The Patient Protection and Affordable Care Act (PPACA), also known as the Affordable Care Act (ACA), or “ObamaCare,” was passed in December, 2009, and signed into law in March, 2010. The website Healthcare.gov, an online marketplace for citizens to shop for health insurance, was launched in late 2013 and was fully implemented on January 1, 2014 (ObamaCare Bill). The intention of this program was to provide high-quality, affordable health care to all American citizens and to curb the growth of healthcare costs. Between the signing of the bill and the rollout of the Healthcare.gov website, numerous problems have occurred within the system. In addition to a variety of technical problems with the website, the Obama administration has been faulted with poor communication and a lack of accountability regarding the rollout of Healthcare.gov.
This paper will explain the basics of the Affordable Care Act and examine the implementation and rollout of Healthcare.gov, in an attempt to understand the problems and lessons learned from the process. The paper discusses the responses of various Democrat and Republican Party members as well as U.S. citizens in general to the process and issues of the Affordable Care Act and the Healthcare.gov website. The paper also discusses what can be learned from the rollout in terms of project management, information technology and web development, and public relations and communication.
In 2011, after the signing of the Affordable Care Act but before the Healthcare.gov website was developed, Rosenbaum called the Affordable Care Act a “watershed in U.S. public health policy” (130) based on its universal guarantee of access to affordable and quality health insurance. Utilizing a number of health insurance coverage reforms, the program was created to improve fairness within the health insurance industry, make the health insurance system more accountable to a diverse patient population, enact changes in both long-term and primary care, and invest in public health (Rosenbaum 130). The Affordable Care Act requires that each citizen obtain health insurance either individually or through employment. Citizens are fined for not obtaining health insurance, and plans are made affordable and accessible to streamline the process of obtaining health insurance. Employers with over 50 full-time employees are also required to offer health insurance plans to employees (ObamaCare Bill). These changes in the United States healthcare and health insurance system aim to improve the general health and wellbeing of U.S. citizens and make health insurance less of a financial burden for people in low-income situations. The Act also aimed to prevent insurance companies from denying coverage to individuals based on pre-existing conditions.
While sound in theory, the passing of the Affordable Care Act created political arguments. The Act was challenged and upheld in the Supreme Court in June, 2012 (ObamaCare Bill). Many Republicans feared that the bill would cost too much money and create too much change in the healthcare system. In addition to political discord, the launch of state and national health insurance exchanges such as Healthcare.gov proved problematic. Through the various problems and issues encountered in the rollout, there are a number of valuable lessons to be taken and implemented to future large-scale political changes.
The Healthcare.gov website went live on the internet on October 1, 2013, for citizens to explore the site, shop for insurance plans, obtain information about government subsidies based on income, and pre-register for insurance policies to start by April 1, 2014. In the first 20 days of the website’s public existence, site administrators reported over 19 million unique visits to the website (Doing Better: Making Improvements), an initial wave of interest that stressed the server. Because of the large amount of people trying to access the site, many users had trouble with account creation, logging in to accounts, web pages loading very slowly, and forms failing to fully load. Specific problems such as error messages and fields that did not allow information input confused consumers as they attempted to navigate the website and understand various aspects of the Affordable Care Act including levels of coverage, premiums, deductibles, and government subsidies for lower-income individuals and families.
The initial experience of the Healthcare.gov website worried many people who already had concerns about the Affordable Care Act. In response, the Obama administration released a blog addressing the technical issues. The blog assured U.S. citizens that the “best and brightest” were being brought in to address and fix the issues and improve the website (Doing Better: Making Improvements). The blog was an attempt to ameliorate public concerns and provide an understanding of why the website issues were occurring. In addition to problems with accessing the website and creating user profiles, many consumers found that Healthcare.gov made mistakes including charging too much, directing the user to the wrong insurance program, or completely denying coverage. Further, as of February of 2014, the Centers for Medicare and Medicaid Services (CMS) did not have an appeal system in place to respond to these issues (Goldstein). While many of the problems consumers faced were solved eventually, some people faced serious setbacks as a result of the broken Healthcare.gov system and website. Goldstein’s article reports that due to a lack of communication by CMS on the functionality of Healthcare.gov, some people remained uninsured while waiting for appeals and incurred medical debt during this period. Others paid for more expensive plans rather than go uninsured while waiting for subsidies to be calculated and ended up paying hundreds of dollars over what their deductible should have been.
Many leaders in the Obama administration expressed frustration and concern with the situation but remained positive. In a White House speech on October 21, 2013, President Obama stated that “there is no excuses for the problems” on the website and that “no one is madder than me about the fact that the website isn’t working as well as it should” (Jackson). House Minority Leader Nancy Pelosi described the technical problems as “unacceptable,” and Treasury Secretary Jack Lew admitted that Healthcare.gov was flawed (Clark). The administration emphasized that they were aware of the numerous problems with Healthcare.gov and that all possible measures were being taken to remedy the situation.
While the Obama administration admitted the numerous problems with Healthcare.gov, they stressed the importance of recognizing that the actual product, the health insurance options, were quality. Nancy Pelosi argued that the error-prone website was still far superior to leaving millions of U.S. citizens uninsured. She encouraged consumers to be patient and have confidence that, once fixed, the website would provide access to affordable, quality healthcare (Clark). In his White House speech on Healthcare.gov, President Obama reminded his audience that aside from the website, “the essence of the law, the health insurance that’s available to people, is working just fine” (Jackson).
The Obama administration also made strides to ensure that health care could be obtained through other avenues. Twenty-four hour call centers were set up to answer questions and provide information, but these call centers often had long wait times to talk to a customer service representative. Consumers also had the option of printing and mailing in an 11-page form to obtain insurance, but this process was generally seen as cumbersome and unclear.
Congressional Republicans did not express the same level of confidence in the Affordable Care Act and Healthcare.gov as the Obama administration. Those who opposed the new healthcare laws argued that the flawed system create doubt regarding the entire program. Senate Minority Leader Mitch McConnell stated that the Affordable Care Act was full of “broken promises” (Jackson). Many Republicans worry that the Affordable Care Act will harm the economy by forcing businesses to spend more money on health care costs. Others believe that the Act is in violation of the U.S. Constitution, although the Supreme Court found this to not be true. However, because of these existing biases, Congressional Republicans used the issues with Healthcare.gov to further prove their opinions that the Affordable Care Act is not a feasible option for the country.
The problems with Healthcare.gov added to the general discord between Republicans and Democrats on the Affordable Care Act. Disagreement on budget, funding, and regulations for the Act were a major cause of the government shutdown from October 1 through October 16, 2013. The shutdown cost the government billions of dollars. Over $2 billion was given to furloughed government employees as back pay, the government accrued additional interest on loans not paid during the shutdown, and other direct costs were lost as the IRS and other enforcement programs were closed and not able to collect fees (Burwell). The government shutdown also affected local and national economies and workforce, and millions of Americans were negatively affected by the shutdown of critical programs and services. Tax refunds were put on hold, the Food and Drug Administration and Environmental Protection Agency cancelled health and safety inspections, critical government-sponsored research was delayed, and many patients were not able to participate in clinical trials at the National Institute of Health (Burwell). While these problems and the government shutdown were not a direct cause of the problems with the Healthcare.gov website, the problems put the entire Affordable Care Act into question and created a stand-still between parties in the House and Senate.
Based on the problems with Healthcare.gov, the Obama administration lost credibility with many U.S. citizens. In the two months after the initial problematic rollout, the President’s poll numbers and approval rating dropped (Dwyer). Many people who were ambivalent about the Affordable Care Act used the Healthcare.gov issues to sway their opinions. Those who already disapproved of the Act used the problems to further prove their beliefs.
In December of 2013, Jeff Zients, who oversaw the repair of the Healthcare.gov system, announced that the website had the capacity to handle 50,000 visitors at a time and up to 800,000 per day. He also reported significant improvements in response time and error rates (Dwyer). Zients acknowledged that the majority of the problems with the website came from hundreds of software bugs as well as insufficient hardware and infrastructure. Technical teams implemented a combined total of 400 fixes to address the problems.
Despite these fixes, the consumers continued to experience unscheduled outages, slow-downs during high traffic times, lack of functionality in the electronic payment system, and unreliable data on applications from the site (Dwyer).
The failure of the Healthcare.gov implementation was due to a variety of issues in project management, information technology (IT), and public relations. Valuable lessons can be learned in each of these areas to ensure that similar issues can be avoided in the future.
One of the major failings of the Healthcare.gov rollout was that it was implemented all at once rather than in stages, and no full-scale pilot tests with actual consumers were performed (Kim). Without any sort of trial run, there was no opportunity to identify and fix bugs and issues before releasing the site to public use. The project management team should have created a system of pilot tests to compile information of what worked, what did not work as efficiently or effectively as possible, and which resources could be applied to streamline the website. A staged rollout would also have allowed the technology team to focus on issues with a smaller number of users while keeping the majority of consumers from dealing with the issues (Kim). Thomas adds that utilizing a beta site is an excellent way to test the integration and improve the processes and underlying technologies before opening the website to the public.
Thomas speculates that risk management was one of the major failings of the project management team. With the important and costly risks of site functionality, schedule delays, security and privacy issues, and miscalculation of costs, mitigating these risks should have been a key priority for the project implementation. The lack of focus on risk management harmed not only the site implementation but the administration’s public image as well. This may have been due in part to the lack of a single point-of-contact or a project management office for the entire project.
There are numerous lessons that IT departments and companies can learn from the many technical problems in the Healthcare.gov rollout. Crader’s article suggests a number of learning points including timeline, design, testing, and development.
The timeline of Healthcare.gov was flawed in that the contract for site development was awarded in December, 2011, but the writing of the site did not begin until six months before the launch. Site developers were still making changes less than a month before the launch of Healthcare.gov, creating pressure for acceptance testing (Crader). This left an inadequate amount of time for thorough testing and solutions. IT professionals can learn from this by creating a schedule of production and ensuring an appropriate timeline with scheduled periods of testing and adjustments. IT professionals should also prioritize testing both in terms of costs and time allocation. Healthcare.gov failed between 200-300 tests immediately before its launch (Crader). Had appropriate budget and attention been given to testing throughout the development, many of the issues could have been attended to before the launch, and consumers would not have been faced with the problems and inconveniences.
Healthcare.gov was reported to run 500 million lines of code or five times as much the code in a standard automobile (Crader). This can be due to building many components from scratch. A program this large opens up many possibilities for error and raises maintenance and troubleshooting costs exponentially. IT developers can eliminate this “software bloat” by consolidating components and identifying and removing unnecessary parts of the program. If Healthcare.gov had created a more streamlined program, it is possible that integration and implementation would have run more smoothly.
Many of the public relations problems could have been ameliorated with more transparent communication. Many U.S. citizens felt disappointed with the system because the administration had over-promised what it offered. Kim recommends that while discussing the benefits of a system is appropriate, it is important to focus on the goals of the system rather than the technology itself. He also recommends acknowledging upfront that issues are likely to occur and explaining how these issues will be addressed.
Clark emphasizes the importance of transparent communication. She noted in her article that many consumers felt frustrated by the lack of communication from the administration regarding exactly where the problematic areas were, how the issues would be fixed, and how the minor and major inconveniences of the consumers would be addressed and fixed. Additionally, Kim acknowledges that while IT professionals are often not known for communication and that communication budgets are not always sufficient, the communication plan around any rollout is as important as the technology itself and must be prioritized. He also suggests that an open dialogue forum should be provided for both critics and advocates to have a two-way discussion with the administration about the technology and product.
Kim expresses frustration that the Obama administration blamed CMS, the vendor for Healthcare.gov, for the problems with the website rather than taking responsibility. He provides a reminder that while the companies that created Healthcare.gov may have been at fault for the issues, the administration hired the vendors and is ultimately responsible for the functionality of the website. Passing blame shows a lack of accountability for the Healthcare.gov issues as well as other components of the Affordable Care Act. The best way to take accountability is for one individual to step up and take responsibility for the problems. This creates a sense of security in consumers who are wondering what will happen next and who is in charge.
While a program as large as Healthcare.gov is bound to have technical issues, hindsight shows a number of crucial errors in the implementation which created more problems than necessary. Primarily, IT issues in site creation, testing, and implementation were at fault for the unsuccessful rollout. Had the IT team started building the software and website earlier, there would have been ample time to perform multiple tests to identify and fix many of the bugs. A staged rollout would have allowed a sample of users to work in the site without crashing under a high volume of individual users in a short period.
Despite the many technical problems, the project management team and the Obama administration could still have mitigated a lot of the problems by addressing what was happening honestly and quickly. As with many public relations situations, the Healthcare.gov problems became worse as consumers became increasingly frustrated and confused. Taking accountability for the website failure, addressing problems quickly and concisely, and thoroughly explaining the course of action to fix the problems would have greatly moderated much of the public frustration surrounding the website and the Affordable Care Act in general.
By understanding what went wrong and studying how to avoid these issues in the future, both political and IT groups can potentially eliminate many of these problems in future program and software implementations.
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