ObamaCare Launch: First Hints of Real Back-End Problems on the Federal Exchange Begin to Appear

This is Naked Capitalism fundraising week. 121 donors have already invested in our efforts to shed light on the dark and seamy corners of finance. Join us and participate via our Tip Jar or another credit card portal, WePay in the right column, or read about why we’re doing this fundraiser and other ways to donate, such as by check, as well as our current goal, on our kickoff post.

By Lambert Strether. Originally published at Corrente.

Via O’Reilly — the highly literate and excellent tech publishing company — we read the following. Note that the grey-haired[1] tech guy has pronounced judgment in the headline:

What Developers Can Learn from healthcare.gov
Remember, even a failure can serve as an example of what not to do
2) Pretty doesn’t trump functional. The site is very well designed from a graphical perspective, and is clearly using lots of Javascript and AJAX to do snazzy transitions and requests in the background. Unfortunately, it doesn’t seem to be interacting with the intermittent failures on the backend very well. If you’re going to make requests behind the scenes, you need to be very tolerant of failures. The healthcare.gov site seems to fail silently and leave a broken user experience in its wake, with no way to continue. Nothing drives a user crazy more than having to go through the same form over and over because of failures that leave them high and dry.

That’s why I’m wondering if backend[2] failures are the cause of site outage experiences like Rainbow Girl’s, or mine. I’m guessing yes. [Others agree. “As few as 1 in 100 applications on the federal exchange contains enough information to enroll the applicant in a plan, several insurance industry sources told CNBC on Friday. Some of the problems involve how the exchange’s software collects and verifies an applicant’s data.” ] So let’s look at intermittent failures. I should stress that although I’ve done work of this kind, I’ve never done it on this scale; to someone at the top of the systems building power curve, I’m an intelligent layman with good research and critical thinking skills. That said, let’s try to dope out what’s going on, given that the Obama administration has been extraordinarily secretive about this project, so we’re trying to figure out what’s going on inside a black box.

First, intermittent failures are the hardest to track down, since intermittent failures are just that: intermittent. (Here’s a real life story where the guy basically twiddled stuff in his vehicle until the #FAIL went away, rather like an ant pushing a crumb randomly until it falls into a hole in the nest. And this post makes the point that intermittent failures can be, institutionally, a cancer.) Here’s what a testing consultant to software firms has to say about the heuristic of finding intermittent failures. I’m going to highlight two important characteristics of their heuristics: Institutional issues and critical thinking skills . (There are many items that have to do with technical skills and observational skills, but in a multi-institutional project, as ObamaCare, I suggest those come under the heading of institutional skills. ObamaCare is not a corporation of systems with one owner, but a federation of systems with many owners, so getting to a place to perform observations and exercise technical skills isn’t a given; it will take at least one meeting. But heck. They’ve got 88 days. Counting holidays.)

Some General Suggestions for Investigating Intermittent Problems:

  • Recheck your most basic assumptions : are you using the computer you think you are using? are you testing what you think you are testing? are you observing what you think you are observing?
  • Eyewitness reports leave out a lot of potentially vital information. So listen, but DO NOT BECOME ATTACHED to the claims people make .
  • Invite more observers and minds into the investigation.
  • Create incentives for people to report intermittent problems.
  • If someone tells you what the problem can’t possibly be, consider putting extra attention into those possibilities.
  • Check tech support websites for each third party component you use. Maybe the problem is listed.
  • Seek tools that could help you observe and control the system.
  • Improve communication among observers (especially with observers who are users in the field).
  • Establish a central clearinghouse for mystery bugs, so that patterns among them might be easier to spot.
  • Look through the bug list for any other bug that seems like the intermittent problem.
  • Make more precise observations (consider using measuring instruments).
  • Improve testability: Add more logging and scriptable interfaces.
  • Control inputs more precisely (including sequences, timing, types, sizes, sources, iterations, combinations).
  • Control state more precisely (find ways to return to known states).
  • Systematically cover the input and state spaces.
  • Save all log files. Someday you’ll want to compare patterns in old logs to patterns in new ones.
  • If the problem happens more often in some situations than in others, consider doing a statistical analysis of the variance between input patterns in those situations.
  • Consider controlling things that you think probably don’t matter.
  • Simplify . Try changing only one variable at a time; try subdividing the system. (helps you understand and isolate problem when it occurs)
  • Complexify . Try changing more variables at once; let the state get “dirty”. (helps you make a lottery-type problem happen)
  • Inject randomness into states and inputs (possibly by loosening controls) in order to reach states that may not fit your typical usage profile.
  • Create background stress (high loads; large data).
  • Set a trap for the problem, so that the next time it happens, you’ll learn much more about it.
  • Consider reviewing the code .
  • Look for interference among components created by different organizations .
  • Celebrate and preserve stories about intermittent problems and how they were resolved.
  • Systematically consider the conceivable causes of the problem (see below).
  • Beware of burning huge time on a small problem. Keep asking , is this problem worth it?
  • When all else fails, let the problem sit a while, do something else, and see if it spontaneously recurs.

That’s a lot of critical thinking required. Do you know a lot of institutions that love and value critical thinking and critical thinkers? No? And that’s a lot of institutional savvy required. Do you think that CMS and HHS — even with Obama backing them with all his lameduck political clout[3] — are going to be able to get institutional cooperation from all these players on a crash basis? I doubt it, especially after the Obama public relations machine told everybody “Relax! It’s just a soft launch!” and “The only date that really matters is January 1!”

From 07/05/2013, here are the institutions whose systems must be integrated on the backend of the Federal Exchange:

So what’s the difference? The system architecture. Medicare has a simple and robust single payer architecture: You determine eligibility in one (1) jurisdiction (the United States) with one eligibility criteria for citizens: Their age. ObamaCare, by contrast, needs to determine eligibility in 50 (fifty) jurisdictions [for ObamaCare as a whole; 36 for the Federal Exchanges], with a complex eligibility formula that’s primarily income-based, but involves systems integration from the IRS, DHS, HHS, and private credit reporting companies (at least), to throw people into the right subsidy bucket. That’s called a combinatorial explosion, and even the best program and project managers — which ObamaCare’s managers clearly either are not, or have not been given the opportunity to be — have a hard time dealing with them. Let me know how it all works out….

Every single one of those institutions owns at least one system that needs to be integrated into the Exchanges, and each is a potential source of intermittent #FAIL. And remember, if one component fails, the system fails. Intermittently. Suppose every applicant on the Exchange has to be checked to see if they’re a Native American; fact, they do. It doesn’t matter if DHS give back its results slick as a whistle if the Bureau of Indian Affairs has intermittent failures; or vice versa. So technical issues aren’t the main story here; the truly challenging issues are never technical. Rather, we have management issues:

  1. Political: Wrangling IRS, DHS, HHS, private credit reporting companies, and IIRC the Bureau of Indian Affairs, and the Peace Corps[4];
  2. Personnel: Finding critical thinkers and deploying them, in whatever institutional settings they are to be found.

Now, in a perfect world, there are just a few bugs, and by Monday, the Federal Exchange will be up and running, and sticking out your arm for health insurance parasites to sink their tiny, rent-extracting mandibles into buying health insurance online will be as easy as buying a flat-screen teebee or a plane ticket. I’m guessing no, because that greybeard’s phrase, “intermittent failure” should give you the heebie jeebies, as it did me. You don’t fix that stuff in a weekend.

So, Kremlinology: If Obama appoints a Czar to fix the Federal Exchanges, we’re in “buff the turd” mode. That will mean the White House has determined that political and personnel problems with the Federal Exchanges are insoluble.[5]

NOTE A word on “the government can’t write software.” The government can write brilliant software: How do people think the Mars Landers are run? Tin cans and string? The question that should be asked is: Why was the government tasked with writing this software, when the rugged, robust, simple and proven single payer architecture was available to them? Jon Benteley: “The cheapest, fastest, and most reliable components are those that aren’t there.” Throw the requirement to preserve rental extraction by health insurance agencies out of the equation, and everything becomes clean. And implementable. Could have been done in a year, as LBJ rolled out Medicare in a year. Whoever wrote the requirements for this thing should be publicly shamed.

NOTE I don’t have the time to add this part, but check out this link for the cultural differences between frontend and backend developers. Note that the famous Reddit thread is frontend developers. More management challenges! And here’s a piece of what turns out retrospectively to have been frontend-centric hagiography back in June.

NOTE [1] Back in the day when I was a fancy pants consultant, I would hear people say “I don’t want my software built by people who don’t have kids.” Unfair perhaps — FaceBook, Google — but those projects often had lives at stake. As does ObamaCare. I guess, to avoid offensive — justly offensive — age-ism, I’d say better to have old heads on young shoulders. Developers like that do exist, fortunately. Oh, there’s a picture of the author at the link. Yes, he has a grey beard. He knows the Great Runes!

NOTE [2] Frontend vs. backend from Stack Overflow:

Generally speaking, the “front end” is the user interface, and the “back end” is the code supporting that front end (responsible for database access, business logic etc). …

Frontend is what you do that the user can see. Like designing a user interface. Backend programming is the code that the user doesn’t ‘see’. This is what works with the data behind the scenes. For example fetching/inserting/deleting/updating a database. …

So, on the blog you’re reading, everything that you as reader or contributor see in the browser, without exception, is the frontend. (Admins control the backend: In essence, in the world of Drupal or WordPress or whatever, the database, the server, and the operating system on which they run, including the file system.) When you press Submit, your post on the front end is sent over the Intertubes and stored by Drupal or WordPress or whatever in the blog’s database, which is why you can retrieve it the following day, which could not happen if your post were stored in the browser, right? Similarly, every time your post is displayed, Drupal or WordPress or whatever is grabbing your post from the database, formatting it into HTML, and sending the HTML over the Intertubes to somebody’s browser, maybe yours, along with the sidebar, the footer, the logo, and so forth, all of which is also, ultimately, stored in the database. (Well, JPGs and so forth are stored on the file system. And I’m leaving out caching. And clever stuff JavaScript in the browser, which can also connect to the server, can do.)

The Federal Exchanges work using the exactly the same system architecture, although on a much bigger scale. Simplifying horribly: The process of setting up an account, for example: You enter data on the front end in a form. You press submit. Your data #1 goes over the Intertubes, and the server grabs it and stores it in a database on the backend, and #2 the backend sends back a confirmation to the browser, again through the server over the Intertubes, that your data has been stored and that it’s OK for the browser to go ahead to the next screen. Imagine a world where the front-end developers had created a frontend of a Jony Ives-like slickness. The backend has at least two points of failure at #1 and #2. Suppose at #1 the database is down. That would look like a failure of the front end to respond (“It’s hung up!”) but it’s really a backend thing. Suppose the server at #2 died, as servers will do. Again, the frontend would look like it died, but it’s just helplessly waiting for the confirmation code, which hasn’t arrived. The intermittent failures could happen either at #1 or #2.

Somebody really technically competent who does this for a living would laugh at the paragraph above, since the blog you are reading is basically a Wright Brothers Flyer compared to the Federal Exchanges, which are more like a Boeing 747 (or perhaps a Spruce Goose). Nevertheless, both sites and both airplanes share a fundamental architecture and fundamental engineering principles, which you must understand to cut through the bullshit and the bafflegab of what’s going on with the Exchanges, technically.

NOTE [3] Remember, it’s highly likely that the White House totally borked the entire project by changing the forms — that is, the stuff you fill in at the Exchange website on the front end — at the last minute for political and public relations reasons. Speculating freely: If the ObamaCare Exchange’s front end, where the form is filled out, was tightly coupled to the back end — that is, if the backend expected to find some chunk of data in exactly one place in the form, from where it would grab it and slam it directly into the database on the backend, that’s quite likely. That’s the quick and dirty way a body shop under pressure would do the job, and we all know the Obama administration would never cut corners on something that didn’t directly impact public relations, right? Ha ha. Anyhow, we do know that changing the forms broke the Connecticut, state-based Exchange, so it’s reasonable to think that the Feds had the same problem. Except for 36 states, not one. And that means that Obama is going to people he screwed over to ask them for a shovel to dig himself out of a jam. To technical people, this is standard operating procedure, but the managers and department heads may not be so compassionate.

NOTE [4] “It’s all gone political, sir.” Terry Pratchett, Thud.

NOTE [5] I missed the obvious one: Privatize it all. The market can never fail. It can only be failed. If Obama actually managed this process so that privatization of the Federal Exchanges is the outcome, my hat is off to him; he’s either lucky as only the truly evil can be, or he really can play 11-dimensional chess.

UPDATE To be fair, there is one (1) ObamaCare website that launched on Day One with zero problems, zero defects. Here it is.

Print Friendly
Tweet about this on TwitterDigg thisShare on Reddit0Share on StumbleUpon0Share on Facebook0Share on LinkedIn2Share on Google+0Buffer this pageEmail this to someone
This entry was posted in Guest Post, Health care, Politics, Technology and innovation on by .

About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.

32 comments

  1. kimyo

    http://www.reuters.com/article/2013/10/05/us-usa-healthcare-technology-analysis-idUSBRE99407T20131005

    Five outside technology experts interviewed by Reuters, however, say they believe flaws in system architecture, not traffic alone, contributed to the problems.

    If they are right, then just bringing more servers online, as officials say they are doing, will not fix the site.

    “Adding capacity sounds great until you realize that if you didn’t design it right that won’t help,” said Bill Curtis, chief scientist at CAST, a software quality analysis firm, and director of the Consortium for IT Software Quality.

    One possible cause of the problems is that hitting “apply” on HealthCare.gov causes 92 separate files, plug-ins and other mammoth swarms of data to stream between the user’s computer and the servers powering the government website, said Matthew Hancock, an independent expert in website design.

    1. Adriannzinha

      Having worked for over a decade in web design, software engineering, and QA for large 10+ million customer applications, it is rather comical how bad the obamacare web launch has been.

      Given than Obamacare is clearly, from a policy standpoint, a plan to cut corporate and government medical spending, while bolstering profits, I suppose they started the cuts with the planning and rollout of the website.

      I know one of the talking points in the political theatre of the past week or so was that obamacare wasn’t ready. Everything we’ve seen so far lends credence to that and certainly the technical aspect is far from prime-time.

      In some ways, far worse is how some people are getting into the site in piecemeal fashion and will wrongly assume their information has been fully transmitted when it has not.

      It is patently clear that even a modicum of nominal load and stress testing were never performed.

  2. middle seaman

    Not being up to speed with current technology doesn’t change the fact that the basic issues behind the online system haven’t changed in decades. Serving high loads requires proper skills today as they did 30 years ago.

    Claiming that lack of servers is an architectural issue is funny. A good design can estimates closely the volume of requests and comes up with the proper number of servers. Servers are relatively cheap. It’s a design problem. Falling on the job will underestimate volume or fail to test the system properly.

    Above everything else, Obamacare’s new system reflects Obama: a lot of glitz with suspect content. What else is new?

    1. Lambert Strether Post author

      Yes, given that the ObamaCare rollout is in essence a political campaign, it’s odd that people expert in GOTV can’t estimate demand (assuming that load is really the issue). We also know that HHS did plenty of market research to determine which segments to appeal to. So, again, how could they not estimate demand?

      1. NotTimothyGeithner

        Do you mean private corporations (governments too) routinely produce buggy software which tend to rise as complexity increases under the pressure of artificial timelines? I am shocked.

        1. NotTimothyGeithner

          Dah that previous comment should be down the page.

          Considering the political nature of any White House, I imagine the planners were under pressure to only consider good news and make optimistic projections about wages and employment. The wealth effect of the Dow should be flowing slowly over rocks towards people who under at least from anyone with a reputation hinging on perception of the economic situation.

          Politicians fire staff and lose elections because they don’t want to see stark realities on a regular basis. When Obama ran, he was a challenger with an understanding Hillary had to be beaten. The numbers could be seen in a pragmatic manner, but Hillary’s campaign seemed to ignore caucuses and odd delegate allotments as a matter of strategy instead choosing to focus on front loading the primaries to favor name recognition because she had a lead, name recognition, a money lead, and the super-delegates endorsing her by and large.

          Obama has saved the economy, so any metric has to reflect that perception of reality or to reflect the political perception he has created vis a vis cost/price tag. The electorate may not care, but there are Senators who think their reputations are staked on meeting some absurd final number supplied by (insert the healthcare Larry Summers).

  3. craazyboy

    The internet IS an intermittent failure. If the app architecture isn’t fundamentally designed with that fact in mind, they will be on a fishing trip in a very big ocean for a very long time looking for what the problems might be.

    If they had contracted this out to TurboTax Online, there is a chance they would of had a working framework to start with.

    Then legislating biz rules and doing software development at the same time never helps much either.

    They also could have broken this up into a phased rollout too. Say break it up where phase 1 is the customer sign up phase. This would handle getting all pertinent enrollment info and persisting the info to a customer account DB record. One small questionnaire form at a time, ala turbotax. Then maybe the part that presents “shopping” info to the customer, ie details, terms & conditions, prices, etc narrowed down to what would be relevant to the particular customer account. Then there is the backend interface and data transfer with all the providers.

    There is of course data integrity checks along the whole way, plus whatever checks the providers, IRS, etc run to verify the submitted info.

    The “order” button is the last thing you work on.

    This also would have helped smooth out the rollout load and pure scalability issues. The way they did do it was like Amazon opening the day before Christmas and offering 1 day delivery.

    But at least now Obama has a good reason to delay it a year. If it weren’t the waskaly wepublican’s idea.

    1. Lambert Strether Post author

      Obama committed — as far as a weasel-worder like Obama ever commits to anything — to the 10/1 rollout in his 4/30 presser.

      So he can’t delay it. And he can’t fix the problems with PR. The system actually has to work, and to be seen to work. It’s not clear to me that either goal can be met. Note that even if they solve the capacity problems they seem to have, all that means is that intermittent failures come to light more rapidly.

      It’s one thing to launch Gmail as a beta and fix the bugs as they come in. Email programs are free, and if they’re buggy, people don’t suffer and die. Neither is the case with health care. People don’t want insurance like the they want flat screen TVs or airline tickets. They want insurance like they want water or bread, because it’s the only way to get care. That accounts for the traffic, and it also accounts for the ticked-off-ness of people betrayed in their hopes by how the Exchanges operate.

  4. Ken

    Running the healthcare.gov homepage through the W3C validator (validator.w3.org) spews out a few dozen errors. That’s just the homepage, but leads me to believe the other parts are coded just as sloppily.

    Bad, and/or non-compliant HTML is frequently a source of intermittent failures.

  5. Jason Boxman

    It’s amusing that the “most transparent administration ever!” hasn’t placed an overwhelming amount of the source code up on say, github, with a BSD or MIT license. Surprise.

    1. Lambert Strether Post author

      I believe that front end code is on Github, and that it derives development done by the Obama campaign.

      However, the back end code is highly unlikely to be, and that is the code that is causing the intermittent failures.

  6. Jim Haygood

    From the WSJ:

    Among the technical problems thwarting consumers, according to some of those people, is the system to confirm the identities of enrollees. Troubles in the system are causing crashes as users try to create accounts, the first step before they can apply for coverage.

    Experian PLC, an information-services firm, holds a federal subcontract to support that system. The company declined to comment.

    http://online.wsj.com/article/SB10001424052702304441404579119740283413018.html?mod=WSJ_hps_LEFTTopStories

    Experian? Are they kidding?

    If you’ve ever tried to correct false credit report info from Experian, then you know that Experian’s business model is based on stiff-arming consumers, by putting them into endless loops of correspondence which never produce any change in Experian’s corrupted data.

    Hiring a nonresponsive, Consumer Enemy #1, evil empire like Experian to code the identity verification model is a prima facie indication of malevolent intent. Experian’s module is going to produce unacceptably high false rejects, because their database is garbage to begin with.

    Gov’s instinct will be to blame its subcontractors for the monumental cock-up that is Obamacare. One hopes HHS will sue Experian and put the lying crooks out of business. But meanwhile, for health coverage seekers, Experian’s seedy, lowlife presence in the bowels of a dotgov website is a neon sign that says, ‘Stay the hell away!

  7. elboku

    Well if the problems continue and the whole thing crashes down, shouldn’t y’all be delirious with excitement? Your hated program will fizzle and plop to the bottom of the ocean never to be heard from again. Then, of course, we will either one, go back to what we had before and lord knows how great a system that is. Or two, we will see the repubs try to put into place their program of reducing tort liability for health care providers, selling across state lines (see credit card industry for how that worked, and Health Savings Account (yep, the poor have plenty of money for that and I am sure employers will pass to their employees any savings in benefits- harahar, oh that’s a good one…).

    There will be no going forward for at least a generation or two. By going forward meaning some people who didn’t have insurance can get it now. Yes, I know it sucks, blows, stinks etc., etc. that not everyone is helped or that we didn’t Green Lantern national health care but this is a step to more people being covered. The alternative republican universe is far, far worse and the destruction of the ACA will simply push us back to square one.

      1. elboku

        Absolutely. I was arguing for that as a lawyer back in the late eighties and early nineties to every politician I came across in my work in MA. I worked with the poor as the primary focus in my practice and saw first hand the results of no health care. But I also ran into countless people who hated ‘them’ and wanted not to pay for ‘them.’ I am going to hazard a guess that 25-35 percent of the population truly hates ‘them’ and won’t ever agree to provide care for them. That is our battle and I don’t know if we can win until they die off. I am no fan of Romneycare that is there now but it is getting more people covered.

        I will say that all along my suspicion has been that once employers get tired of paying benefits that we will ‘magically’ get national health. (The antis above will just suddenly and mysteriously/snark be ignored.) There are some signs of that in the ever shrinking number of employers paying health care benefits and the shrinking the benefits they cover. But i have faith it will happen.

      2. LucyLulu

        We don’t have single payer though. It didn’t get passed in 2009, this is what was passed instead. If Obamacare fails, do you really think there will be political will or enthusiasm to convert to trying another program? Or will it be decided government can’t run healthcare and it be put on the back burner for another 30 years? Today the Senate is holding hearings on fraud in SS disability. Most people on SSDI will tell you approval is very difficult to obtain and takes an average of 2-3 years (with meanwhile no income, since that would prove capable of work), and average benefits of $1100/month (the Medicare and Medicaid is the more valuable component, since all are “uninsurable”). Having a serious disability and on SSDI, unemployable without accomodations (no willing employers anymore), SSDI may be next on the chopping block. It’s unsustainability is a regular topic in the halls of Congress. I’m fighting to keep the safety net we currently have that’s under regular assault.

        Medicare was NOT a smooth roll-out either. Johnson was extremely concerned when nobody was signing up. He ended up hiring tens of thousands of low-wage, mostly minority, workers to go door-to-door trying to solicit enrollees. There were no online glitches obviously, and it could meld seamlessly witb the SS database, being one plan catering to the same population subset.

        Government isn’t known for its competence and efficiency. If they screw this up and can’t get it sorted out, there won’t be any confidence they’d do better with single-payer, no matter how long one argues the lesser complexity required. Single-payer was my choice too, but I’m ready to accept that ACA is totally unworkable. There is lots of potential for the provision of better care at lower cost, by addressing problems that would be faced in a single-payer system as well, problems that the legislation DOES encourage addressing…. the perverse incentives of providers, focus on secondary and tertiary care instead of prevention, for example. Because it’s not an ideal solution doesn’t make it all bad. Accountable care organizations, that eliminate third party insurance, are options under exploration. It requires some creative thinking though, as are single-payer systems in aging societies as well, who are facing the same rises in cost that well exceed inflation and increasing portions of GDP (but have advantage of lower baseline), and are exploring policy changes. Should energy be focused on trying to live in sandcastles and denigrating our humble abode or shoring up the walls of where we live.

        Me thinks the general commentary here smacks of schadenfreude. The reaction is similar to what happened during the rollouts of social security and Medicare. Fortunately they had strong political backing with Roosevelt and Johnson who continued to push forward despite all the backlash.

        Constructive criticism would be more helpful. Healthcare in the US sucks. This is an opportunity to make meaningful change, even if not the ideal. We have a Congress that can’t even raise the debt ceiling, pass tax reform or immigration legislation that all agree is needed, does anybody think thee public option is realistic? The opportunity can be wasted and we can stick with what we have if that is preferred, since that is plan B.

        1. LucyLulu

          Correction: Insert bolded text in post above “but I’m not ready to accept that ACA is totally unworkable.”

          Kinda changes the meaning a bit, eh?

    1. NotTimothyGeithner

      Good work takes time and resources, and ACA is hideously complicated. Obama’s relatively young by beltway standards, but Obama was 30 years old when the WWW went live. Computers were not ubiquitous, and in many ways, they are merely magic which can be achieved by snapping fingers.

      The old jokes about grandparents having the four year old get rid of the blinking light on the VCR are based in truth. Just because Obama fiddles with a blackberry to avoid an OCD-style addiction to cigarettes, he is at an age where it should be expected that he has no concept of the hard work (not necessarily difficult, but it does requires hours) required for good programming for a complex system or even an inate understanding of the limits and potential of computers/internet. This is not a random generational divide but a serious one. If not him, who is making the decisions? Max Baucus? Joe Lieberman (he’s retired, but he was in the chair of Homeland Security and the primary elected official dedicated to making sure naughty words weren’t in music)?

      I know Obama has talked to “Social media consultants,” but those are just fraud pr people who post on websites and worry about local blogs no one reads. Does Obama have an IT person who is going to tell him what it entails? Does Obama have an IT person who is going to tell him they can’t even program half the stuff until they know what the exchanges are going to look like?

      1. Lambert Strether Post author

        Purely speculative, but Obama’s first year team — the people who got him elected — left the administration to cash in, out in the dreaded private sector. I would be very surprised if there were anyone in his inner circle who can tell him “No!” He’s also been cossetted his entire life — he has only had to say “Do it!” and it’s done. This works when you’re a rising star and everybody wants to ride your wagon. It works in campaigns. It doesn’t work in governing, at least not for long. It most certainly does not work in software engineering, especially for unprecedently large systems. Obama is the pointy-haired dude in Dilbert.

  8. ChrisPacific

    The list of approaches to tackling intermittent problems is very good, and I am familiar with a lot of them. It’s essentially a set of tools for applying some structure and a systematic approach to a problem when you really have no immediate idea how to proceed. This used to be a big part of my job description, and still is some days.

    That said, part of delivering a robust, high-quality and bulletproof system is thinking about all possible failure cases and ensuring that the system handles each of them in a sensible way. This is a crucial requirement for systems where the consequence of failure is very high (think of embedded control systems for ICU medical devices, for example). The government is capable of doing this very well (there are a wealth of examples in the military sector, for example) but only if given enough time and resources, and only with the correct people working on the problem.

    The issue is that, depending on the system concerned, dealing with failure cases and exception scenarios often amounts to the bulk of the work – up to 80% in some applications. (This is sometimes termed ‘hardening,’ although I prefer to avoid this term around non-technical stakeholders as it sometimes makes them break out into giggles). Neglect it and do just the 20%, and you end up with a system that superficially looks good and works quite well as long as everything goes according to plan, but that quickly breaks down when unexpected circumstances arise and either works unpredictably or not at all. This is a very common corner to cut if time and budget pressure are a factor, and it sounds like the Obamacare sites are showing some of these symptoms.

  9. Kim Kaufman

    Democracy Now gets into it today: “Computer Glitches Plague Obamacare Launch as New York Accidentally Says Site Won’t Be Up Until 3013”
    http://www.democracynow.org/2013/10/7/computer_glitches_plague_obamacare_launch_as

    “Is Obamacare Enough? Without Single-Payer, Patchwork U.S. Healthcare Leaves Millions Uninsured”
    http://www.democracynow.org/2013/10/7/is_obamacare_enough_without_single_payer

    If you don’t want to watch/listen to this on your computer, there’s always a transcript of the pieces.

    1. LucyLulu

      I have a question. Who are the people left uninsured? From what I’ve read they are either illegal immigrants or those who ended up in the gap left by states who took advantage of loophole left by SCOTUS’ unforeseen ruling on Medicaid expansion, and no available fix for either due to intransigent Congress. Congress would be equally intransigent had public option passed, and its doubtful illegal immigrants would have been granted coverage (European nations are starting to revoke this, Cameron spoke about last week, and legal immigration outside EU is nigh impossible).

      Are there other groups left uninsured that I’ve missed?

      P.S. Those who live in states that chose not to accept Medicaid expansion: Expect to see further rise in premiums or increases in taxes. Providers negotiated reduced reimbursement rates on projected reductions in non-compensated services. They are re-evaluating these rates, which will be passed along. These are people who will be forced to use the ER as their very, very expensive primary care provider.

      1. Alexa

        Hey, LucyLulu,

        Wish I could be as optimistic!

        According to CBO, quite a few Americans, and not all undocumented immigrants, will remain uninsured.

        Posted on: Wednesday, May 15, 2013

        http://www.pnhp.org/news/2013/may/cbo-now-estimates-31-million-will-remain-uninsured

        CBO now estimates 31 million will remain uninsured

        CBO’s Estimate of the Net Budgetary Impact of the Affordable Care Act’s Health Insurance Coverage Provisions Has Not Changed Much Over Time

        Congressional Budget Office, May 14, 2013

        Proposed regulations recently issued by the Department of Health and Human Services and the Department of the Treasury expanded the number of people who will be exempt from paying a penalty for being uninsured relative to our previous expectations. CBO and JCT now expect that, as a result of those regulations, between 500,000 and 1 million fewer people will obtain health insurance coverage each year. In our current projections for 2023, the ACA reduces the number of people without health insurance by 25 million, leaving 31 million uninsured (compared with 30 million in our February estimate).

        **********

        Comment:

        By Don McCanne, M.D.

        After the Affordable Care Act is fully implemented ten years from now, the number of people who will remain uninsured is estimated to be 31 million. Since there will be a net gain of 25 million with insurance, that means that Obamacare – a plan to cover everyone – will have been only 45 percent effective in the goal of reducing the net number of uninsured. Pretty lousy.

        This result on the uninsured will put us just about where we were when the Clintons began their effort to achieve universal coverage. . . .

        Forget repeal, REPLACE!

        From what I gather, it will be those individuals just over 400% FPL who will likely be the most adversely impacted.

        IOW, many millions will not be able to afford the insurance, since they will get no subsidies, and remain in essentially “the same boat” they are in today.

        Except that now they will be “fined” or punished for not being able to afford the coverage.

  10. Psychoanalystus

    Ha! Ha! Obamacare is exactly what America deserves. Let’s just call it “Karma”. Just watch your premiums double and triple in the next year or two. That’s because Obama loves you. That’s why.

    But if you’ve got a problem with that, just call 1-800-FUCK-YOU. I’m not kidding. That’s what the mnemonic for HealthCare.gov’s telephone number translates into (1-800-318-2596). Try it.

    Remember: Obama loves you!

    Cheers,
    Psychoanalystus

    PS – boy, am I glad I left that hellhole called America. What a psycho dump.

    1. Yves Smith

      Hi, we (or at least I) missed you. Hope you’ll participate in the conversation here from time to time.

  11. ian

    Things I don’t get:
    1) why they didn’t get help from commercial companies with relevant experience – Amazon, for example for the web and server stuff, one of the income tax program companies for the complicated rule stuff (eg HR Block or Intuit)?
    2) The overconfidence – I have always treated demos (and that is what the launch was ) as critically important. It goes back to the old adage “you only get one chance to make a first impression”.
    3) Did noone ever think to stress test this before it went out to the public? I work for a medical device company as an embedded developer. We design tests and beat the hell out of software as part of certification (we even have full time people whose job it is to beat the hell out of it).

  12. Robert M

    As someone on the front lines of enrolling much of the carping at this site is misplaced. It is one thing to complain about flaws in the software, incompetent handling of the politics and the issue of using credit agencies-double ugh. It is another to trash the project as wrong headed. I have never been in favor of the insurance companies issuing the policies and always in favor of a universal system which would have brought it’s own political and implementation issues.

    That said the correct way to look at the PPACA is that it is a call for Americans to look at health and keeping healthy as a maintenance issue as opposed to a repair system. If you take advantage of the health physical, update your vaccinations and take your lab work on a health appropriate basis you will have a base line for your health. If you do not go to the doctor but once a year for that alone the probability is you will catch the vast majority of diseases at stage 1 or 2 where the probability of survival(repair) is high. At the same time if you have a catastrophic accident(fall off the roof because you think you can install the dish antenna less expensively than the company your maximum costs on a individual policy at base levels is $6350 + premiums for the year. That is a lot less than what would come out of your pocket if you paid it yourself or as is most common today have everyone w/ insurance pay for you through higher premiums as costs are transferred from providers to payers. You do have to decide if tax credits and cost sharing help(for those w/ incomes less than 250% of FPL out weighs having a beef and brew fundraiser because you have poor quality insurance-take a look at many policies that do not meet the new standards-ten essential benefits for that catastrophic illness/accident.

    For those who continue to ignore these aspects and continue to go to the ER and have it paid for courtesy of President Raygun there is nothing that will convince you the implementation pains are worth it. Nor will the idea of incremental improvement. For those who think everyone in America should have healthcare that is the same as everyone else’s in terms of coverage and take it anywhere you go in America you’ll be pleased.

    1. Yves Smith

      And what economic strata do you live in? Are you actually going to be buying a policy under the ACA?

      First, even with subsidies, low income people are still going to pay hard costs for their insurance. They are having another budget item imposed on them. And the cheap plans have high copays and high deductibles, and in many cases, thin networks too. So this isn’t necessarily the boon to them you suggest.

      Second, research shows the annual checkup is not a good way to catch or prevent serious ailments in people without known ailments or disease symptoms. It’s basically tolling for doctors.

      http://www.nytimes.com/2003/08/12/health/annual-physical-checkup-may-be-an-empty-ritual.html?pagewanted=all&src=pm

      http://www.kevinmd.com/blog/2012/11/annual-physicals-harm-good.html

      http://www.sciencebasedmedicine.org/re-thinking-the-annual-physical/

      So the fact that you are pushing annual physicals suggest that you either don’t know this terrain as well as you think you do or are spreading disinformation.

Comments are closed.