided to serve as the project integrator. Instead of tapping the expertise of an industry technology integrator like IBM, the Government decided instead to retain its own Centers for Medicaid and Medicare Services (CMS). Instead of providing a simple and free flow of health care product and price information to customers, it decided to reveal pricing information coupled with the determination of subsidies so as to avoid expected sticker shock by customers if presented with actual market rates. Instead of the requisite 4-6 months of testing, the Government decided to neglect that testing by delaying its start until 4-6 weeks before the rollout date of October 1, 2013 and only then deciding to finalize project requirements, a decision which further delayed the start of testing until 4-6 days before the rollout.

Consequential Outcomes Emerging

As a result, the outcomes have been consequential characterized by gaps, defects, complexity, and growing Technical Debt as problems are encountered faster than they are corrected. Confidence in the old style architecture of the ACA website has been  eroded with each new revelation. Not yet in evidence but on the forefront of every technical practitioner is the deep seated concern over Cyber Security risks that arise whenever projects encounter difficulty, architecture is questioned, evidence of poor practice abounds, lack of evidence of software assurance and risk management are to be found, and extreme politicization of decision making and heavy duty senior management intervention are the rule.

The Way Forward

Those pretending that the problems being encountered are glitches, kinks, or simply bugs to be fixed and hoping that the problems will simply dissipate with the relaunch need to cease their wishful thinking. It is time to insist on the professional management steps needed to get to the bottom of this and right the ship.  

The following ten steps are called for immediately:

1. Use of ACA website by customers seeking healthcare insurance should be terminated. 

2. Existing customer profile data, personal data, and decision data should be quarantined. 

3. The ACA website requirements foundation and technical architecture should be reviewed, assessed, and audited by a team of experienced industry experts.

4. The management, engineering, and process practices employed on the project should be reviewed, assessed, and audited by a team of experienced industry experts.

5. The accumulated Technical Debt on the project should be reviewed, assessed, and audited by a team of experienced industry experts.

6. A professional team should be charged with assembling factual analytics associated with assurance metrics, compliance metrics, noncompliance metrics, product engineering metrics, project management metrics, and process metrics. 

7. A full scale program review should be conducted to assess requirements, architecture, practices, and metrics. The review team should record its findings and consequences and provide recommendations and rationale for carrying the project forward.

8. A professional team should be charged with assessing Cyber Security vulnerabilities in accordance with the NIST Cyber Framework.

9. A professional team should be charged with assessing privacy and civil liberties vulnerabilities in accordance with the NIST Cyber Framework.

10. The completion date for these activities should be established as January15, 2014.

Taking a Calculated Risk

The job now is take a calculated risk and not continue with the crap shoot. Just how is a calculated risk determined?

The goal is to enroll 7,000,000 people in affordable health care by March 2014. The ACA web page (Healthcare.gov) is the means chosen to accomplish the goal; however, the web page has proven to be a problem and a timely remedy to the web page as currently construed is unlikely. The web page application costs are approaching $500,000,000. With 55 companies now on the job, continuing on this tech surge path may raise the cost to $1,000,000,000 or more.

In his October 21, 2013 speech on the ACA web page project (Healthcare.gov), President Obama acknowledged the problems with the web page and encouraged people to use telephonic or paper applications if they encounter web difficulties. So one alternative to achieving the goal to enroll 7,000,000 people is manual by phone (1-800-318-2596) and paper. At a productivity  rate of 1,000 applicant signups per year per navigator with a burdened annual cost of $250,000 each, the estimated cost for manually enrolling 7,000,000 people might reach $2,000,000,000.

So the available options are:

1. To proceed on the current course and hope that it works out. [$1,000,000,000]

2. To take the professional management steps needed to get to the bottom of this and right the ship. [$1,500,000,000]

3. To employ the manual telephonic and paper application method.[$2,000,000,000]

The risk management decision is whether to select one option and proceed [$2,000,000,000 max.], select two options and proceed in parallel [$3,500,000,000 max], or to select all three options and proceed in parallel [$4,500,000,000]. 

It's All About Trust

Success of the ACA and its web page rollout depends on trust, trust in the web page product, trust in the ACA government policies, and trust by the people who are being asked to sign up.

1. Trust in the web site product was destroyed by the failed rollout.

2. Trust in the ACA government policies evaporated when the President's promise to keep your own doctor and health care provider at a lower cost proved untrue.

3. Trust by the people being asked to sign up is eroding with each passing day due to the failed rollout, due to the false promises, due to the objectionable policy to gather personal information before being allowed to browse health care plans, and due to emerging concerns about privacy and Cyber Security vulnerabilities.

On privacy and Cyber Security concerns, the ACA should be considered as part of the nation's critical infrastructure and subject to the NIST Cyber Framework standards and practices.

Even if the ACA web site is operating by the end of November and some level of trust restored, how can millions of applicants be enrolled in health care plans through ACA in just two weeks by December 15.

Furthermore, the pushback against the policy makers that forbid anonymous browsing by interested customers seeking information on health plans without first disclosing private information is an indication that people don't trust these government decision makers to protect that information. This and the emerging emerging concerns about privacy and Cyber Security vulnerabilities in a poorly designed web page are apt to be lingering concerns that impact enrollment going forward. Encryption protections were neglected thereby unnecessarily exposing personal data to misuse and abuse.

ACA contractors with insufficient skills, capability, and expertise  are like people with no health insurance. They both end up in the emergency room. The only difference, in the ACA there are no doctors ready and able to heal the patient.

The Beginning of the End

With the Affordable Care Act (ACA) Rollout in a state of failure and numerous inconvenient facts now widespread, the White House is now in full retreat. It is playing nice with Insurers in encouraging them to sign up people directly, skipping the healthcare.gov website entirely, despite the fact that going direct to insurers undermines the much ballyhooed comparison shopping. 

Even here, nothing is smooth. Since the mechanism to calculate subsidies is not working, subsidies for those who qualify must be estimated by insurers. Estimates can be wrong; these might be overestimated or underestimated. Insurers recognize this risk and are seeking to transfer the risk to the Government by asking for a guaranteed payment of any under estimates while demanding to keep the proceeds from over estimates. Do you sense that insurers are playing hardball here as the White House grip on the situation is weakening?

All this highlights the fact that people not entitled to a subsidy should avoid the ACA web site and its overreaching demand for personal information. Instead these people should go directly to an insurer and buy their health insurance without any Government assistance or interference.

In the meantime, the Obamacare death march continues as the clock is ticking on the upcoming HHS numbers reveal to be followed by the promised November 30 resurrection of the ACA web site already being downplayed as a minor milestone in the facade of continuous improvement.

What incentives do the Young Invincibles, impervious to adversity, have to enroll in Obamacare? Under 26, simply stay on parents insurance. Over 26, pay a $95 tax/fine. Oh yes, get a job and get on employer health insurance. All these options trump beating your head against the wall that has become Obamacare.

Then there is the is the self-serving "apology", a failed attempt at damage control.

The Wall Street Journal reported that only 49,100 enrollments were received through the ACA web site in the month of October. On the ACA web site repair, 60% of the items on the punch list have been completed yet there continue to be problems with volume, performance, stability, and functionality. And all the while, 5,000,000 people have lost their insurance.

And the real answer, please! In October the ACA website enrolled 26,794 and the states enrolled 79,309 for a total enrollment in Obamacare of 106,185 or one-fifth of the 495,620 expected and projected. All this underscores the need for the Keep Your Health Care Act despite the current cost expenditure of $600,000,000 for the ACA web site. Estimated cost at completion, unknown.

For Some, It Is the End

Earlier I recommended that HHS should consider consider terminating the use of the ACA website by customers seeking healthcare insurance and quarantine existing customer profile data, personal data, and decision data.

To date the ACA web site operational failure has blocked health care enrollment for 80% of its customers. As the November 30 deadline looms closer, the ACA web site availability target is the "vast majority" defined a 80% of the customers who want to use it and need it to shop competitively. 

So we progress from 80% being blocked because of the ACA web site failure to 20% being blocked by design. Why should anyone be blocked? Why isn't the goal set at 100% availability and 0% blocked?  The message for the 20% being blocked by design, "If you want to use the ACA web site, you can't." The result, the ACA Health Care Exchange is in danger of becoming a high risk pool since only the sick will persist and fight through the problems with the ACA web site.

Settling for a 1% error rate (1 in a 100) yields 80% success. Why not set the standard bar at .1% error rate (1 in 1000) to achieve ten times the success? Instead of a 20% failure rate or an 80% success rate, it would be a a 2% failure rate or a 98% success rate.

And the Beat Goes On

Will the defects encountered in the 1% error rate be added to the ACA web site Technical Debt and be corrected after November 30? If so, what will be the next scheduled ACA web site release after November 30 and what will be the error rate goal for that release?

With an objective of 7,000,000 enrollees, six weeks into the ACA rollout, just 3% have actually enrolled and their confirmation of payment from insurers is awaited. As a result, the December 15 deadline for enrollment to start coverage on January 1, 2014 has been slipped to December 23. And a closer look at the 3% reveals that Young Invincibles are enrolling at half the necessary rate required to sustain the viability of the program. A failed ACA web site, lagging enrollments, and a boycott by Young Invincibles… a toxic mix!

Box score: ACA enrollments= 100,000, Health Care cancellations= 5,400,000

ACA web site triage death panel deciders appear to be active:

1. As the Small Business Health Options Program (SHOP) exchange has been postponed a year until November 2014. 

2. As the marketing effort for Healtcare.com has been postponed. Why drive customers to a web site with inadequate capacity?

The Punch List is Punching Back

Not enough resources on the ACA web site repair and renovation project and a punch list repair tactic that is now punching back as more defects are being identified than are being fixed, the ACA web site triage tactics now have more bugs and glitches on the red tarp than they can handle. The result, the Small Business web site feature has been decommitted and Small Business enrollment postponed until the end of next year.

The Next Big Thing

The next big thing… the 834 Electronic File Transaction to Insurers with Enrollment Information. This is the entry way to the backend of the ACA web site, comprising the 40% not yet available, linking enrollments and selections to insurers. ACA success depends on getting 7,000,000 verified selections with the right mix of Young Invincibles and older citizens.

With the December relaunch of the ACA web site came the news that one-third of the 834 files did not arrive at the insurers in usable form and that customers were being advised to call insurers to verify that their paper work was in order and that they had been accepted for coverage. Also with the relaunch of the ACA web site came the news that 100,000 enrollments had been processed in November up from 26,794 in October. 

Uh oh, more of the same! People were promised a night and day difference in performance and a web site able to handle 50,000 users concurrently. If there is a night and day difference, why are people told to take a ten minute timeout when traffic reaches 35,000?

And there is more… the ACA web site transmits a Medicaid flat file listing people thought to be eligible for Medicaid. Like the 834 files, these flat files contain errors and omissions, such as, immigration status missing, wrong state, already in the system… just some of the problems. It gets worse… these people will be enrolled in Medicare despite these difficulties. The difference between night and day should not be a nightmare. If this is the velocity of business, we need to slow down.

Some questions for under-26 year olds who want to stay on their parents policy:

1. Does the under-26 year old child have to live in the state of the parent to be covered? No

2. Does the under-26 year old child have to live in the household of the parent to be covered? No

However, the under-26 year old does count in household income calculations if the under 26-year old lives at home without regard to the insurance purchases. With an ACA goal to enroll 7,000,000 of whom 2,700,000 must be 18-34 year olds, how can ACA work if the under-26 year olds stay on their parents policy and do not enroll?

Two Months and Counting...

Overall, 365,277 chose health plans in October and November from both the federal and 14 state exchanges. And there's another 50,000-60,000 paper applications sent directly to insurers.

While HHS is busy hand matching thousands of enrollments sent from HealthCare.gov to insurers due to the flawed 834 Electronic File Transaction mechanism, the ACA web site is busy adding to its October enrollment total of 26,794 with another 110,410 for a two month total of 137,204. Then there's the 15,000 erroneous 834 files insures are manually trying to make sense of.

Can someone please explain why Jeff Del Bene, househusband of a Congresswoman, is the best choice for the healthcare.gov job? This ex-Microsoft executive is slated for a six month assignment. What's that all about? Before him, these was Jeff Zients on a three month assignment to work off a punch list. Does this ex-Microsoft househusband also have a punch list to work off or does he actually come to the job with an approach… one that can be completed in six months?

On another front, the Obama administration estimated that people who received insurance cancellation letters but have yet to sign up for a new plan is less than a half million. Other estimates show this to be 5.6M people. On Friday December 20, 2013, the ACA took another hit as it was announced that these people, whether hundreds of thousands or millions, are now allowed to obtain catastrophic insurance without penalty under the hazard provision, thereby, rewarding the procrastinators and punishing those who signed up diligently and took their medicine.

Still struggling, ACA website difficulties prompted an additional slip in the enrollment deadline from December 23 to December 24 for those hoping to be covered by January 2014. Except in Connecticut, which said it couldn't take any more slips… enough is enough!

With a goal of 3.3M enrollees by January 1, 2014, the ACA enrollments hit 100,000 through October, 365,000 through November, and 975,000 through December. Not good with numbers, the government claims that this totals 1.1M versus the goal of 3.3M.

Facing the Music in 2014

100,000 Medicaid enrollees through the ACA website aren't enrolled. Advice being dispensed to non enrolled enrollees, sign up through your state, the ACA website can no longer help you. In an effort to make sure qualified Medicaid candidates are covered, they are being automatically enrolled and sent letters sating that they are enrolled. This means that thousands who attempted to enroll weren't enrolled and that additional thousands who didn't enroll now find themselves enrolled. 

The route cause of this latest failure is the automatic transfer system from the ACA Website to the states Medicaid systems. Part of the so called backend system, these transfers are not working dependably and sometimes not at all. Adding to all this, insurance companies do not have reliable enrollment information and do not who their new customers are. These insurers are also finding that are unable to update customer accounts for changes in address and family additions.

MISSION ACCOMPLISHED… why was Jeffery Zienst allowed to leave his post before the ACA web site was fully operational?

On the important issue of the demographic mix, just one quarter of the 2.2 million people who enrolled in health care plans whether federal or state as of Dec. 28 were adults under age 35. Not only that, 80% of these enrollees received subsidies as incentive for enrollment. This is a clear indication that Obamacare is not a market-driven health care system; instead it is a government-driven welfare system. And still the number of enrollees that have actually paid their premiums and are actually insured is unknown.

State of Maryland Follows Suite

The Maryland health care web site mismanagement parallels the ACA web site experience failures. For the state of Maryland Health Insurance Exchange, October saw 1,284 enrollments and November, 2,474…  against the now illusive goal of 150,000. In early January the total hit 20,358. This is a lot of ground to make up, and wishful thinking can take us only so far. Whether the fault lies with Martin O'Malley, Anthony Brown, or the fired-Rebecca Pearce, these results are below par. Late to discover Maryland's own technology resources, Maryland health care officials relied on contractors from North Dakota, Maine, Florida, and … yes, the Ukraine with its Cyber Security risks before discovering a contractor in Columbia, Maryland. What were Gov. O'Malley and Lt. Gov. Brown thinking?

With a defunct Maryland web site and a failed ACA web site still not right, the state of Maryland is now asking people to resort to an old health care system. Maryland lacks confidence in both its own site and the federal site, and the people now lack confidence in government both state and federal. Even Congressman John Delaney is urging Gov. O'Malley to abandon the failed Maryland health care site and ask people to use the failed ACA web site instead. Wow, the choices government offers!

References:

1. Gillum, jack, "The Coders Who Built The Obamacare Website Knew It Had Huge Problems", Business Insider, October 22,2013

2. Barone, Michael, "A software installer's view on the Obamacare IT mess", The Washington Examiner, October 20, 2013

3. Pace, Julie, "Officials say 476,000 applications filed with insurance exchanges", Washington Post, October 20, 2013

4. Pace, Julie, "Obama Frustrated Over Health Care Website Issues",  Washington Post, October 20, 2013

5. Pollock, Richard, "Troubled Obamacare website wasn't tested until a week before launch", The Washington Examiner, October 17, 2013

6. Klein, Philip, "Behind the curtain, more waving red flags for Obamacare", The Washington Examiner, October 17, 2013

7. Sun, Lena H. and Sandhya Somashekhar, "An old-fashioned answer to glitchy health-care sites", Washington Post, October 13, 2013

View YouTube presentation  "Affordable Care Act (ACA) Rollout: State of Failure" at http://youtu.be/ohFUQOURu8M