Obamacare: a “Train Wreck” in for Repairs

Republicans called the Affordable Care Act a “train wreck” well before it left the station but the sputtering web engine has made it clear that Obama's administration doesn’t know how to run a railroad.

The website's dysfunction persists but the topic has shifted to the president's shiftiness in telling the public they will be able to keep the insurance plan they have and therefore their same doctors. As many as 10 million of the 15.4 million policies bought by individuals directly from insurance companies are expected to be canceled by year end for not meeting the minimum standards imposed by Obamacare. Most companies will offer replacement policies, but at higher cost, given the added benefits the policies must now carry. But even if everyone could afford the upgrade, the deadline to apply for coverage to start the 1st of the year is December 15. Later than that and a person will face a gap in which he or she has no coverage. But will healthcare.gov be able to handle this many applications by then?

The president's Big Lie, endlessly repeated in the 2012 campaign and since, lit a fuse that would inevitably blow up in his face once the facts of the law overtook his fictions. He must have foreseen this, but thought he slip one past us. Instead he has given opponents in Congress and elsewhere grounds to attack the health care law, criticism embellished by their own forms of dishonesty and half truths. Marsha Blackburn (R-Tn) hectored Health & Human Services Secretary Kathleen Sebelius about those policy cancellations, but Blackburn failed to mention that her state refused federal funds to expand Medicaid, leaving hundreds of thousands of Tennessee's poor with no protection. Her state also left it to the Obama administration to manage its exchange. Blackburn would later go on Fox News to inveigh against medical privacy violations and not wanting "financial and health information to be hacked". Ms Blackburn, surely you know that Obamacare doesn't ask for medical history. Because there is no turning away for pre-existing conditions, remember? The Fox interviewer left Blackburn's lies unchallenged.

Whenever the subject of cancelled policies comes up, Democratic propagandists such as Debbie Wasserman Schultz (R-Fl and chair of the Democratic National Committee) immediately switch to "but it only affects 5%". Like Romney's 47%, it seems the Democrats have their own 5% they don't care about.

News outlets aligned with the loyal opposition scoured the land to find worst case scenarios of people affected by the cancellations, leaving readers and viewers to think they are the norm. Fox, for example, found a 56-year-old woman whose cancelled $54 a month policy would be replaced with one costing $591 a month. Well, yes, that is what real insurance policies cost to pay for our runaway medical system; it is her $54 policy that is the joke. And someone who can only afford a $54 a month policy might very likely be eligible for subsidies to drive down the cost of the new policy, but it was not in Fox's interest to point that out.

"This law itself is born from an architecture, a foundation, that is just not workable", is Wisconsin Republican Paul Ryan's verdict. Oddly, Ryan's plan for Medicare relies on exactly the same architecture. It would give vouchers to seniors to buy insurance on the Internet on a government-run Medicare exchange. But there is a difference. The Ryan plan would send 50 million to enroll on the Internet, a number that dwarfs Obamacare's potential applicants.

The problems with the federal insurance marketplace — hours to sign up, bad data sent to insurers, inability to access the system at all — have become well known. Outsiders brought in to probe for causes found a loosely coded site that lacked error checking. One could enter multiple spouses, could list spouses as children, could sign up for more than one plan, could enroll more than once — when users repeatedly hit the “Submit” button in the unresponsive system — and could even change someone else's data.

One consequence is flawed data being handed to the insurance companies that are “straining their ability to handle even the trickle of enrollees who have gotten through so far”. Insurers are finding they have to correct a high percentage of submissions manually and even hire temporary workers to phone applicants. They fear an inability to handle the load once the current trickle turns into a flood.

How did it happen that to design the linchpin of the President’s key accomplishment, in a country that teems with the sophisticated technology that spawned Facebook and Amazon and many more, the Obama administration contracted with companies relatively inexperienced with the Internet?

Why did they think that playing politics, holding back the regulations that dictated the system’s specifications until after the 2012 election lest they cause controversy, would have no consequences? How could government officials think that last-minute changes requiring re-writing of code would not squeeze the test window in the months leading to the October 1 deadline? And no one seemed to feel responsible for end-to-end stress-testing, which should have been ongoing in the months before the release date.

tangled web

When Congress creates laws, its members seem utterly unmindful and unconcerned for how those laws will be implemented. That is certainly the case with the Affordable Care Act. Like tax law, it is larded with requirements, many of which are inconsequential and simply add to complexity. Government departments and agencies are then left to deal with the mess.

Example enough was in a Wall Street Journal column that said, “The Government Accountability Office last year calculated that for the IRS alone, implementing ObamaCare would be a ‘massive undertaking that involves 47 different statutory provisions and extensive coordination’". That applies only to those eligible for subsidies to help pay for their insurance, but the coding job remains the same.

If repairs do take months, only the sickest will have persevered to buy insurance. The young and healthy — whose participation is key to offsetting the cost of those with illnesses — will give it a try but not come back. That raises the specter of a "death spiral" for Obamacare, say health care economists. Losing the young will make insurance premiums soar, forcing healthier policy holders to take their chances and drop out. The cycle repeats as rates for the rest rise again, and yet again from more dropouts, until only the sickest are left in the pool and the system collapses.

So lamented Secretary Sebelius. “We didn’t have enough testing, specifically for high volumes, for a very complicated project". The Food and Drug Administration, an agency that reports to her, engages in rigorous clinical trials before approving drugs. Why didn't those best practices occur to her for the huge launch of the federal insurance marketplace? Months before, they could have found a hacker to launch a distributed denial-of-service attack to bombard the prototype exchange website with increasing millions of logon requests to reveal at what point the system broke. They would have discovered well in advance that another warehouse of servers was needed.

Actually, Sebelius did say that the system had been stress tested. They had set the bar at five times the highest volume that the Medicare.gov website had ever experienced. But Medicare’s universe is only a slice of the population, and when would millions of seniors have had cause to rush that mature system to make for a comparable peak day?

How could it be that President Obama paid so little attention to the status of what is endlessly called his “signature” achievement that he was clueless about its problems? Did he simply take the word of equally non-technical Sebelius (a former governor) that “we’re on target”, as she said in a July interview after months of “projecting optimism and confidence”?. How could he be so unaware of the exchange’s complexities that, in a Rose Garden appearance, he would say "Nobody's madder than me about the fact that the website isn't working as well as it should, which means, it's gonna get fixed", as if the commander in chief can simply order millions of lines of code to rearrange themselves.

And so, as the Bloomberg/BusinessWeek article put it, “we are witnessing the beginnings of the single most exhausting, hellish code review in software development history”.