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Healthcare.gov: Why the Washington state site eclipsed D.C.'s

What went wrong with the Feds' Affordable Care Act website and why the other Washington did so well.

Like the Mariners’ string of depressing seasons and lost opportunities, this month’s botched rollout of the federal Department of Health and Human Services (DHHS) healthcare.gov website represents a huge lost opportunity for the federal government. And some of the root causes of these two fiascos are amazingly similar.

Washington state’s own, separate, health benefit exchange registered phenomenal success, enrolling over 35,000 people in three weeks.

How can one state succeed where the federal government, with all its resources, cannot?

In many ways, software development is like running a baseball club. The club will have an owner, or, if multiple owners, a board. The board hires the general manager (GM) who, in turn, hires the players, negotiates their contracts and hires the coach. The coach makes sure the players work together, trains the team and practices practices practices in preparation for game day. 

The state of Washington succeeded by starting off with a solid infrastructure for the project, and by creating a separate Health Benefit Exchange – a public-private partnership – with its own board. Although the board is appointed by the governor and the Legislature, it is otherwise independent. And it hired its own CEO – veteran health executive Richard Onizuka. For their part, Onizuka and his staff made smart choices, contracting with a single vendor –  Deloitte – to build its exchange.

As prime contractor, Deloitte bore sole responsibility for creating a successful exchange website.  To ensure their success, Deloitte built the Washington exchange in the cloud – which allowed them to add extra server space to meet surges in demand – and tested it extensively with hundreds of different use cases. According to Michael Marchand, the exchange’s Director of Communications, they also tested the site with three waves of real, off-the-street, consumers.

During the project, Marchand reports, they hired BlueCrane, a separate quality assurance (QA) company to independently track Deloitte’s progress and deliver monthly reports to the board. “The reports showed red-yellow-green project status, and those reports are public on the Exchange website,” Marchand said. 

The Washington site did have problems during its first few days, but the root cause was quickly found and fixed. Now the software is performing almost flawlessly. 

In the Washington Health Benefit Exchange, Richard Onizuka is the GM, Deloitte is the coach and the team is well-practiced, with help from BlueCrane and  diligent user testing. The Federal approach, with its numerous problems, provides a sharp contrast:

1. No strong GM. One of the basic principles of information technology project management is clear identification of a business owner and project sponsor – a GM – whose business is on the line for the project.

President Obama and Secretary Kathleen Sebelius, the owners of the Federal healthcare exchange, hired a bureaucracy — the Centers for Medicare and Medicaid Services (CMS) – to act as GM and oversee its technology. The administrator of that bureaucracy is Marilyn Tavenner, whose name has been almost absent from news reports and press conferences since the fiasco began.  

2. No coach. Another principle of project management is having “one throat to choke”, a single person or entity responsible for making the project happen. A baseball team can buy a lot of highly skilled players and put them on the field, but unless the coach gets them to work together, the season will be a disaster.

Where the Washington state exchange hired Deloitte, the CMS bureaucracy assumed this role itself, hiring 55 contractors to build different pieces of healthcare.gov. CMS took on the role of “system integrator”  - making all the pieces work together. That’s the equivalent of Mariners’ GM Jack Zduriencik and his whole front office coaching the team themselves. 

3Poor quality assurance (QA). A staple of good project management is to contract with independent consultants or agencies to oversee work and give early warnings of problems. A QA is similar to the batting coach or hitting coach hired by baseball teams, working to improve specific skills and warning the head coach of problems.


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Comments:

Posted Thu, Oct 24, 6 a.m. Inappropriate

Isn't it amazing how efficient the State of Washington is at giving away taxpayer subsidies. I guess it's all a matter of motivation.

Cameron

Posted Thu, Oct 24, 1:36 p.m. Inappropriate

Not as nearly as efficient as private insurance companies were at denying coverage, of course. The private sector is always more efficient.

nullbull

Posted Thu, Oct 24, 10:09 a.m. Inappropriate

Do we know if other state exchanges are as successful as ours, or are we unique in that?

Jon Sayer

Posted Thu, Oct 24, 11:35 a.m. Inappropriate

Jon:
Washington State, Rhode Island and Kentucky are doing best. Here's an article with more information about those three and other states. http://www.nextgov.com/cio-briefing/2013/10/why-states-are-doing-obamacare-better/72554/

Posted Thu, Oct 24, 11:41 a.m. Inappropriate

I am fully supportive of ACA but the small business portion of the site is buggy. I've been slowly adding my employees so I can do a comparison with my current plan and I get a "crash" every session. I'm in no hurry so not really a big deal, but just stating a fact.

r2715

Posted Thu, Oct 24, 1:26 p.m. Inappropriate

Kilgoretrout (and all):

Thanks for the statistics. Here's a link to all the statistics for the 15 state-run health care exchanges. Washington state has about 20% of the total of all applicants nationwide and a whopping 1/3 of all those successfully enrolled nationwide.
http://www.advisory.com/Daily-Briefing/Resources/Primers/Obamacare-enrollment-tracker

-bill

Posted Thu, Oct 24, 1:32 p.m. Inappropriate

R2715:
Thanks for mentioning this. Sorry it is so hard. Have you let the folks at the Healthcare Benefits Exchange know about this? Email them at customersupport@wahbexchange.org
-bill

Posted Thu, Oct 24, 12:12 p.m. Inappropriate

http://kplu.org/post/strong-enrollment-wash-health-exchange-medicaid-plan

35,528 enrollments

30,999 were Medicaid

4,529 qualified health plans

So, 87% of the enrollments were Medicaid.

My concern is, unless there is success getting the "young and healthy" to sign up, all the State of Washington exchange will succeed in doing, is causing the system to collapse faster.

Posted Thu, Oct 24, 1:27 p.m. Inappropriate

Kilgoretrout (and all):

Thanks for the statistics. Here's a link to all the statistics for the 15 state-run health care exchanges. Washington state has about 20% of the total of all applicants nationwide and a whopping 1/3 of all those successfully enrolled nationwide.
http://www.advisory.com/Daily-Briefing/Resources/Primers/Obamacare-enrollment-tracker

-bill

Reply
— Bill Schrier

Posted Fri, Oct 25, 11:05 a.m. Inappropriate

You're welcome, of course, but the statistics come straight from your own link.

I fear all that Washington has accomplished is to do a beautiful tune-up of a car that is headed straight over the cliff.

Nearly 90% of the people signed up for health insurance, was Medicaid.

You could have done that through the Medicaid office.

The remaining 13%, one can only speculate how many of them were previously considered high-risk uninsurable, pre-existing conditions and all that.

The funding could have been directly, through taxes. Instead it comes from higher premium charges for the "young and healthy", and they are not signing up.

Did we have to create this complicated system to do what was already done through Medicaid and the state high-risk pool systems?

My concern is all we have done is create a very efficient collapse.

Posted Mon, Oct 28, 7:21 a.m. Inappropriate

Kilgoretrout:

Perhaps you are right. I don't render an opinion on whether the ACA as a law is a good idea or not, which is why I've not responded to the several negative comments on this article about the law itself. But, given that it is a law and is to be implemented using technology, it should be done in the most efficient, effective way possible. Washington State came close to doing that. The Feds, definitely not. Will be interesting to see how much this "tech surge" of fixes costs the Federal government.

-bill

Posted Mon, Oct 28, 3:39 p.m. Inappropriate

Fair enough, to at least create a well-engineered system.

However - A perpetual motion machine will not work, no matter how well-engineered. A perpetual motion machine is what has been contemplated with the ACA.

What seems to have happened with the high sign-ups in Washington State, is Washington State reported MONTHLY income.

The Federal system expected income reported as ANNUAL income.

So a family income of, say, $120,000 in Washington State was reported to the Feds as $10,000. The Feds thought that was $10,000 a year.

Hence, the family got a health policy with a nice subsidy.

At least this is what I gather from the Seattle Times:
http://seattletimes.com/html/healthcare/2022125947_acaexchangeerrorxml.html

That family will get a nasty surprise when the problem is straightened out, and they see the unsubsidized cost of that insurance.

Posted Thu, Oct 24, 12:46 p.m. Inappropriate

Sir,

Kudos to the State of Washington for doing it right, and getting it done.

Over 40 years of spending taxpayer dollars on technology, my best - and bitterest lesson - is reflected in the joke that goes: What's the primary difference between a used car salesman and a computer software
sales person?

Answer: The used car salesman KNOWS when he's telling a lie.

Ross Kane
Warm Beach

Ross

Posted Thu, Oct 24, 10:49 p.m. Inappropriate

There's truth in your anecdote, Ross. I think many of the "salesmen" selling computer system are good at procurement and following the procurement rules and promising anything to get the sale, and really don't understand what they are selling.
-bill

Posted Thu, Oct 24, 2:58 p.m. Inappropriate

I appreciate the article and have been pondering this situation.

One of the features in Washington State was transparency. It is something that is a hallmark of Lean/Agile, but difficult for political and deadline driven projects. Along with a clear Product Owner, one acting on behalf of the citizens, hard choices regarding scope, features and even schedule, needed to be made in a transparent manner. I say schedule because it is not like we are going to 'run out' of the products on offer on the exchanges!

I have two other notes. First, Deloitte is to be managed. They have done an abysmal job in California's EDD system. Some blame lies with government managers accepting flawed product, and the fact of no backup manual systems in place. But, the consequence is people, who can ill afford it, not getting their unemployment checks for months now. The repuation of Deloitte is greatly affected, no matter how blame gets apportioned.

Second, and this is back to requirements and expectations, the back end of the federal system is obviously working well or else Washington and other states' exchanges would be DOA. My perception is that the website and health plan filing work became larger and larger while the timeframe shortened, as states opted out. That was exascerbated by waiting for the SCOTUS ruling and then its aftermath. I also heard that the workflow requirements and interactions were either never really decided or were decided fairly late in the project.

I often say, in the Systems development context, it takes 9-10 months for a woman to have a baby and you can't get a baby by assigning 10 women to produce one in a month. Most 'deciders' are like a woman deciding she wants a child and expecting the baby to show up in her arms the next day.

Posted Thu, Oct 24, 10:39 p.m. Inappropriate

Critical Thinker:

These are astute and well-considered comments.

100% agree about managing Deloitte (or any other contractor). The government employees / project sponsor have to be heavily involved and demanding. Your citation of the California fiasco is spot on.

You are also right about the back-ends of the Federal systems. That fact made the managers of the Washington State healthcare exchange very nervous because they could not test such things as Medicare and Medicaid eligibility - which depended on federal systems - at all. They went live just hoping those links would work, and they did.

Again, good comments. Thanks.

-bill

Posted Thu, Oct 24, 4:19 p.m. Inappropriate

Seems like a lot of "Monday morning quarterbacking," to extend the sports analogy a bit more. I have no idea whether the author is writing from inside knowledge or just speculation. My own speculation is that if you try to build such a giant software system from scratch in such a short time, with hundreds of stakeholder groups and ever-changing requirements, problems are inevitable and no development model is going to handle them well. It was probably an impossible assignment to begin with, and I'm surprised it didn't turn out much worse than it did. I'm just glad I wasn't managing it.

Posted Thu, Oct 24, 10:46 p.m. Inappropriate

PaulBellevue:

You are right about the Monday morning quarterbacking. But the blunt fact is that the true nature of problems was hidden from the President and public by the bureaucrats in DHHS. Secretary Sebelius admitted as much today:
http://usnews.nbcnews.com/_news/2013/10/23/21094684-obama-administration-clarifies-dates-related-to-health-care-rollout

I don't have inside knowledge of Washington's system - I interviewed two principals involved in the work on Washington state's system. Also, as Chief Technology Officer for the City of Seattle from 2003-2012 I oversaw about 200 IT projects worth $150 million+, so I know project management principles and saw both successes and failures in action there.

Your comment about the difficulties faced by the feds is a good one. But they also failed to follow the most important principles of project management too.

-bill

Posted Thu, Oct 24, 8:16 p.m. Inappropriate

http://www.dailykos.com/story/2013/10/21/1249417/-Healthcare-gov-isn-t-just-a-website-dagnabbit#

Posted Fri, Oct 25, 5:17 a.m. Inappropriate

We have one of the best built, most efficient Judas Goat systems in the country. Once we get the targeted 750,000 Washingtonians that are required to either register or pay the penalty, we can get past all of the cheerleading and see if a massive expansion of Medicaid will actually improve health care and lower costs.

Cameron

Posted Sat, Oct 26, 5:18 a.m. Inappropriate

Apparently Washington State has not "eclipsed" the Federal Website, they simply "miscalculated".

http://seattletimes.com/html/healthcare/2022125947_acaexchangeerrorxml.html

Cameron

Posted Sat, Oct 26, 4:59 p.m. Inappropriate

Am I reading the article correctly? The difference was Washington entering income as MONTHLY income, and the Feds expecting the reported income to be ANNUAL income.

So the Washingtonians were actually earning TWELVE TIMES what the Feds thought they were earning.

They will be in for a surprise when they get hit with the true, unsubsidized cost of their insurance.

Posted Sun, Oct 27, 11:15 a.m. Inappropriate

Great observations Bill. As someone who does technology consulting in New York City, I'm dumbfounded by the staggering cost of this web site. The figure I read was $678 MILLION. How can that much money possibly be spent in 2 years to create a web site??!! What was the budget for the Wash State exchange? What was the cost of the largest project for the city of Seattle you were involved with?

Posted Mon, Oct 28, 7:36 a.m. Inappropriate

Good question, Richard, about the costs of the Washington State Exchange. In a 2012 report to the legislature, the Exchange reported receiving $150 million in Federal grants for the construction and estimated the annual operating cost at $50 million.

It looks like there were two grants and they've expended approximately $80 million to date out of about $180 million awarded.
Source: http://www.wahbexchange.org/index.php?cID=407

The year-to-date exependiture figures are about $60 million.
Source: http://www.wahbexchange.org/files/7513/8263/9689/HBE_EB_131023_2013_Actual_vs_Budget_Variance.pdf

These are not definitive answers to the question, but there is more about it in the Board archives at:
http://www.wahbexchange.org/index.php?cID=407

The largest project I was involved with at the City of Seattle was the replacement of the utilities' customer service and billing system (electricity, water, wastewater, solid waste) which cost about $41 million and was completed in 2002.

-bill

Posted Sun, Oct 27, 10:06 p.m. Inappropriate

I hate to rain on the parade, but your link to the state web site leads to a broken page.

Posted Mon, Oct 28, 7:39 a.m. Inappropriate

Casey:
As of this morning, Monday, 28 October 2013 at 7:38 AM, the Washington Healthplanfinder site appears to be offline. Their phone number is 1-855-WAFINDER if you'd like to contact them via phone.
-bill

Posted Tue, Oct 29, 8:59 a.m. Inappropriate

This state provided subsidized medical care first for children of illegal immigrants and then expanded that to coverage for a little under 50 thousand people, a little over 30 thousand of whom were illegal immigrants, adding another reward to the many supplied by this state for illegals to come unsustainably here. The idea that this cohort will decrease costs and increase quality of care for the 80 plus percent already covered will be interesting to see.

Posted Wed, Oct 30, 10:55 a.m. Inappropriate

The business model of the ACA requires millions of uninsured, mostly young, people to buy private health insurance. On this point, both Democrats and Republicans are in full agreement. The fact that more than three-quarters of those signing up in Washington are landing on Medicaid - which requires no monthly premiums from its participants - is alarming. The program will collapse economically unless these numbers change dramatically in the months ahead. At that point, the ease of its website will be an insignificant footnote.

Posted Thu, Oct 31, 7:58 a.m. Inappropriate

Thanks for the comment John.
Again, the article is basically about the project management of the technology. How the technology is used - for better or for worse - is a different topic which has received lots of attention elsewhere. I will say, in my opinion and having spent far too much time in the Harborview Emergency Room watching them try to treat folks without any insurance or safety net - that the goal of ACA is a noble one.
-bill

Posted Wed, Oct 30, 6:13 p.m. Inappropriate

I've visited the state healthcare site several times and more often, it's down. I keep seeing the text below. Some irony here.

"Thanks for your patience
Washington Healthplanfinder is temporarily unavailable. We apologize for the inconvenience - Please check back later."

Washington's site may be good, but it ain't flawless.

Posted Thu, Oct 31, 8:02 a.m. Inappropriate

You are right Casey. The problem is not the Washington State site, but the Federal data hub which the site uses to determine eligibility from Federal sources such as Medicare and Medicaid. See:
http://blogs.seattletimes.com/healthcarecheckup/2013/10/30/federal-hub-outage-brings-down-washington-healthplanfinder/

One problem Michael Marchand identified when I interviewed him was zero time to test the Washington State healthplanfinder software interconnection with the Federal government software such as the data hub because the Fed site wasn't available for testing until "go live" on October 1. This fact and the present outage underscores the abysmal project management of the development of the Federal site which is the subject of this article.

-bill

Posted Thu, Oct 31, 8:59 a.m. Inappropriate

If the debate about the ACA could have been expanded to include single payer "Medicare for All", the difference between scaling up an already working system vs. building a highly complex almost entirely new system could have been seen as the obvious path both economically and functionally.

The fact that more people have so quickly been able to enroll in the Medicaid system than in the Exchange is testimony to that fact.

nwcitizen

Posted Thu, Oct 31, 6:13 p.m. Inappropriate

"Now the software is performing almost flawlessly."
I have not found that to hold true- have been trying every day without success to register my family on the WA website since Oct. 1st, multiple times each day! Every time something minor like checking the wrong box for a child's tax status, a totally unrelated error message come up, which directs you to call the Exchange (instead of being able to correct the minor error myself). Each day I have called the Exchange, and every day I get the same message, Please call back when we are not so busy." When I finally get through (usually late in the afternoon), the customer service is aware of these multiple error messages, but they cannot fix them themselves, but offer to write a Ticket # up for me, which will take 7-10 business days to fix. So, this is day 31 and still not one ticket # has been fixed!
Other errors are deeper. There have been so many problems with trying to register the non-US citizens online (ie those with Green cards) that each of the reps are well aware of these problems. Recently obtained passports are not recognized, older Green Cards don't have the required "receipt numbers", etc. and all send up new error messages. The last rep I talked with told me that they were recently told that the best way is to register all non-citizens as American (!!), just to get the process through, and then the system will come back & ask you to send in more documentation.
Still frustrated & still not registered!

Posted Thu, Oct 31, 7:47 p.m. Inappropriate

Seattleparent:

I really appreciate seeing your comment. None of the others commenting had actually tried to use the site to register (and I haven't either). I wish I could offer some solution, but your experience underscores the problems with this software - including, obviously, the Washington
State Site.

bill

Posted Mon, Nov 4, 1:21 a.m. Inappropriate

Assuming you continue to follow this, would be interested to know, of the people signing up both here and elsewhere, how many did not previously have insurance, how many were dropped and have to go here, and how many just decided to change because they found something that works better for their situation.

Posted Fri, Dec 6, 3:55 p.m. Inappropriate

Reports of "success" with the state's web site remain slightly overstated.
Here's the Seattle Times on continued problems.

http://blogs.seattletimes.com/healthcarecheckup/2013/12/05/nagging-performance-issues-bring-down-washingtons-health-exchange-site/

It seems that the surest way to invite problems is to declare publicly that you've avoided problems.

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