At the end of last week, documents released to the House of Representatives’ Energy and Commerce Committee by Department of Health and Human Services revealed that about three months before the error-plagued launch of the cornerstone provision of the Affordable Care Act — the online health insurance marketplace designed by the federal government — officials were worried the federal website would “crash the plane at take-off.”
But even as early as March of 2013, approximately three full years after the healthcare reform was signed into law, the Obama administration was given a warning by the private consulting firm it hired to assess how the insurance enrollment system was progressing. With the magnitude of the website’s problems on full display thanks to ongoing congressional hearings, the concern expressed by the consulting firm, McKinsey & Co., fits squarely in the role of prologue in the ongoing narrative of Obamacare implementation. Documents newly released by the Centers for Medicare and Medicaid Services, or CMS, showed that report compiled by McKinsey & Co. foreshadowed many of the technical problems that troubled the rollout of the federal healthcare website, health.care gov, which links the 36 federally-facilitated insurance exchanges.
The firm cautioned the Obama administration that insufficient testing of the site would make it difficult to fix any problems that materialized after the exchanges opened for enrollment. Those online marketplaces launched on October 1 to numerous software errors and design flaws that caused hours-long wait times, prevented potential customers from creating accounts and completing the 30-step enrollment process, sent insurers the wrong information, and made it difficult for customers to get an accurate cost estimate. While the site has been updated several times with new code that included “bug fixes,” and additional capacity, it took weeks for the website to operate more smoothly and still significant glitches remain.
In a further set back to the enrollment process, when the website crashed on its October 1 debut, insurance customers were told they could enroll via call centers, but those call centers employed that federal health care website for sign ups. Yet, McKinsey had noted in the analysis that in the event that the federal website malfunctioned, the online system could not be sidestepped by using the call centers.
According to the House Energy and Commerce Committee, which obtained the documents from CMS, McKinsey’s risk assessment was presented to senior White House and Health and Human Services, or HHS, officials in four briefings held between March 28 and April 8. HHS Secretary Kathleen Sebelius; Marilyn Tavenner, then acting administrator of CMS; and White House Chief Technology Officer Todd Park attended the April 4 meeting, while President Barack Obama’s health policy adviser Jeanne Lambrew and then-White House Deputy Chief of Staff Mark Childress were briefed on April 8. However, despite the sizable problems that the firm described as possible derailments to the implementation of the insurance exchanges, the congressional testimonies of key health care officials before the October 1 launch date carried no hint of those potential issues.
After the documents were obtained, Republican Representative Tim Murphy of Pennsylvania — chair of the panel’s subcommittee on oversight and investigations — said that 14-slide presentation prepared by McKinsey suggested that government officials knew the enrollment system was flawed, according to the Washington Post. “Despite assurances from Secretary Sebelius, Marilyn Tavenner, and [CMS official] Gary Cohen that all was well and on track with the launch of the Affordable Care Act, we now have documents dating back to April that call into question the assertions made to this committee,” he said.
In response, CMS issued a statement that described the McKinsey assessment as “part of a standard process to identify potential risks and develop mitigating strategies.” That statement, which was acquired by the Post, further explained that, “The review was completed six months before the beginning of open enrollment, was in line with industry best practices and was followed by concrete action to address potential risks — as was intended.”
Providing a slightly more elucidating explanation for how much the government knew, White House spokesman Eric Schultz told the publication that, “Flags were definitely raised throughout the development of the Web site, as would be the case for any IT project this complex. But nobody anticipated the size and scope of the problems we experienced once the site launched.”
Yet, administration officials maintained that the assessment was by no means a technical review of the federal website’s functionality. Instead, it was meant to be a series of recommendations, some of which the administration took — like improving communications between states and channeling more resources to in-person helpers and call centers. Further, it is true that the document did not predict that the problematic design stage would derail the rollout of the insurance exchanges, although it did make clear that projects of the scale of the new marketplaces are ideally conducted in a more orderly process with “significant testing and revision” before they launch.
In particular, one slide shown a light on why the creation of the federal insurance marketplaces were so riddled by errors. McKinsey’s analysis explained that the policy and the requirements of a program are best defined at the outset, so that enough time is left for testing and revision. But in the case of Obamacare, the federal marketplace’s design was changed numerous times to comply with “evolving requirements” of the Affordable Care Act throughout the design phase, leaving little time to test the system before launch. In addition, the firm found that problems were also materializing because the federal contractors who created the marketplace lacked an “end-to-end operational view” of the system, which prevented them from ensuring the different aspects of the website and the exchanges worked well together.
Even worse for the success of the project was the fact that there was no “no single empowered decision-making authority,” or person in charge, who could guide the design process and make necessary changes. Without that single authority, various entities within CMS gave conflicting direction. Still, the analysis not determine whether the administration should have delayed the launch. Rather, McKinsey recommended that CMS create a “version 1.0” to be fully tested before implementation and assign a single leader to oversee its implementation and rate its success.
It is also important to note that some of the firm’s fears did not come to pass. The reported warned that the “data hub,” the network that connects federal, state, and insurer databases, could be vulnerable.
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