This looks great, but haven't the big, embarrassing problems been with scaling the back end? Even if this were a superior UI and flow, it wouldn't address the issues that made the news.
E.g. the front end registration problem is due to a late requirements change in August that had the effect of preventing window shopping, plus we know there were changes ordered though the week before launch, and no integration testing until 1-2 weeks before launch, and that discovered it locked up if 200 simultaneous login attempts were made or if it had ~1,100 users on it.
So, yeah, those are scaling problems, but not ones we can necessairly blame the techies for, given that they didn't have enough time, and couldn't do integration testing (the government's CMS was the integrator and integration tester, now replaced by QSSI, the ones who did the "data hub"? I think it's called, which is supposed to be not so bad).
But also no, in that the fix-it czar's #1 declared priority is to fix the garbage 834 EDI transactions that are being sent to insurers. That includes incorrect data and incorrect transactions (e.g. multiple enrollments and cancellations for the same person). Based on that, the front end's problems have been a blessing in disguise, because the insurers are only getting a few hundred enrollees a week and that low volume allows the insurers to call each up and straighten out problems.
An estimated 16 million policies in the individual market, and an unknown number in Obamacare's interim high risk pool must sign up for new policies by December 15th or so or they'll suffer a lapse in coverage, which for many of the latter will be fatal. The only way to get subsidies is through the Federal system, i.e. the state exchanges use it for that (maybe with inaccuracies, but it's evidently working for the state exchanges that are working, but don't judge that for any given state exchange until you find out which are getting Obamacare and the much larger numbers reported to be signing up for Medicaid), and that makes sense to avoid fraud, since it results in direct payments from the Federal fisc.
Valid point with the window shopping comment.
A huge mistake on the part of the administration though. The site was apparently flooded with visitors and you have to wonder how many of those visitors were people who already had decent coverage, privately or through their employer, but were just curious to check it out because they had heard so much about it. I know I was one of those people.
Errr, as I read things, bypassing registration would have run up against the 1,100 simultaneous users limit ... rather hard. Of course that was presumably increased over time, it's not like they were able to do much performance tuning until those first end to end tests were conducted by CMS a week or two before launch.
An 1100 user limit is absurd for a website this scale, and is likely predicated on serving content to logged in users, not anonymous readers. With some simple caching they could serve hundreds of thousands easily with very basic tech if they didn't require login.
The biggest problem, from a usability and a technical perspective, is the hiding of the information till you have signed up and given details. Apparently this constraint was added at the last minute, I wonder if insurance companies insisted on it?
>> An estimated 16 million policies in the individual market
What percentage of people with individual plans (who need to get new plans) would actually qualify for subsidies? I don't, so I have more options: (1) I can buy another individual plan from my insurer (2) I can shop other insurers or (3) I can buy from california exchange
In none of those scenarios do I actually care whether healthcare.gov is working. I suspect I am not alone.
True, I suspect the fraction is relatively smaller; when I put on my political hat, I call them kulacks. And they're more likely to be up to the task of finding all of this out on their own. But I think we can also assume the numbers who are not up to this, or are in the expiring high risk pool, are in the millions.
People are going to suffer, because of lapses in insurance, or because they simply can't afford the costs of new Obamacare compliant policies (between the new essentials like coverage for your kids till age 26, and all the cost shifting), or are too proud, moral, or whatever to divorce to get their costs down.
ADDED: This is going to really hit the early retirement thing and availability of slots for people to move up in. A very large fraction of the horror stories I'm reading are about early retirees who are not yet 65 and therefore moved to Medicare.
> What percentage of people with individual plans (who need to get new plans) would actually qualify for subsidies? I don't, so I have more options: (1) I can buy another individual plan from my insurer (2) I can shop other insurers or (3) I can buy from california exchange
I don't understand why you're required to use the exchange to get the subsidies, anyway. Why not let people claim the subsidy directly through an insurer? Then turn healthcare.gov into a static site that simply displays the options and redirects to an insurer's web site.
After all, the subsidies are only an estimate. The actual amount is only calculated on the 1040 tax return. So why should this be any different from tax withholding?
We don't make everyone pay estimated taxes through a centralized site. We let employers withhold an estimated amount, and then the IRS balances the accounts annually, in a batch process.
Well, as I understand it the subsidies result in direct draws on the Federal fisc by the insurers, and the latter can't afford to wait till the next calendar year to get paid. And there's certainly a desire to avoid fraud given that schedule of payments, if I'm correct about it.
Erk: if you're right about estimates and it depending on that years tax return; what do you do if you lose your job and can't afford to pay the unsubsidized rate? What if you earn a lot more money, spend too much of it, and then get hit with a huge bill next April 15th?
I'm disabled and on Medicare so I haven't been looking into these fine details ... this all sounds unworkable to me at first glance, unless it's retrospective based on ... the last year's tax return, but, erk, can't do that either since that don't be doable before the mid-December deadline necessary to get you into a insurer's system.
WTF???
ADDED: this probably explains why the Federal system has to do this, access to IRS payments data (e.g. withholding) is required, it's sensitive data and only they have all of it. Although Experian has a income verification role (people without credit, like sick young adults who can't leave the nest are at last count thoroughly screwed because the Federal site isn't handling this manual intervention well or at all), but I assume that's a double check. Maybe not? Maybe they couldn't get that info out of the IRS's generally high latency (often weeks and months, sometimes years) computer systems?
> And there's certainly a desire to avoid fraud given that schedule of payments, if I'm correct about it.
But why is it any different than the desire to avoid fraud through underwithholding of income tax?
If someone files an in incorrect W-4 and underwithholds by $2000, then the Treasury is out $2000. If someone files a fraudulent insurance application and gets $2000 of unwarranted subsidy, then the Treasury is also out by $2000.
It's the same $2000, whether the Treasury writes some checks to the insurance company, or fails to collect it from an individual on his paychecks. Either way, the $2000 gets paid back on the tax return -- or the IRS goes after you.
> Erk: if you're right about estimates and it depending on that years tax return; what do you do if you lose your job and can't afford to pay the unsubsidized rate? What if you earn a lot more money, spend too much of it, and then get hit with a huge bill next April 15th?
Again, not different in principle from income tax withholding. If you do not withhold the right amount, then you may get hit with a big bill or receive a big refund when you file your 1040.
The main difference is that the subsidy does not automatically adjust. Withholding tends to automatically go up and down with income, because it's calculated by the employer on the paycheck. Whereas the insurance subsidy stays constant unless you make changes.
If you lose your job, you're supposed to tell the exchange so that you can get a bigger subsidy. If your income goes up, you're supposed to tell the exchange so that you can get a smaller subsidy.
The big difference in the first point is who collectible the debt is. Someone who underwithholds has to have that money in the first place to do so. Sure, they may have spent it, but it suggests an ability to earn money commemorate with the debt incurred.
With insurance subsidies, scamming "insurance" companies can sign up nonexistant people etc. and collect those payments from the Treasury until someone catches on months or years down the road. Hence the need to reconcile everything in one central system.
In the case of individuals committing fraud, many would do so simply because they can't pay the higher premiums now demanded of their subgroup (there's a lot of cost shifting), so you have more of a "can't get blood out of a stone", and the optics for the IRS are horrible.
For your latter point, you're saying you make a 2013 enrollment based on partial 2012 data, and if you've got your act together you adjust with healthcare.gov or the linked state site as things change. Which I'm familiar with, the quarterly payments for those who don't withhold ... but I bet this'll hit a lot of people who aren't used to this sort of thing, but the automatic withholding of income that HR/ADT/whomever does for your paycheck....
> Someone who underwithholds has to have that money in the first place to do so. Sure, they may have spent it, but it suggests an ability to earn money commemorate with the debt incurred. ... With insurance subsidies, scamming "insurance" companies can sign up nonexistant people etc.
If you claim an undeserved subsidy, then that means you earn too much for the subsidy. Which means you earn enough to pay for healthcare. You may want to spend it on something else, like your mortgage. But then we're back to the underwithholding situation.
The Social Security Number prevents subsidies from being claimed for nonexistent people. It's like the "phantom dependents" problem on income tax returns. When the IRS began requiring an SSN to be provided for each dependent, the problem went away.
I'm not convinced that fraud would actually be a major problem. It's not like you get the whole year's subsidy at once. You get it a month at a time. Instead of running the income-check interactively, run it as a batch process after the first month of coverage. Then investigate the most egregious cases -- either individual or insurance company fraud.
If an insurance company is committing fraud, take it out of next month's subsidy payments. Remember -- we're already trusting these insurance companies to provide a whole year's worth of coverage, until the next open-enrollment period. They're around to be accountable.
"If you claim an undeserved subsidy, then that means you earn too much for the subsidy. Which means you earn enough to pay for healthcare. You may want to spend it on something else, like your mortgage."
Your last sentence indicates you know the truth about the statement your penultimate sentence makes. Which might be better stated as "Which means you earn enough to pay for healthcare according to this dog's breakfast known as the Affordable Care Act", which following our version of Newspeak for the naming of political bills tells us it's unlikely to be always, or maybe generally affordable.
"The Social Security Number prevents subsidies from being claimed for nonexistent people."
Good point. Change "nonexistent" to "real people under 65 not in the system" (the SSA knows the age). Like illegal aliens using other's SSN numbers, a scammer "insurance" company could just harvest numbers and other ID information for people who aren't buying insurance through Obamacare (hard to say, but a selection of young ones should be fairly safe) and those covered by employer plans, unless and until those people are reported to HHS.
"[Insurance companies will be] around to be accountable."
I'm postulating the creation of new, entirely or partly fraudulent ones (e.g. Obamacare subsidizes the creation of co-ops), or the subversion of existing ones. If there's "free money" to be had, it's likely stupid people will try to grab some, no matter how likely or certain it is they'll get caught.
> Your last sentence indicates you know the truth about the statement your penultimate sentence makes. Which might be better stated as "Which means you earn enough to pay for healthcare according to this dog's breakfast known as the Affordable Care Act", which following our version of Newspeak for the naming of political bills tells us it's unlikely to be always, or maybe generally affordable.
You cut off my actual last sentence in the paragraph, which compared it to underwithholding on income taxes. This is what I keep bringing up, and you keep ignoring. This is not so different from income taxes.
Someone who earns 400% of poverty level owes $5000 in federal income tax, plus maybe another $5000 in local property tax and possibly state income tax. They might want to pay that $10000+ towards their mortgage, rather than to the government.
Since you're clearly very concerned about the financial burdens imposed on those less fortunate among us, I hope you'll support eliminating all taxes on those earning 400% or less of poverty level. We can make up for it by taxing the rich more heavily. What do you say?
Or perhaps we should do the same for health insurance. Single-payer system, paid for by progressive taxation.
I'm suspecting that there's a diversity of situations among the people in the individual market that would make this challenging. These are people who are self-employed, or have low wages, or irregular work.
> I'm suspecting that there's a diversity of situations among the people in the individual market that would make this challenging. These are people who are self-employed, or have low wages, or irregular work.
I'm afraid I don't follow. Why would self-employment or low wages make it more challenging to sign up directly rather than through an exchange?
I'm not proposing any changes to the subsidies. Simply remove the requirement to go through an exchange to get the subsidy.
I don't know how it would be done, but I can only see two scenarios. One is to charge the insured the full, unsubsidized premium, and give the tax credit in 2015. The other is to pay the subsidy to the insurance company throughout the year.
In the former situation, some people just cannot afford it.
In the latter situation, you can have some fraud (by the insurance companies).
I guess they could offer both options, and if you choose the latter, you need to apply through the government, so they can verify that you exist, etc.
I'm not convinced that insurance fraud will actually be a big problem.
Just do a random spot-check of all the policyholders that the insurance company is claiming a subsidy for. If the amount claimed is more than x% over the amount calculated by the government, then the insurance company gets cut off.
Right now, by forcing people to buy on-exchange to get the subsidy, we're essentially doing the spot-check interactively. This is putting tremendous load on the healthcare.gov back-end. There's no reason this couldn't have been done as a batch process instead.
It doesn't need a back end at all. They've done exactly what I suggested in my blog but was too lazy to do — make a rough guess based on static data and hand you off to the vendor. It can be done client-side off static content. Using the IRS service to verify income would be something the real site could easily do, but it's not really necessary.
Not even going to click to find out how stupid people are. Did they implement integration with data streams from hundreds of national insurance companies? Didn't think so.
Your point may be valid, but you put it so maliciously that I winced when I read it. Smart but malicious comments are the worst thing about HN. They are like dioxins where stupidity is mere sewage. PG has written about implementing a comment filtering mechanism. I hope he does and that it will catch stuff like this.
I don't mean to pick on you; it's just a cumulative reaction, plus it happened to be the first thing I read this morning. I agree that back-end integration is likely orders of magnitude harder than UI for a system of this nature.
It is stunning just how much a lack of education and expertise went into this. This says nothing about HIPA, security, scaling, data source integration. It's staggering how much misinformation this PR stunt is going to cause.
HIPAA is not implicated in the new health insurance marketplace. HIPAA protects personal medical information, and under the Affordable Care Act, you cannot be asked any personal health information on any insurance portals because insurers are required to cover any pre-existing conditions.
Now now now. They're only 20 but "have plenty of experience working at places like Twitter and Microsoft." Surely they \cough\ know what they're doing.
They dodged the hardest issues and politics by piggy-backing on the actual site to obtain the data. So you cannot really say that they did what the government contractors were unable to do.
But without a doubt they eliminated all of the cruft and whittled the site down to exactly what consumers want. I want the ACA to succeed and would love to see some variation of this "quick lookup" on the official site. The government would be wise to pay it some attention.
To say they have completely replaced healthcare.gov would be stupid, but have the developers said that? I went and had a look at thehealthsherpa vs healthcare.gov. The people how made thehealthsherpa don't seem stupid to me - in fact they've identified the main pain point with the healthcare.gov website for the user, and tried to do something about it. The experience was as follows:
Click on see plans now - this leads to a page of info with no plans information - great! Hit back.
Go back to home and click 'apply online'
Choose a state - read some info on the problems with this state
Click another apply online button
Click 'get started' to really get started this time!
Am confronted with a form asking for all my personal details, I stopped here.
Now of course that doesn't mean they have replaced healthcare.gov, or done in two weeks what all those developers working for the gov took $400m, but I'd say they've delivered something which is more valuable because it delivers what people actually want - a quick set of choices about healthcare for their specific area, and contact details for the same. It's a good summary of a complicated situation, presumably based on lots of the hard work done for healthcare.gov (assume they scraped the data).
You're not going to sign up for a plan without verifying costs anyway (by phone or on the providers website), so providing a quick summary with contact info is really all they need. I'm not convinced the apply online side of obamacare is actually helpful...
In the UK and quite a few other countries, this monthly insurance cost comes out of taxes and we don't choose an insurer, I think I prefer that single-payer solution.
The original healthcare.gov allowed for as they call it "window shopping", but a decree from the White House less than 2 months before launch demanded they change it to require a signup.
I also want to be an informed citizen, and "how much does it really cost" is an obvious question that anybody might be inclined to ask. In my view, knowing the magnitude of the numbers should help provide a reference point for political debate.
Most Uninsured Americans Ignoring Health Exchange Sites
Three in 10 are familiar with the exchanges
November 8, 2013
Eighteen percent of uninsured Americans have attempted to visit a healthcare exchange website. The percentage is slightly higher, 22%, among uninsured Americans who plan to get insurance through the exchanges.
This is probably because a lot of them lack internet. Our internet penetration is around 75%. Medical insurance is 85%. I suspect there's a lot of overlap between the un-internetted and un-insured.
They didn't build a healthcare.gov clone, but a useful site that can give people much of the information they need. It looks like a very good MVP, and it's absolutely clear that they didn't try to brag how easy it is to build healthcare.gov, but actually tried to help people until the gov site is fixed.
I don't understand how it can help if it is just a facade on top the healthcare.gov. Creating alternative sites like this can only create confusion for average users.
I don't know their motivation, but the reporting definitely as an undertone of "look, all these professionals couldn't do it for millions of dollars, and 3 kids did it in a week for free".
From the convoluted articles I've read, not only was the main bottleneck in the identification process, but the issue seemed to be that the authentication was necessary to just show the plans, because the gov wanted to make sure you were 25 before showing you a range of prices...was that the case? If so, whatever happened to letting people just browse the entire table of prices....remember when people had to look things up and scan tables once in awhile, instead of living in a Minority Report world where every piece of info is handcrafted to the user?
I wonder how much of Healthcare.gov's problems could have been eliminated if the sign up was more modular...users were allowed to browse before signing up for anything. Then they could sign up via email and tentatively pick a plan. Then in 3 days, they go through the full authentication process...this is similar to how Amazon does things...you can sign up without a credit card, you can browse without signing up, and you don't go through the processing bottleneck till the very end.
The contractors were ordered in August to change the system to require up front registration and submission of "correct" information on penalty of perjury, no window shopping allowed, nor checking out "what if" scenarios (e.g. using the Kaiser Foundation's calculator, someone was unable to find any scenario where being married wasn't more expensive, and of course subsidies are based on income, and that can be very flexible for a lot of people).
Since then window shopping has been allowed, but I don't know if the "under penalty of perjury" bit was dropped.
Note also the front end traffic jam has avoided sending the insurers more garbage 834 EDI enrollment and cancellation transactions than they can manually clean up by contacting enrollees. That's the #1 thing to correct according to the fix-it czar.
And I do agree with you, an Amazon system, which I'm sure is based on the BASE eventual consistency back ends, e.g. you don't get your confirmation email until it decides who "won" the last copy of an item, would have been a lot better. But then again the contractors were doing a lot less of that sort of top level design that you'd think (see the Post article).
Seriously -- this tool is equivalent to a cardboard cut-out of computer. It is embarrassing this is getting attention. They're dumping a publicly available spreadsheet that contains example age-group pricing... i.e. unless you're 27 or 50, it's giving incorrect information.
I just tried it, and it's great. Nice job, on many fronts: Recognizing a problem, coming up with a simple, uncluttered solution, and making it work.
In my view, a site like this is useful for a lot of purposes beyond actually signing up for health care. For instance, I've got employer sponsored care, but I was simply curious about what my costs would be through the exchanges. I also want to be an informed citizen, and "how much does it really cost" is an obvious question that anybody might be inclined to ask. In my view, knowing the magnitude of the numbers should help provide a reference point for political debate.
Thanks for that! I had assumed that I wouldn't qualify for a subsidy, and indeed I don't.
As others have mentioned, these sites don't actually solve all of the problems, but it seems to me that a few free tools that just help people gather information would take some of the pressure off of the main system. And if enough of these tools were to crop up, then none of them would have to be 100% reliable.
Simply making people less nervous about signing up will make the official process work better.
"I had assumed that I wouldn't qualify for a subsidy, and indeed I don't."
And having learned that, you could now go to individual insurer's sites, or various ... marketplaces? like http://www.ehealthinsurance.com/ which I've also tried, shopped around (that site even integrates "is your doctor in the network", at least for Humana), and gotten yourself covered.
But everyone was told to go to Healthcare.gov, and right now individual states are doing a lot of marketing for their own sites, some of which aren't sufficiently functional....
A smaller fraction of the individual market I'd assume, but I also assume a rather large fraction of the temporary Obamacare high risk pool, many of whom could die if they suffer a lapse in coverage (I imagine kludges will be arranged if Healthcare.gov is not too late in becoming a MVP).
Well, there's the caveat that the Federal site has the last word on whether you're really due a subsidy.... If you can't afford, or can only afford a new Obamacare policy, you'd really like to know you aren't due a subsidy, and how much do you trust random non .gov web sites???
And I think most of us know why that message "is not getting through".
(Totally unrelated side note: damn it, we really should change standard legitimate English so through -> thru and leave thorough standing "by itself".)
> Well, there's the caveat that the Federal site has the last word on whether you're really due a subsidy....
It's worse than that.
You are required to buy through the exchange to get a subsidy. The way the law is written, you cannot get a subsidy if you buy insurance off-exchange.
The absolute worst case is someone who earns precisely 400% of federal poverty level, buys a policy outside the exchange, gets laid off on April 1, and can't find a job for the rest of the year. Open enrollment is over, and he's stuck paying full-price even though he only earned 100% of federal poverty level.
This is the absolute worst-case scenario -- but even less dramatic examples could still benefit from the exchange. Earn 600% of FPL? Are you 100% positive that you won't get laid off before August? The optionality is worth keeping.
We've only got 7.5 weeks to go before some plans start expiring. Healthcare.gov had better be 100% operational by then.
> damn it, we really should change standard legitimate English so through -> thru
Teddy Roosevelt thought so, too. That was 100 years ago. It didn't really stick, highway signs excepted.
And we've got less time; realistically, the insurance companies need finite time to process enrollments. The official deadline is December 15th, which I've been modifying to "mid-December" assuming they do a Maximum Effort if the exchanges are working well enough to give them a lot of valid enrollments.
And of course a lot of people who don't realize this, got to a subsidy calculator like the Kaiser Foundation's and satisfy their gut feeling they aren't due one, will bypass the dysfunctional exchanges and just buy on their own ... then some subset who hit hard times will get screwed.
Blah. Thanks for the good discussion and bringing up yet another screw case.
Well, it's not quite that bad. Until open enrollment ends, you could always drop your off-exchange coverage and re-buy on the exchange. So up until March 31, you only lose a pro-rated portion of the subsidy due to you.
That's why I selected April 1 as the worst-case scenario. When open enrollment ends, the potential lost subsidy jumps from 25% to 100%. You have to wait until the next open-enrollment period to change plans.
But that having been said: why should anyone give up even $1 of the subsidy due to him, because of a failure of healthcare.gov? That's why I think the subsidy should be claimable off-exchange: https://news.ycombinator.com/item?id=6702966
Problem is, the requirement to buy on-exchange to get the subsidy is written into the law. That means that it is not changing. The Republicans certainly won't want to fix any screw-ups in the implementation of Obamacare.
The government contractors should of just built healthcare.gov as a data service and asked people like these guys to build an intuitive front-end for it. Then if people don't like the interface, they can do something about it :) This may also help to dissipate the traffic load and present the same data in more relevant ways to different types people. The idea of building apps as single, monolithic system is out-dated.
Even though I'm a Brit, some governments are making moves to modernise and open up their data for others to play with, over here we've got a great government-funded team working on exactly that (called the GDS). (http://digital.cabinetoffice.gov.uk/)
Frankly I think this is a massively expensive and missed opportunity for the US Government's digital service team.
Well, the government contracts didn't have that level of control, political and bureaucratic types from the White House on down to HHS's CMS were running the show, delivering requirements very late in the game and making constant changes to them, including the "no window shopping" registration first in August, and from many reports change orders through the week before launch.
So you ought to say "The government should of just built healthcare.gov..." ... except that's very clearly not the style of this government.
E.g. one simple way to take traffic off most of the system would be to provide an interface to the subsidy calculation to entities beyond the state exchanges (who have to use it; when Verzion accidentally took the site offline, they couldn't do much), like insurers. It's said to be on the todo list, but at a very low priority.
A closer reading reveals that 11 billion (I assume that's thousand million) pounds was the projected cost at the time for completion of the system. "Only" 2.7 billion, or 4.3 billion USD, has been spent, although I don't know if there are contract terminations of serious size to be paid.
Still, it's an epic failure, said to be the greatest single one in government IT contracting.
(E.g. I'll bet the FAA's eternal quest to upgrade from their 1940's (sic) technique and '60s or so architecture has cost more over time, but not any single failed effort.)
Yea we get stuff wrong too. That was a massive balls up, but well before the time of the GDS team.
Also note that the NHS system was about building a database for every NHS health record across the country; prescription notices, medial history, etc. etc.
I'm not sure it'll even be legal now. HealthCare.gov isn't going nearly as far as that.
I'm assuming the task these guys have done is tiny portion of the actual work needed for the website.
I've been wondering for a while, though, why the federal government can't just buy/beg a copy of software running one of the exchanges for one of the states doing things themselves. Then they could modify it to work for other states. Maybe they'd then have to replace existing federal exchange with 26 different instances (one for each state that's a member of the federal exchange), but I can't imagine that the technical difficulties of modifying one state exchange's software to run with another state's data would be as bad as fixing what seem to the problems with the existing federal exchange website.
Probably too late for the very hard mid-December deadline for those losing their insurance, maybe too late for getting enough young healthy people enrolled before adverse selection forces insane 2015 premium filings from insurance companies, which are due by the end of March.
They also have only 4 well functioning states' systems to chose from as I understand it.
The centralized subsidy calculation/verification/etc. process, which the Federal system does for all the exchanges is another issue, although I've only heard that some time ago is was known to produce incorrect results under testing.
Also would require the Federal government to admit a much bigger screwup than they've been willing to so far, in a process entirely driven by politics (http://www.washingtonpost.com/politics/challenges-have-dogge...) until the last week of last month when CMS was fired and the fix-it czar was appointed.
If you've been in this game long enough you've seen projects and companies destroyed by a failure to take decisive action when it could have made a difference (or read, for example, Churchill's The Gathering Storm, or any shorter version of how WWII could have been so easily averted by preventing German rearmament). The odds are pretty high this is going to be another example of that.
For an MVP this is a great start. Front-end code is clean, concise and the flow far better than the gov version. If the gov is looking for solutions to their problems these guys just showed what local talent can do vs outsourcing an important piece offshore and messing up.
As a Canadian living in the U.S. (SF bay area), I still don't understand why American make healthcare so complicated. At beginning, HMO vs PPO vs whatever makes me very confused. Why not just move to a public national health care that works for all?
money * low information voters * paranoid messages = tea party
Also, around 80% of people are in private insurance plans through a plan at work. Some fraction of these people are happy with their HMO or PPO. These are the middle class and upper middle class or rich. They are also politically resistant.
The support for national health care or even single payer would come from the uninsured and people who have lower-end insurance (high deductible plans) and are forced into a kind of expensive PPO (insurance that makes you pay most of the costs of doctor visits).
Hilary Clinton's single payer plan was demolished by the insurance industry. So this time around, they kept insurance companies in the reforms. That negated some of the resistance from the well-insured.
I don't understand how this site works. A few days ago when it was first posted here, I tried my zip, and it returned
"Plan Results
Found 0 exchange plan."
Today I searched my zip again, this time even messing with the different options of insurance type, and still zero results. Is this saying there are no insurances available for people in my area?
You haven't provided enough information for anyone to give you advice about what might be the problem. Perhaps you live in a state that has its own exchange (e.g., Kentucky or Maryland). Or maybe there is no data for your area yet. Try Chicago (60609) for some sample data to use for an experiment. If that doesn't work, perhaps some error is occurring on the page; check the JavaScript console and report it to them.
A little skeptical of this, as others are. How was this tested? Just because it seems to "work" with responsiveness and items on the screen does not mean the info is correct.
Not saying healthcare.gov is any better, but there is just no mention of the information given and/or calculations done being correct.
This makes me so infuriated! This site is great, it's exactly what needed to be done, it works, and of course, it was NOT designed by our government, because it works, and that just makes way too much sense! I used the CA site before to look at available covarage. It's much more dificult to use, and it hides from me the more affordable "Catastrophic Plan" for which I do qualify, because I am under 30 years old. They do not want people to sign up for that plan, so they just hide it! This is outrageous beyond belief.
All this site now needs is the ability for the insurance companies to upload information about their plans directly to thehealthsherpa.com and we can forget about healthcare.gov all together. People signed up for years for insurance coverage by phone, directly with the companies, and they can continue to do so. The exchange should be just be an informational tool. This site does the trick.
I think thehealthsherpa.com should provide links, or better yet, add pages to the site directly, to explain the different plans and regulations for different states, so it can be more of an information hub. Great Job!
For me it comes out to $250/month for Bronze Plan, and only $170/month for Catastrophic Plan. I don't go to doctors unless I need to, and when I need to, I can afford paying cash. I can take a $6,350 bet on my health, but I still want to be covered above and beyond that.
And the question isn't about whether or not I should get catastrophic plan. I have the right to get it under the new law, and CA's Exchange site should have the duty to show me it as an option. Instead, they hide it, which is very underhanded.
I must admit I have not devoted any time to understanding the real technical issues behind healthcare.gov. What little I know is from interpolating and extrapolating what I read here and elsewhere. One impression I got is that this $600+ million dolar website's authors tried to do it all. I don't get that at all.
So, here's what I would have done. This is completely sit-of-the-pants. I'm sure it has holes. Nothing that couldn't be sorted out by applying real thought to the problem beyond this quick and admittedly faulty definition:
My approach would have been to first develop a specification for an API all insurers would have to implement. They would be required to have a full implementation of this API in order to participate in the service. Now you have hundreds of teams working for you. This would cost almost not taxpayer money.
The next step would be to develop an automated test suite to test for API compliance. Open source it and release it. Setup a method through which this API could be used to certify compliance. Perhaps this would be an insurer's portal in healtcare.gov. Upon certification they would receive an expiring token identifying the plans submitted as being fully compliant with the API. More on this later.
Now everyone knows what they have to do to communicate their plans and how to make sure their API is fully compliant. No tokens. No participation.
Each plan has a token. The token is also the GUID for each plan.
Unit and regression testing are your friends. Insurers would do their own testing and they would be forced to continue to guarantee compliance by means of the tokens expiring at preset intervals (a year?).
Next the API would be released for anyone interested to implement health insurance browsing sites. Yup, let entrepreneurs battle it out for best-in-class discovery services. You would have hundreds of sites pop up with all kinds of really good solutions.
You would then publish another API anyone could use to actually communicate with government servers and "book" insurance.
Now you have a potential of tens of thousands of people working for you. And still virtually zero cost to taxpayers.
If that's too open, perhaps the plan browsing sites simply redirect you to a government site for the actual booking. They pass the token for the plan that was selected and a secure government site takes it from there.
Not done yet.
I would also hold a pre-release contest with cash prizes in the range of $1,000 to $100,000 for faults found during penetration testing of the government booking site. Release the code to the .gov site and let hackers mount massive attacks from every angle. Do this until top hackers agree the site is pretty damn hard. Give the top ten contributors cash as well as some kind of a presidential recognition at the White House. In other words, make it very public and very prestigious. Money and time well spent.
Once there, load test for something in the order of a million simultaneous users. The site must be built with elastic capacity as it will have to be able to manage insane traffic for a few months and then scale down to a more reasonable baseline.
Then open the doors.
However. This does not happen all in one shot.
Segment the population around data centers. Perhaps a couple of states on the east coast and a couple on the west. Announce it across all media. Schedule additional population segments across a period of a few months in order to average out a reasonable load on the system.
All independent browsing sites would have API access to the schedule. They could then save your selection and email/sms you when your turn comes up.
In other words, decouple the act of browsing and researching plans from actually booking it. And, at the same time, utilize a mechanism through which the rate of booking per unit time might be controlled. The browsing sites would simply not be able to forward to healthcare.gov unless it is your time slot. Now you have a situation where you simply can't have a hundred million people hitting healthcare.gov.
One could further segment booking by implementing time slots based on other criteria. For example, the last digit or two digits of your SSN.
Yet another approach would be to offer a limited number of booking time slots per hour. Browsing sites, through the API, would have access to this information. This means they could provide a virtual appointment system where you pick the time and date that is most convenient for you to actually book your plan. If a slot is available you are in. Otherwise you are offered alternatives. With this you could easily throttle the number of people who hit healtcare.gov per unit time. Again, healthcare.gov would NOT be a browsing site. You'd have to go through private sites for plan discovery.
Once booked, healthcare.gov would --via a pre-published API-- forward a completed and validated application to the insurance company.
I am sure further checks and balances would be required. And, as I said above, this game-plan surely has holes. It is seat-of-the-pants, I am coming up with it as I type. No way it is perfect.
However, there is one thing I know: The general idea here is to leverage the free market and private enterprise in order to delivery a massively better product. I realize this goes counter to the ideas the current administration must have about how a country ought to be run. However, if this healthcare disaster has done anything at all for all of us is to potentially prove, once and for all, that central planning and management by government is a horrible idea.
This is exactly how everything is done in government. We simply don't get to see it and experience it in daily life. With the ACA there was no way to hide it. This has been and continues to be a very unique opportunity for the American public to really see how bad government is about specifying, planning, managing and executing anything at all. If this makes people understand the fallacies in that school of thought this could very well have been the best $600 million we ever spent.
You need to add to your seat of the pants concept how the government is going to control the payment of subsidies to prevent fraud. Those result in direct payments from Federal fisc to insurance companies....
Right now the Federal system is doing that for everybody, Healthcare.gov and all the state exchanges (single point of failure as Verizon's goof demonstrated). In theory insurance companies will get access, but it's said to be a very low priority.
Then there's, oh, the straight out fraud problem, i.e. you sign up, pay your first payment, then come January you or one of your fellow enrolees find out when you try to get services or prescriptions, the insurer you thought you signed up with has never heard of you. That pretty much requires starting at a blessed government site, I don't think your stopping at a government booking site would work since that could be spoofed, right? So could close the loop snail mail confirmations from insurers.
That's why each plan has a GUID. This GUID would be authenticated when you go to healthcare.gov. They would not let you purchase a plan that does not authenticate. They are the ultimate authority and filter. They'd also handle details such as subsidies, etc.
In addition to that the transaction from healthcare.gov would, of course, ultimately reach the actual insurer who would have to further authenticate it, communicate with you and possibly also send some kind of an ACK to healthcare.gov.
The process could be full circle with many layers of confirmation and verification. This does not need to be overly complicated.
The idea is that the free market would handle the implementation of the massive first layer of a national system such as this one. Get government involved only where and when absolutely necessary.
How will people reliably get to healthcare.gov from a friendly scammer's web site...? The system has to be built for ordinary people who seldom if ever look at URLs unless entering them.
For your second point, I posit a scammer simulating all of that, right down to sending out authentic looking enrollment snail mail. Or just disappearing after getting your first, up front payment.
My point here is that we need something like what you describe in your last paragraph, with people like you putting on white hats to design the system and people like me putting on black hats to break it in principle. And of course trading hats as we see fit, etc. This most damning article yet, from the Washington Post, points out how unopen, often the point of secrecy, the process was, even to the point of suppressing release of architecture diagrams to the state exchanges: http://www.washingtonpost.com/politics/challenges-have-dogge...
Yes, yes, I agree. This isn't difficult. Right. I mean, here are two guys talking it out. Imagine if you put together a dozen real experts, took them to a nice resort for a week and tasked the with coming out with a complete definition covering architecture, operations and penetration/scam testing. It isn't like we are trying to build a Star Trek transporter. There is nothing about this that we don't have a pretty good handle on. And that's kind of my point. The government is and was the worst possible project leader for something like this. It isn't that complicated.
As I said in my opening to the prior post. I know it's full of holes. At the same time, I know it would be a million times better than what we have now and it would probably cost $595 million dollars less.
Works great until that group includes, even if by proxy, someone from IRS IT.
Have you ever dealt with any of them? I suspect not, for it's in my experience unforgettable, and unique compared to every other governmental IT person I've ever dealt with.
See this diagram drawn from the first set of hearings:
I have no idea what HHS's computer systems role in this is ... well, tracking, I suppose. Healthcare.gov is for managing enrollment in plans; does it's remit even include knowing who has what at the moment?
"SSN" is I assume the Social Security Administration, and I also assume is to verify citizenship.
IRS in theory has all the relevant income data and is the non-criminal enforcer.
Equifax is also used for income verification, suggesting IRS isn't up to delivering all that's needed, or not reliable enough. Not part of the government, fortunately!
You can't just "reach out". There's a complex procurement process for government contracts. The companies that get contracts are usually those who are best at navigating the bureaucracy, not those who are the best at creating the product. Most of these companies have been in this business for a long time. It would take years for a startup to figure out how to get these contracts and build up the contacts in the bureaucracy necessary for it to actually happen.
this is very short sighted. hire a contracts person away from one of the big contractors, or get a recently retired contracts person as a consultant. other startups do this, you can too. odds are low they'll relocate to SF though, maybe they should work remotely ;)
The "contracts person" is one link in the chain. The far more important and relevant links--the ones with the connections and personal relationships with people in the government who award these contracts. One of the reasons government contracting is the wasteful, corrupt mess it is is because it's an extension of the rest of politics in Washington: a machine designed to move taxpayer money into the hands of the connected and already-wealthy.
Having a "contracts person" may slightly increase one's chances of getting smaller contracts. Having the right pedigree is the almost the only thing that matters with contracts as big as the web of HealthCare.gov contracts, and no startup is going to be able to offer a level of financial or intangibles compensation to pull those with the right pedigree away.
"One does not simply walk into government contracting."
Seriously, it's a really involved thing. E.g. you need competent, domain experienced lawyers, there's massive amounts of law and regulations to follow. I've seen it at various levels, including working closely with a small firm's lawyer who e.g. got many of its products on the GSA catalog.
Indeed. There's a big difference between what I call the Minimum Viable Demo (which is what was reported to have been shown to Obama before the launch, the thermocline of truth was in evidence there: http://brucefwebster.com/2008/04/15/the-wetware-crisis-the-t...) and a MVP, which is what we desperately need.
