I
. THE UNTOLD STORY
OF HEALTHCARE.GOV
HENRY CHAO
Copyright © 2018 by Henry Chao.
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work with people who are applying for retirement benefits, disability,
and to help shepherd people who have become eligible for Medicare.
The critical information SSA collects, tracks, processes, and shares
with other agencies, such as CMS, is a tremendously large-scale and
complex operation in which health-care programs like Medicare
greatly depend on.
So, people lead messy lives, and in order for people's information in health-care systems to be as accurate as possible, all the inputs
flowing from initial engagement to ongoing changes, including
information flowing from government authoritative sources such as
SS.Ns Death Master File, must be tracked in the health-care system
to determine eligibility-who's in, who's out, and for what reason.
Since the very early days of mocking up wireframes for HealthCare.gov and thinking in earnest about how to best shepherd an
applicant through the process of online enrollment for themselves
and potentially an entire household, we had to consider all the
possible permutations of how people dynamically live their lives and
how co best capture point~in-time information as well as providing
the ability to return ~nd update information on any life changing
circumstances. Perhaps you could say that we were trying to provide
for a world-class experience, but more importantly was factoring the
entire range of possible circumstances in which an applicant would
need accommodated in their initial enrollment plus accommodations for what may change going forward.
THE PROCESS
The risks involved in implementing programs such as the ACA can
increase due to established government processes in which you have
no direct control over. When government undertakes a direction or
SUCCESS OR FAILURE?• 55
a policy that's set forth by the legislative or executive branch, it must
go through a structured process designed to be highly inclusive of the
public in what it does. For example, if a law is p~ed, the law really
serves as the high-level framework for the ideals, outcomes, and ways
that policy is to be financed by the government. It frames that set of
public policy intent.
The next step in the journey is the rule-making, or regulation.
process. The regulations are not detailed guidance, but they spell
out how programs will operate, how the funding mechanisms will
work, the types of data that will be collected, and the impact to the
economy of a given sector or sectors that the law and regulation
would impact. In the case of health care, there would be an impact
on costs, coverage, and the number of people covered, so that impact
analysis is also included.
Then there's a public comment period where the regulation is ·
published in the federal register for a number of days, generally sixty
days or so. The "public,, in "public comment" is a very broad term.
Individuals can certainly submit comments on the regulation back to
the government, but most commenters on regulations in the healthcare sector are representing groups of interested parties such as the
American Medical Association, American Hospital Association, and
other industry associations chat represent insurers, health IT vendors,
and many others that have a stake in any major change to the US
health-care landscape.
Then all the comments are factored into the final regulatiQn.
That final regulation is published and stands as the next level of detail
in the framework for implementation.
Concurrently, as the proposed regulation moves through the
process to final regulation, agencies were already assigned responsibility not just for writing the regulation and shepherding it through the
56 •THEUS HEALTH CARE SYSTEM-IT'S COMPLICATED
process, but also responsibility for implementation, as was the case
with HHS and CMS, stan looking at the implications of bringing up
that program. That includes everything from organizational structure
and human resources to budget and contrac;ting.
Typically, throughout the rule-making process, the policies
begin to mature and are vetted through the public comment process
and further details emerge in the form of sub-regulatory guidance
such as formal letters to certain official bodies, bulletins, briefings,
etc. Through multiple iterations driving to greater details about the
program and policies including sometimes taking a step backwards to
regroup and realign, we document business requirements and other
associated artifacts chat are necessary for design and development of
the system or systems. In theory, as the process unfolds, you eventually have enough clear requirements identified for all the stakeholders involved to make progress towards implementation. Typically,
there's never enough time to work out every last detail by the first
implementation dace, but in the case of how the ACA unfolded from
passage of the law to regulation to requirements the process had to
withstand numerous o_ther constraints brought about by tremendous
political opposition to the implementation of the law. What usually
is already a frantic pace to get as much done as possible in the allotted
time under normal circumstances, became significantly more challenging to conduct the process from law to implementation with
great clarity and transparency under ACA.
THE SECURITY OF THE DATA
In some cases, the process can take place in less than a year. In other
cases, it can take multiple years. Jes understandably bureaucraticafter all, you dont want your government to make unilateral decisions
SUCCESS OR FAILURE?•. 57
about what data it colleccs and shares about citizens. That's why there
are laws and regulations such as the Health Insurance Ponability
and Accountability Act (HIPAA) to govern how the government or
other entities handle your data and keep it secure and how they work
with you to understand the allowable uses and your preferences for
sharing that data.
In that context, people begin to understand that they want the
government to provide benefits and services as it should, as dictated
by Congress and the executive branch, but at the same time, they
want caution exercised in the secure design and implementation of
the program that provides those services. For example, most people
do not want a program that creates unsecure situations with the col•
lection and handling of their data.
Within health care, there is an abundance of caution along with
a duty and responsibility to ensure that no information is shared ·
unless there is a specific, sanctioned use of that data set by prece-
dence, by a regulation, or by law. Again, the system is understandably bureaucratic because people generally want their government
to be very cautious about how it handles their information and how
it operates the programs that are supposed to help people, such as
facilitating health•care coverage.
THE MONEY FLOW-FROM THE FEDS AND THE STATES
Of the federal, state, and local governments, the federal government
has the greatest taxing authority, and, in our federalist system, it is
generally looked upon by states as a good and evil twin. The good
that it provides is that it generally can, through national economic
and tax policies, generate revenue for the government at much
greater volumes than each individual state. Thus, it can hdp states
58 • THE US HEALTH CARE SYSTEM-IT'S COMPLICATED
implement and operate programs such as Medicaid. The states, in
many cases, tolerate the federal government because Big Brother has
a pretty large purse.
The downside is that the purse comes with rules and regulations
about how the money is used. The tension in that relationship exists
in part because states have to work individually and collectively to
establish their aspect of public policy implementation. In the case
of the ACA largely passed in the form of the Senate version of the
legislation, the expected model was that states would set up their
_ own respective state-based marketplace (SBM) using very generous
federal grant dollars rather than opting our of building their own and
deferring to the federal government to provide for the functionality
through the federally facilitated marketplace (FFM).
Then there's also the fact chat very large states like California,
Texas, and New York have numerous counties, some of which are
l~ger than some states. For instance, Los Angeles County in California is larger than the state of Rhode Island. County-based services,
such as the social services offered locally, in many cases serve as the
frontlines in managing health and human services programs. This
is an impo~t factor to consider because through much of the
pathways that existed just prior to ACA, and even after in many cases,
consumers find their way to healthcare coverage through their overall
interaction with various channels that assist people in identifying a
range of benefits they might be eligible for, from food and nutrition
assistance to housing assistance to medical assistance. In this case, the
ACA context can mean eventual enrollment in the Medicaid program
in a given state or perhaps the children in that same household
enrolled in the state,s CHIP program, or some in the household may
even be determined to qualify to enroll in an Insurance Marketplace
plan with or without premium assistance. What existed in the context
SUCCESS OR FAILURE?• 59
of how people found their way to health-care coverage prior toACA
had to be factored in to how the enrollment process would work for
Insurance Marketplaces because the new ACA requirements involved
a significant amount of business process, system, and data/information integration in order to produce a good or perhaps even a "worldclass experience'' for the consumer that has to navigate through a
meld of the old and new.
Therefore, complex technological challenges begin with complex
business and policy changes. Rarely, if ever, are new programs fully
thought through in an operational context that must make sense
of what is brought up as new that then has to coexist with what
already is in the ecosystem. One of the most valuable experiences
while at CMS was being directly exposed to, and being responsible
for, large-scale complex systems integrations where new program
requirements expose all the less than optimal c1short-term,, solutions
that now exist as limitations or constraints to what you are trying to
achieve with the new program, such as being able to enroll people in
health-care coverage and adjudication their application while online
and in real-time. The valuable experience isn't just being exposed to
that challenge, but also being able to find solutions that can properly
service the new requirements while not endangering and gravely disrupting existing critical processes.
TACKLING PIECES INSTEAD Of THE WHOLE
Projects the size and scope of the ACA are about more than just tra~
versing technical issues. They involve first learning about the programs
and policies, and the interconnections and dependencies inherent
in the US health-care system. I was attracted to those complexities,
having already encountered several. large-scale CMS challenges and
60 •THEUS HEALTH CARE SYSTEM-IT'S COMPLICATED
relishing the sense of ownership in handling all that they presented.
But in overseeing the transformation that became HealthCare.gov, a
number of new lessons were learned-lessons that I believe can be
useful when overseeing a big project in either the public or private
sector. In the following chapters, I will share these lessons in hopes
that they hdp others facing similar challenges.
SUCCESS OR FAILURE? • 61