Filed Under:Markets, Employee Benefits

Shock and flaw

To your good health

So much for her marketplace... (HHS image)
So much for her marketplace... (HHS image)

Hanlon’s Razor dictates, “Never attribute to malice that which is adequately explained by stupidity.” 

The first 30 days of the PPACA marketplace implementation have left Americans divided as to the appropriate Hanlon choice. Regardless of your viewpoint, one thing on which nearly everyone has agreed is that, thus far, the user experience has been pretty dreadful.

In 1996, Harlan Ullman and James Wade gave a name to the military doctrine intended “to affect the will, perception and understanding of the adversary to fight or respond to our strategic policy ends.” 

The PPACA version of this doctrine is most likely what the administration had hoped to achieve with the marketplace rollout. Ullman and Wade called it “shock and awe.” Sadly (for all of us), what they actually achieved was “shock and flaw”.

Shocks began arriving nearly as soon as the marketplaces opened. The very few people who were able to see rates and plan details thought (or hoped!) that what they were seeing was a typo or system glitch. Sadly, they were experiencing bait-and-switch taken to a new level.

One friend emailed me with his experience and gave me permission to quote him here as long as I did not use his name. (He did not want to risk retribution from the government.) 

“I am a father of seven who has been buying health insurance since 1999. Our old plan cost $634 a month for family coverage. We had a $10,000 deductible with a 20 percent co-pay after our deductible. Our annual outlay, after taxes, is $17,600 before the insurance kicks in. Our new plan would cost $1,763.98 a month for limited family coverage, with an $11,000 deductible in network and $22,000 out of network and a 30 percent co-pay after the deductible is met. That equates to a 180 percent increase for less coverage — this is the bronze level, the lowest level of coverage.”

“That means,” he continued, “that before I even get any benefit (other than having a card in my pocket) my household outlay will be, after taxes, approximately $33,000 a year ($21,167.78 plus $11,000). After that, I get to contribute another 30 percent to any services rendered under my new plan. This will be the single largest monthly outlay in my household. It will be more than my house payment, more than all my utilities combined, more than my food bills and more than what it costs me to send my son to a state-run university!”

My friend’s total plan cost is in the middle of the pack of increases some are finding. Remember that these are just premium and out-of-pocket costs. For even more disappointment, we need only wait until people start to utilize these plans and realize that their networks and providers are so thin that they are unable to access the facility or provider they want, and that waiting times for non-emergent appointments have skyrocketed.

The flaws began showing up even before the shocks. Brokers attempting to complete certification, available only weeks before the “grand opening” were subjected to misinformation, long waits for CMS to verify that they had indeed finished part one (even though the system showed they had not) and interminable waits for part two of the certification to become available.

In mid-September, one broker described her experience trying to get one small question answered. “I just called the CMS help desk. The ‘system’ finally verified that I had taken part one. Then it said I needed a higher level of security so I completed that section and it said I was already in the system. 

So I logged out and logged back in, and it did the same thing. That is when I called CMS help desk on their website. I didn't hold too long, but the guy said I called the wrong number. They had the wrong number on their website. I said do you know how long it takes to change a phone number on a website and hit refresh? So I called the number he gave me, and I held for 30 minutes, and they said that I needed to complete all of the sections but don't put in my Social Security number when it asked me for it. 

So I did that, and it worked, and I said, ‘Now what?’ and he said, ‘That is as far as you can go.’ I said I was going to take part two. He said they had system glitches, and where I was — everybody else was at the same point. Hilarious.”

This was a precursor of a tragically flawed marketplace rollout. We have all heard the continuing horror stories of citizens’ attempts to access the HealthCare.gov website.

Long before the public’s frustration with the site began, the government had serious worries about the marketplace infrastructure. Henry Chao is CMS’ deputy director and chief information officer. Way back in March, he met with insurance executives and told them that he was extremely concerned about the marketplace technology. “Let’s just make sure it’s not a third-world experience,” he said. Given the appalling experience in October, I would begin worrying about third-world countries suing us for defamation.

As someone who has spent a decent part of his working life with responsibilities for IT and software design, just thinking about the complexities and interactions of a properly functioning marketplace system gives me the heebie-jeebies.

I have a somewhat unique perspective on this Rube Goldberg type of software. As part of the executive team some years ago, our company administered an indigent care plan for a large county. One of the tasks the system had to accomplish was to retroactively check to determine that participants were not eligible for Medicaid. It took months upon months and specially crafted software to reliably accomplish that goal; a goal which, when viewed against the monstrous complexity of the marketplaces, seems minuscule. Once the architecture was in place, additional months of checking and cross-checking took place. Only then did we go live.

By comparison, and by any objective measure, the marketplaces were cobbled together at warp speed. The system deals with nearly 50 statutory provisions. L. Gordon Crovitz, columnist for the Wall Street Journal, captured just the tip of the iceberg in his Oct. 13 column. “Signing up uses a Byzantine process to check if a family is entitled to a subsidy, requiring data from dozens of federal and state agencies using databases built on different technology platforms.” These include Medicaid, the IRS, the VA, the OPM and various state Medicaid and CHIP programs. Once the calculations and verifications are done, the information has to be transferred to an insurance company. The insurers are already getting incomplete, incorrect and erroneous information, and they are beginning to question the long-term viability of the current system.

A reader once commented that I must be a “rabid, wacko, right-wing conservative.” He was correct on one of those pejoratives. (Readers are free to decide which.) So lest anyone think that the shock and flaws have garnered only the attention of one side of the aisle, none other than former Obama press secretary Robert Gibbs told MSNBC’s Alex Wagner that the problems with the exchange are “excruciatingly embarrassing” for the administration.

Gibbs said, “This is not a server problem, like too many people came to the website — this is a website architecture problem […] When they get it fixed, I hope they fire some people that were in charge of making sure that this thing was supposed to work,” he said.

That would be shock and awe.

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