How Healthcare.gov Dared Greatly and Won
Since the third annual Healthcare.gov open enrollment season began on Nov. 1, Centers for Medicare and Medicaid officials said, 2.8 million people have selected plans in the federal marketplace, and one million of them are new customers.1
– Robert Pear, New York Times
As open enrollment continues, millions of Americans are visiting Healthcare.gov. After its inauspicious start, today’s health insurance marketplace has come a long way from the cost sinkhole many predicted it would become. Making its debut to a great deal of political and technical skepticism, the marketplace, also known as “Obamacare,” has been transformed from the poster child of political controversy into a model digital data hub that impressively represents the federal government’s ability to leverage modern technologies to effectively manage exponentially growing volumes of complex, unstructured data with 99.9 percent up time and user response times under .01 of a second.2
Now, that’s nothing to laugh at.
Necessity Is the Mother of Invention
Born of necessity, the federal government’s turn toward new generation database technology might not have ever happened if Healthcare.gov hadn’t launched directly into crisis mode when it debuted in 2013. You may remember, or think you remember, the story, but for the sake of posterity, let’s wind back the clock to the beginning.
President Obama’s Affordable Care Act (ACA) passed in 2010, mandating that an online health insurance marketplace be up, running and available to the public by October 2013. Healthcare.gov – would be a data hub capable of pulling together a wide array of information to enable consumer eligibility and verification processes. Having never before attempted a data integration project of this scope and magnitude, the federal government tasked The Centers for Medicare and Medicaid Services (CMS) to develop and launch the marketplace.
Healthcare.gov soon became the biggest challenge in CMS’s 50-year history. What made it so difficult to pull off? Behind its deceptively consumer-friendly veneer, the site is built upon a data hub of amazingly complex information, including user identity and IRS records, insurance plans offerings from multiple providers, and information stored in legacy systems hosted and maintained in various states. All of this data flows into the marketplace in variable formats from diverse systems but has to be delivered to end-users seamlessly and securely. The integrated data also needs to be fully operationalized into a helpful, frustration-free experience for consumers – many of whom initially only reluctantly visit the online marketplace to avoid being fined for lack of health insurance coverage.
Compounding these data integration challenges was an ambitious timeline. The ACA mandated the system would go live on October 1, 2013, however, the broad scope of this project made the timeline extremely unrealistic given the state of data integration technology supported by the big database software companies.
As you may have heard, the initial launch of Healthcare.gov wasn’t exactly smooth sailing. So, what went wrong and how was it fixed?
Business as Usual Wasn’t Going to Cut It
From the start, CMS approached the Healthcare.gov project like most other federal projects, awarding contracts to suppliers of proven and safe, yet older technologies. This was a big mistake. Once development began, it quickly became obvious that the older generation database technology underlying the online marketplace wouldn’t handle the wide variety of data formats used by all of the states, insurers and other federal agencies flowing into the system. It also became clear that these database technologies wouldn’t be able to scale up quickly once consumers hit the site in droves on the first day of open enrollment. Ultimately, these shortcomings meant that applications built on top of the existing relational database wouldn’t function in a way that adequately supported the CMS’s mission.
A year into development, Henry Chao, the Deputy CIO at CMS, made a daring decision (remember, we’re talking about a federal agency not Google!) to change course and adopt new technologies that effectively supported CMS’s modern marketplace initiative saying, “When things were bad, we had the option to pivot, to scale out of a poorly written application.” The new database technology “gave us a set of options that would not have been possible with other technologies.”
To make up for lost time, CMS brought in an entire emergency team of hundreds of people from many of the most forward-thinking tech companies in the U.S., including VMware, MarkLogic and Red Hat, along with tech professionals from United Healthcare and Accenture. Some of the Silicon Valley’s best and brightest came aboard, too.
With a more agile, scalable Enterprise NSQL database now underlying the system, the newly formed team was able to jump right in and reconfigure or replace applications – all without incurring an increase in database interference, data loss or security risks. This would ultimately prove critical to shaving months off the development time in late 2013.
After a much-reported difficult launch, the site was quickly stabilized by Thanksgiving of 2013. And within a year’s time, the new team succeeded in transforming Healthcare.gov into the “Amazon.com” of the health insurance world – a feat that wouldn’t have been possible without Henry Chao’s savvy decision to try an innovative approach to modern data management.
Millions Now Have Access to Affordable Healthcare
Over the past two years, the operations of the health insurance marketplace have only gotten better. At the close of open enrollment in February 2015, Healthcare.gov had enabled over 11.7 million enrollments or automatic re-enrollments.3
This year, 38 states will rely on Healthcare.gov. When the new enrollment period began this last November, the site offered some highly useful new features, including a cost calculator feature that makes it easier for consumers to understand their total costs under various health plans. Jocelyn A. Guyer, a health policy analyst at the law firm Manatt, Phelps & Phillips, told The New York Times, “The new website helps consumers understand the importance of looking beyond premiums to consider deductibles and other out-of-pocket costs when selecting a plan.”4
General perception of health insurance marketplace has changed dramatically since its first rollout in 2013. Today, Healthcare.gov is running on some of the most modern technology in government, if not in business on the whole. And CMS is proving what can be accomplished when historically unchanging federal agencies dare to adopt modern technology and innovative thinking. It doesn’t have to be rocket science. You just have to have the right people and the right technology in place – and the willingness to try something new.
1. NYTimes.com: Affordable Care Act Plans Get 1 Million New Subscribers
2. MarkLogic.com: A New Data Prescription: How Healthcare.gov Was Delivered
3. NYTimes.com: Affordable Care Act Plans Get 1 Million New Subscribers
4. NYTimes.com: Revamped HealthCare.Gov Opens With New Tools for Gauging True Cost of Insurance