OPINION: While mountains of commentary appeared about the problems with the so-called “roll out” of the computer system for the federal Affordable Care Act, there were also similar problems in several states that had decided to run their own public exchanges. Little has been written as to the reasons why there were so many problems in several totally separate environments using different contractors, forms of governance, and scale. Problems have been most pronounced in Oregon, Hawaii, Maryland, Minnesota, and Nevada in addition to those encountered at the federal level with healthcare.gov.
Many of the people assigned to oversee implementation are very experienced, hard-working and committed public servants. Many of the firms contracted to build these systems are amongst the world’s largest and most experienced IT system developers who have successfully built large, complex systems for a variety of public and private clients. A significant amount of funding was provided to build the computer infrastructure. A substantial amount of time between the signing of the legislation in March 2010 and the planned rollout in October 2013 was available. In spite of these relatively favorable circumstances, there have been multiple problems that occurred and some of these problems are far from being successfully overcome.
Why?
Given my past experience in government, nonprofit, not for profit, and private sector, I have some thoughts as to why there were so many failures in the timely implementation of several systems simultaneously. Here are a few for your consideration:
The individuals appointed to oversee implementation were nearly all what I would call “policy” experts and not “operations” experts. The challenge required more “operational” expertise.and less ‘policy’ expertise.
Many of those involved in implementation had some latent ‘hostility’ toward private insurers (even as they needed to interact with those insurers to develop the systems) and therefore were not open to seeking input and advice from experienced insurance ‘operations’ experts.
None of the primary computer system contractors are well-recognized in insurance operations which have traditionally been served by a small group of firms focused on the niche of insurance operations (firms such as TriZetto); therefore, there was little understanding by the contractors of the project.
Too many of those involved in the implementation underestimated the complexity of the projects and the numerous interfaces that were needed. Those highly involved in system development didn’t have any good idea about the overall state of the public Medicaid systems that need to interface with the new ‘websites’ and in turn with the systems at IRS and Homeland Security and multiple private insurers. For instance, few knew that in California there are three different IT systems on which Medicaid data resides – all three are relatively old and running on old hardware using older languages like COBOL Nearly all of the original designers of these ‘legacy’ systems retired long ago. Therefore, nearly all involved grossly underestimated the challenges in designing systems to interface with so many disparate systems. As is common in nearly all federal and state large initiatives, there is a high potential for ‘turf’ wars – so for example there are issues that arise such as:
- Will the call centers hire existing public employees or employees from the private sector?
- Will the governing board be independent? Who appoints them?
- Which agency, if any, is the lead organization? Who, if anyone, resolves inter-agency conflicts?
- Will we rely on brokers/agents or community groups to do outreach?
- Will we do criminal records checks or other background checks on those doing outreach?
This list could fill several more pages and these are just a few of the typical issues that arise. This is an interesting case study in a failure of “problem” definition. This is perhaps a tortured analogy but it is as if when the proverbial patient was rolled into the OR there was uncertainty whether she was having a bunion removed or about to have heart surgery. My sense is that too many looked at the implementation challenge as akin to set a minor fracture when it should have been considered to be simultaneous cardiac and neurosurgery.
Patrick Pine is the chief administrative officer for the Robert F. Kennedy Medical Plan and Juan De La Cruz Pension Plan. Both are Taft Hartley benefit trusts that provide benefits to approximately 10,000 to 12,500 employees and dependents. He directs a staff of 15 with a main office in Keene, California. Mr. Pine is a current member of the Southern California Association of Benefit Plan Administrators (SCABPA), the International Foundation of Employee Benefit Plans (IFEBP) and the National Coordinating Committee for Multi-employer Plans (NCCMP). He is a past president of the Oregon Health Care Purchasers Coalition and past president of the Oregon Municipal Finance Officers Association. Mr. Pine has an MBA and BA from Willamette University.
Patrick Pine can be reached at [email protected].
