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Healthcare and bugs                                                                                    

Posted at: Oct/25/2013 : Posted by: mel

Related Category: Healthcare, Politics & Gov, Watching America,

Healthcare in America is a serious problem. Millions of Americans can’t afford basic care and therefore either go without, or burden our emergency rooms for their care in the most expensive cost model possible. In response to this challenge, the Obama administration pushed through Congress the Affordable Care Act (ACA) in March of 2010. Also known as “Obamacare,” this act has become the signature legislation of President Obama’s administration. Unfortunately, our government has again proven that if they are given the chance to take on a major task, they can do an abysmal job at it. “Let them alone: they be blind leaders of the blind. And if the blind lead the blind, both shall fall into the ditch.” (Matthew 15.14 – King James Edition)

I understand the need for healthcare reform in America. I consider myself a fiscal conservative and a social moderate. Many people would tell me those are contradictions, if true it just means I’m not perfect which I gave up on years ago. We have millions of citizens who are without basic medical care. I am unsure whether everyone needs access to colonoscopy or a full series of psychiatric consultations. Setting a broken leg and getting antibiotics for pneumonia should be accessible to all. Finding the balance between freedom where some will achieve and get more than others, and equality that is not socialism is the fundamental American debate.

Obamacare is the latest Federal Government attempt to attack this challenge. Like so many things our government attempts as problem resolutions, the unintended consequences and collateral damage can make the cure worse than the ailment. For a major health insurance plan, whether public or private to work, a large number of young and healthy people need to be buying in, to subsidize the cost of the old and ill who need access to care. With a declining middle class and most new jobs in the service sector, there is no real indication that the young and healthy will be able to afford the ACA. The ACA attempts to make medical care more accessible, but does nothing of substance to reduce the skyrocketing costs of healthcare that have vastly exceeded inflation for more than 20 years. With the healthcare industry now representing 1/6 of the American economy, any changes can have a broad impact on everyone and everything in America.

The centerpiece of the ACA rollout was supposed to be web portal known as healcare.gov. Through this portal the un-insured and the under-insured were supposed to be able to shop for insurance and based on their income level determine how much of a federal subsidy they would be eligible for. The high profile failures of this web based system have already inspiring Congressional hearings, and it has only been live for a few weeks. I think most people would call this an auspicious beginning at best.

As an Information, Technology and Software consultant I am aware how difficult a major application rollout can be. You have to anticipate a few *bugs, but this appears to be more like an entire infestation. The Obama Administration managed the development of healtcare.gov and its resulting failure in a way that no tenured technical professional would ever have. They set themselves up to fail in both their contracting strategy and their project administration. They ignored adverse data that could have been leveraged early to manage for success and did none of the risk reduction that is normally an integral part of major acquisition projects focused on success.

(* nerd trivia: the tendency of insects to short out vacuum tubes in 1st generation computers gave rise to the terms “bugs” and “debugging” in computer science.)

It does not surprise me that officials at the department of Health and Human Services (HHS) are getting nervous. Faced with the looming February 15 deadline for the Individual Mandate, they have to either ask Republicans for a delay (force the President to eat crow), or hope that most people signing up, do so through one of the state systems. These challenges began much earlier than Oct 1 when the portal rolled out.

Rather than open the contracting process to a competitive public solicitation with multiple bidders, officials in the Department of Health and Human Services’ Centers for Medicare and Medicaid accepted a sole bidder, CGI Federal, the U.S. subsidiary of a Canadian company with an uneven record of IT pricing and contract performance. This meant there was no market research and no one had to compete in a proof of concept challenge to demonstrate their competence prior to the contract award.

A proof of concept or “bake-off” challenge would have given the industry and the government a wealth of data to evaluate the feasibility and adaptability of current technology and proposed designs to the problem at hand. The government could have then selected a best value offer to award a contract. Leveraging the “bake-off” data would have provided an advanced look at test cases, sample data sets and potential challenges. Oh, wait…none of that took place. As a software engineer I’m very disappointed. It appears the people who built the portal don’t know what they are doing, never used it, and clearly did not test it. As a taxpayer, I see this as another example of a federally run program in which we surely paid too much, and clearly got too little. Fixing, testing, and redeploying a live application is very difficult; doing so with an application of this scale is extremely daunting.

I would love to be able to hold the managers of this program accountable. Apparently, the Centers for Medicare & Medicaid Services (CMS) decided to take on unto itself the role of central project manager, assuming the responsibility for integrating all the various pieces they’d subcontracted to CGI Federal Systems. Taking the role of lead contractor can be viewed as an attempt to cut costs, but the CMS is not known to maintain a pool of project managers and leading edge software engineers.

”We are seeing and hearing that enrollment files going to carriers are incomplete, there are errors,” said Dan Schuyler, a director of exchange technology at Leavitt Partners, a firm that consulted with several states in setting up their websites. “In three weeks or so when they start receiving these in mass volume, tens of thousands per day, it doesn’t matter if there’s a 1 percent error rate. Insurers don’t have the resources to go through them and clean them up.”

Henry Chao is the Deputy Chief Information Officer (CIO) for the CMS and recently stated that “the time for debating about the size of the text on the screen or the color or is it a world-class user experience, that’s what we used to talk about two years ago.” Chao went on to say that the focus now is; “Let’s just make sure it’s not a third-world experience.” There is a clear sense of stress and nervousness in that frank statement.

I would love to pin this mindset of poor engineering exclusively on the Federal Government and a botched $600 million website, but there are a lot more groups standing behind the same 8-ball. As it turns out, only the State of California even considered doing a soft rollout of its healthcare exchange (beta testing to a limited audience of users).

I have another concern that may make all the debate and angst over healthcare.gov moot. In my dealings with families that are financially challenged, most of them do not have computers and internet access. I know for many this notion is foreign, but it is actually very common. If those most in need of affordable medical insurance aren’t internet enabled, how are they going to sign up? I have asked this of 3 people and all said some variation of the same thing including options like going to their local library to get online. My experience tells me these people are misguided in their understanding of people they do not personally know. But, if it were true, there could be a very long line at libraries to enter in the required personal data into a healthcare website while someone is standing impatiently behind them. From my own experience, these families won’t use the library to register their children for soccer or little league; I just don’t see the online exchanges and the related heavy focus on the online entrance solving the healthcare gap. I can’t believe I’m the first to point this out, but since most of our new media appears to have a very liberal agenda, maybe this is being ignored.

If there are conclusions to be drawn here, none of them are very positive. Clearly, awarding a contract to a single bidder is not smart and contrary to most rules of government contracting. As if to compound the development effort challenges, the Centers for Medicare & Medicaid Services chose to act as their own project and program manager though they clearly do not own the proven skill set for this scale of effort or type of task. Even if they solve the problems of website functionality, I have major doubts about whether it will reach its intended audience. If a paper form needs to be developed, then you will hear the budget request for the hundreds or thousands of staffers needed to review the forms and enter them into the database.

I am not a fan of socialized medicine or the Affordable Care Act, but I will concede that for the time being it is the law of the land and there are other things Congress needs to focus on. Maybe I really don’t need to worry about it after all. Going down their current path, it’s doubtful that the intended millions and millions of Americans for whom the Affordable Care Act was written will be able to actually sign up anyway….

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