We talk with a long-time mental health service provider who works with vulnerable citizens about the state of mental health care, progress made in recent years and the way forward.
In the three weeks since the federal insurance marketplace, HealthCare.gov, launched, officials have scrambled to fix myriad glitches with the site. While users point to long wait times and software hiccups that have hampered their ability to get insurance, web developers, experts and journalists point to more fundamental problems. Kojo explores the challenges behind launching massive government web sites, and finds out what kind of impact the botched health care rollout could have on future IT projects.
- Alex Howard Fellow at the Tow Center for Digital Journalism, Columbia Journalism School; former government correspondent, O'Reilly Media
MR. KOJO NNAMDIEarlier today President Obama addressed the problems that have been plaguing the healthcare.gov site. He was introduced by Janice Baker, the first person in Delaware to sign up for Affordable Care Act coverage through the site. She spoke of her frustrations with the site, but satisfaction with the plan. The president then spent some time explaining the program, saying the product is good. Before getting down to the glitches, noting…
PRESIDENT BARACK OBAMAThere's no sugar-coating it. The website has been too slow. People have been getting stuck during the application process. And I think it's fair to say that nobody's more frustrated by that than I am, precisely because the product is good. I want the cash registers to work. I want the checkout lines to be smooth. So I want people to be able to get this great product. And there's no excuse for the problems. These problems are getting fixed, but while we're working out the kinks in the system I want everybody to understand the nature of the problem.
PRESIDENT BARACK OBAMAFirst of all, even with all the problems at healthcare.gov, the website is still working for a lot of people, just not as quick or efficient or consistent as we want. And although many of these folks have found that they had to wait longer than they wanted, once they complete the process, they're very happy with the deal that's available to them.
NNAMDIPresident went on to stress we're just three weeks into a six-month open enrollment period, that they've got a crack IT crew on the case, and that they've boosted staff at call centers. The phone number for which is 800-318-2596. Reminding everyone in the end that his administration didn't run a long and contentious battle over a website, yet the website is what many are talking about. And here to help us understand how the administration got here is Alex Howard. He's a fellow at the Tow Center for Digital Journalism at Columbia University. He's the former government correspondent for O'Reilly Media. Alex, thank you so much for joining us.
MR. ALEX HOWARDIt's a pleasure to join you.
NNAMDIWe just heard from the President about the healthcare.gov rollout. What were you listening for in or expecting from those remarks, and did you hear it?
HOWARDWell, I was -- I think, as many people who've been following this for some time -- looking for an admission that things were more troubled than just an overwhelmed system with too much traffic. At least that's what we've been hearing about since really October 2nd, when people started to report that there were issues. And, as usual, I think I was looking for more specifics about what those problems were and how they were being fixed, so an acknowledgement that this wasn't built as effectively as needed to be, and that the administration was taking steps to fix that.
HOWARDThere was a 600-word blog post that went up on hhs.gov last night, which everyone has then been reporting on since then, which offers a bit more detail, but not a great deal more. He talked about bringing in people from the private sector, some of the best tech talent in the country, without saying who those people are, just that they worked in some relevant industries, relevant businesses. And the post itself says that some of the presidential innovation fellows who've been brought in to help the administration with some of their tech challenges will also be involved.
HOWARDYou know, he talked a lot about the issues with the website, but played up the other things, obviously, that the law itself is standing up for, and, as you've noted, in order to push people to a phone number. I will say, just before I came on the air, however, I saw someone say that someone on that phone number, call center, directed them to the website. (laugh) So there can be an issue with a reciprocal loop here.
NNAMDITo some extent the rollout of and subsequent problems with healthcare.gov were overshadowed by Republican efforts to strip down the healthcare law, get rid of it all together and the resulting partial government shutdown, but now that's over. The press is bringing the rollout back to the front pages. This weekend we found out that just under half a million health insurance applications had been filed through the federal and state health exchanges, but what we did not find out was how many people had successfully enrolled. What should we take away from these numbers, or lack thereof, three weeks after the initial rollout?
HOWARDWell, if you look at a given e-commerce website and you're in charge of that, say amazon.com, and at the end of a couple of weeks you determine that you're not actually selling many things to the, say, 20 billion people that have visited, you know that there's a problem with the backend of it. In this case you can get to the site every time, but actually completing enrollment is something we just don't know anything about.
HOWARDThe administration says they'll give us those numbers in mid-November. From what we understand, from what they're telling us, about 250,000 people have completed an application through the federal version. And another 250,000 or so have completed through the state healthcare exchanges.
HOWARDOf course there are, you know, a variety of approaches to doing this online elsewhere. And what that suggests is that it is possible to do this, but for the vast majority of people they're not able to get through all of the bugs they're being confronted with to accomplish it.
NNAMDIWhat kind of impact do you think this negative press will have on enrollment numbers moving forward?
HOWARDI don't think there's any question it could have some impact. There has already been a tremendous amount of misinformation, disinformation, discouragement with respect to getting people to come in and apply out there. I think if we looked at the beginning of the summer, many people still didn't understand the law itself or what it meant to them personally. I think you saw, actually, the president assume somewhat of the role of an explainer-in-chief in the rose garden this morning, as he talked a lot about the provisions of the law, what's still going in.
HOWARDI see administration officials, Dr. Farzad Mostashari tweeted back to me today that the website is not the same as the Affordable Care Act. They're trying to clarify that all the provisions that are out there are actually going into people's lives, you know, if they already have insurance, this is affecting them in a positive way, and clarifying that just because this one part of it doesn't work, doesn't mean that the whole comes apart. Now, as you know, estimates from the federal government I think were somewhere around seven million people might come in in this open enrollment period. For this to work, they need a lot of the young, healthy people to enroll.
HOWARDAnd certainly doing through the front end of the website is a natural way to do that, not necessarily a call center or downloaded an application and mailing back, etcetera. So it is, I think, fair to say it's mission critical to get it working to make this succeed. It is conceivable to imagine it working without it, but, you know, the time does grow a little bit short.
NNAMDIOur guest is Alex Howard. He's a fellow at the Tow Center for Digital Journalism at Columbia University. He's the former government correspondent for O'Reilly Media. We're taking your calls at 800-433-8850. Have you tried to sign up for a government health insurance plan online? What was your experience, if so? 800-433-8850. You can send us a tweet @kojoshow or email to email@example.com. Alex, you have noted that this administration, which used technology so well during its campaign, botched the tech infrastructure behind one of its most important government initiatives. What's the short answer for why that happened?
HOWARDThe ways that the federal government can buy, build and maintain technology are very different than the ones that a campaign can have. That's the short version. There's a much longer one that goes to this dreaded word called procurement, which, of course, is how we describe the buying and selling of technology to governments. And there are a lot of regulations that exist. There are a lot of challenges that exist for government to access some of the most cutting-edge -- start ups are used to newest technology. That's why you often see this five to seven year lag between what the government IT systems do and what happens in the private sector.
HOWARDPerhaps ironically this administration has been working hard in a lot of ways to try to improve that. If you look at what's happened in the consumer financial protection bureau, if you look at their adoption of these innovations fellows I mentioned, one project of which was focused specifically on something called project RFPEZ, making it easy for government to bring on smaller web shops to work with them.
HOWARDAnd now they're getting tripped up by this great challenge, this fact that there's a single-systems and an integrator that often works on a lot of projects, things get bid out, and they get very, very complicated. They get very expensive. Healthcare.gov I think is the first time for many Americans -- they're coming up against this challenge around IT not being built very well by the federal government.
HOWARDUsually they come up against state and local systems. But it's unclear whether this will be enough of a catalyst to really shock that system and to, you know, really make people in Congress understand there's something at issue here. Because it's, I think, a very difficult issue for politicians to get behind. It's not a very sexy issue to talk about procurement or building and buying technology. And it's actually, potentially politically risky one for them as well because these very same contractors are significant contributors to campaigns and they're lobbyists. Right? So, you know, do take that honor.
NNAMDIA couple of questions.
NNAMDISo you win the White House, after you run a technologically sophisticated campaign, then you're confronted with two tech challenges, a mammoth procurement process that's mired in rules and regulations, and older tech infrastructure. Why are there so many tough rules around how technology can be bought and how it can be upgraded?
HOWARDWell, there I think it's useful to step way back and go back into history and look at all the examples of contractors, of businesses selling government stuff, going back to the revolutionary era, you know, going back to the Civil War -- perhaps most famously, during World War II, when contractors were profiting from building the arsenal of democracy, you know, and you remember the Truman Commission where he brought them up and front. There is the potential for huge amounts of waste, fraud and abuse when you're talking about billions of dollars. And the federal government spends on the order of $80 billion a year on IT.
HOWARDSo these things are there for a reason. The challenge is that those regulations become quite onerous and it's very difficult to navigate them, especially for a lot of smaller businesses that don't have the time to invest in someone to help them get through federal procurement. And on top of that there are a lot of certifications that businesses have to get to be able to do this kind of work.
HOWARDOne of the things people here in town are watching or seeing Amazon and Microsoft and other companies getting FISMA certified, this is Federal Information Security Management Act for their clouds. Right? And this is something that the big guys are going after and having huge challenges around, not smaller companies.
HOWARDSo there's a difficult, I think, you know, balance between finding ways to make it easy enough for smaller companies to work with government -- and government needs to be able to be flexible -- and also protect the American taxpayer against the potential for huge amounts of mismanagement and abuse. It's a really thorny problem.
NNAMDIThere are reportedly more than 50 contractors involved in creating, managing or supporting healthcare.gov. Is that typical for a project like this?
HOWARDWell, I don't know how many projects like this there have been.
HOWARDI think that's one thing that's fair to say about this. For one, you know, Congress made kind of an artificial deadline. They didn't say build this thing. They said build it by this time, which creates, you know, an extra degree of difficulty. It was a single sourced to one contractor, CGI Global. It has a U.S. arm called CGI Federal. It's based up in Canada, which is already working with the centers for Medicaid and Medicaid services and HHS. They essentially transitioned into them. I wish we could be clearer about how many contractors there were.
HOWARDIf you go to USAspending.gov, if you go to clearspending.org from the Sunlight Foundation and try to untangle who's being paid what and for what, it's very difficult. Standardized reporting is really needed to understand this. I think that you'll typically see a prime contractor and then lots of subcontractors for components of a given engagement like this. That's not so different here.
HOWARDI think one of the major departure points and something that's increased in the amounts of criticism, in terms of understanding what went wrong, is that it looks like CMS acted as the systems integrator here, which is not a common thing for a government agency to do, and that that may have led to some of the issues. There wasn't, say, a single contractor playing quarterback, so to speak, on all the different pieces.
HOWARDAnd what led up to things going so badly is that for whatever reason, they didn't get enough time to test the system end to end before it went up. And anyone who watched it go up and then watched there being really rough problems just with login on the first week could see that. It was very clear.
NNAMDIOnto the telephones, here's Hans, in Washington, D.C. Hans, you're on the air. Go ahead, please.
HANSI just want to comment on the complete disparity of accountability on the issue of state-based and federal marketplaces here, that many of the critics of the federal government's healthcare.gov rollout are coming from the right. And states, in many cases, had their opportunity to mount their own marketplaces, yet in many cases refused to do so. As you may know, Kentucky is the only southern state that actually mounted its own state-based marketplace.
HANSAnd it's having a great job showing enrollments for its state-based marketplace. So there's a real absence of accountability for conservatives who had a chance under the basic concept of local governments being better to mount state-based exchanges and yet they criticize the federal government's effort to step in, which was an obligation they created by their failure of responsibility here.
NNAMDIHans, thank you very much for your call. Probably a great deal of what you say is true, but to what extent? People living in the 16 states and the District of Columbia, that set up their own exchanges and websites, have had a different experience. How have these state health exchanges performed so far?
HOWARDWell, there is a gradient. You know, I think one of our founding fathers famously said there's -- a laboratory is a democracy and people now look at cities, laboratories of innovation. Well, we're actually seeing federalism expressed through code right now. (laugh) There are all these different approaches to delivering the same thing. He mentioned Kentucky. Kentucky is actually having quite a bit of success if you look at this gradient of exchanges.
HOWARDOthers have thrown a lot more bugs. Oregon, which was one of the states to take federal grant money early on in the process and got far out ahead, combining it's government IT workers directly with the vendor in this case, Oracle, reported signing up, I think, 10 percent of, you know, people onto insurance, but it was through a fast-track program that the ACA made possible.
HOWARDIt’s not clear if they've signed up anyone through their exchange yet. So there are, I think, a lot of issues at the local level. Here, closer to home, of course, in D.C. they are managing to register people. Maryland's exchange has, however, been plagued by some bugs.
NNAMDIYeah, the lieutenant governor, Anthony Brown, said last week that the state stumbled out of the gate with its health exchange. Is the process for procuring and creating state sites less complicated than at the federal level?
HOWARDMaybe marginally. I have to give the benefit of the doubt to federal regulations for being about as labyrinth a thing as you can get. But not significantly so, and the fact is, is that the issues around procuring, building and maintaining large IT systems, so Enterprise IT software in governments at the state level is also significant and many people say broken. If you look around the news reports over the last couple of decades, even the last year, you'll see that the states are having issues building their different kinds of IT as well. It's not just about these healthcare exchanges. It's really about how government is able to build and deliver upon these larger uses of IT.
HOWARDAnd, you know, this is something that a lot of people thought this administration would be better at when they came to D.C. in 2009. The, you know, challenge is they have been, I think, justifiably focused upon wars, financial crisis, lots of other huge issues. They haven't been able to take on this one.
HOWARDYou know, maybe the tragic irony is that not doing so has, I think, led to one of the most important legislative achievements of the administration becoming undermined. It's become unfortunately, you know, fodder for late-night talk show hosts because people understand a website not working. That's something every American can get their heads around, not what led it to not work.
NNAMDIGot to take a short break. When we come back we'll continue the conversation with Alex Howard. He's a fellow at the Tow Center for Digital Journalism at Columbia University and former government correspondent for O'Reilly Media. The number to call is 800-433-8850. What government-hosted sites do you use regularly? How have they worked for you? 800-433-8850. You can send email to firstname.lastname@example.org or go to our website, kojoshow.org, ask a question or make a comment there. I'm Kojo Nnamdi.
NNAMDIWelcome back. We're talking with Alex Howard. He's a fellow at the Tow Center for Digital Journalism at Columbia University and the former government correspondent for O'Reilly Media. But what went wrong with healthcare.gov, which President Obama attempted to address this morning. We're inviting your calls at 800-433-8850. Do you think it takes the government a long time to adopt new technology? Why or why not? 800-433-8850.
NNAMDIAlex, on the user side of this equation, one of the biggest criticisms of healthcare.gov was that you had to create an account before you could browse the offerings. Here's an email we got from Joe, in Baltimore. "The first step, before a user can do anything on the healthcare site is to create an account. What? No. Wrong. This would bring in a ton of people all at once trying to create an account."
NNAMDI"Did the contractor anticipate that? No. The simple solution would have been to make that a step after the user researches available plans. This would have slowed down the sign-up on the first day to very few, the first week to manageable, and spread the remaining sign-up load across more time. Why was that decision made and why has it been so problematic?" Alex?
HOWARDWell, boy, you'd really need to get someone from the government in here to talk to you about that. (laugh) You know, there are decisions that are expressed through code choices. This is, you know, a classic situation where this is true. And to be fair, 10 days ago healthcare.gov tweeted out that you can now use a tool where you can get information about plans in your area without having to log in. Now, I don't know why they made that call? Clearly, I think they could have diverted a lot of traffic where people just wanted to come and browse without getting there.
HOWARDBut I think you can go to -- what -- healthcare.gov/find-premium-estimate. So you can do that now, but it's not clear how well that's, you know, "surfaced" to people as they come in. And I think there is a failure of, again, thinking through how users might be going through the process there, to offload some of them right at the front-end of the experience. Again, you'd have to get someone from the government to understand why that decision was made. It doesn't seem like it's a particularly strong one, particularly after they took a course correction and added it afterwards.
NNAMDIKenneth writes on our website, "Most people have no conception of what it takes to stand up a major software product for millions of users. No testing will ever cover all of the ways 300 million people might interact with the software. We're used to end products that have had many years of commercial development before release. I think Obama understands that and will get his team to make it happen."
NNAMDIBeth, in D.C., emails, "Critics keep comparing healthcare.gov to private operations like Amazon or Apple. The Amazon site took decades to build. And Apple downloads are far less complex than the healthcare exchanges. A better comparison is the new online application system for colleges and universities, which has run into precisely the same type of rollout woes. My company does online shopping and training sites, as well as phone apps, so I know more of the technology ins and outs than most," says Beth. On now to John, in Alexandria, Va. John, you're on the air. Go ahead, please.
JOHNYeah, I tried to log in -- thank you for your show, by the way. This is an excellent topic today. I tried to log in to set up an account, which frankly I didn't have too much trouble, but it is an odd account. They require that you have a special character and a number in your log on id, which I thought was a tad odd. Then they send you an email, which confirms things. I can understand that.
JOHNAnd then you have to go back through and have to answer a series of questions to identify who you are. I didn't go any further because quite frankly I don't need health insurance at this time. I'm covered by my employer, but -- and I didn't want to add any more burden to their problems. Is that standard government speak, that they have to put in certain kinds of user id's and those kinds of qualifications?
NNAMDIStandard government speak, Alex?
HOWARDWell, I don't know about standard government speak. That usually, for me, means saying something that isn't really clear. You know, if you look through communications from government to citizens it's often not holding up the great standards of plain language. Here, for this particular part of the site -- which was, honestly, the one that stymied most people until they fixed it after, a couple of weeks -- what they are trying to do is authenticate that you really are who you are online. And on the backend there's an identification system that's querying databases the government already has to compare information about you.
HOWARDThis issue with the special character and the sign-on -- you know, I've heard this from other people as well -- I'm honestly not sure why that was part of the process. I know it's made some people kind of quirk a little bit, but, you know, the reality is that they need to know who you are to start interacting with you in a much more secure way. I think there are justified issues with the way the security of the site has been analyzed. Unfortunately, without sitting down with a security expert and looking at the code of the architecture itself it's harder to say exactly what's going on for sure.
NNAMDIWe talked a bit about the consumer experience, but what are we hearing about how functional insurers are finding the system?
HOWARDWe're hearing about a lot of data coming their way that's unfortunately in error. The insurers are the other source to look at here as the government makes claims about enrollments. And we'll be hearing their side of that story, instead of the administrations, in mid-November. They're saying X amount of applications, but how many people actually are enrolled? The insurers, when they've been asked by the media -- and there's been lots of good reporting now, over the past couple of weeks from the various papers coming through and saying how many successful enrollments have you actually gotten -- are saying not that many have come through.
HOWARDAnd they're also saying -- and this is significant -- that there may be duplicates or errors or other issues with the applications themselves or errors in the way that these subsidies are calculated. One thing that I think the issues with the log-in, is that initial -- that cropped up, that the caller referred to -- masked is that there may be deeper issues with the site itself from how subsidies are calculated to kind of getting the enrollment to happen. And unfortunately, those may be things the insurers tell us about in another month or so.
NNAMDITwo years seems like a long lead time for almost any project, but after the launch a New York Times reported noted that time was a huge factor. Given the complicated procurement process we've been talking about, was two years too tight a time frame for launching a site of this magnitude?
HOWARDI think if they had had all of the requirements in place at the beginning, the rules, the regulations, clarity upon what the states would and would not be doing, had brought in special tech talent or an integrator at the very beginning, as opposed to letting the government agency run it, had hired more technologists inside of government, maybe. Maybe they could have gotten it done. Unfortunately, with the way that this was set up and the way that it was, I think, overseen, my sense is that it may have been impossible to deliver a working product on October 1st, at this point.
NNAMDIBack to the telephones, here is Tim, in Chevy Chase, Md. Tim, you're on the air. Go ahead, please. Hi, Tim.
NNAMDIYou're on the air, Tim. Go ahead.
HUGHYeah, my name is Hugh. I think you just got it mixed up.
NNAMDIOh, yeah, I probably did.
HUGHI'm fine. I guess the question is going back to what one of your web comments was, you know, there's a political component to this and then there's a design technical component. I mean if you look at the internet companies, like Netflix or eBay or Amazon or even a recent failure of NASDAQ, you know, during the high-volume period, which has been much publicized, you know, a lot of these newer companies work through the growth and the capacity of their systems over time. I mean eBay and Amazon didn't get a fraction of the kind of traffic that this site was getting when they launched, and it took them 10 or, you know, 10 or 15 or 20 years to get to this point.
HUGHAnd even a more mature system like the NASDAQ system collapse during a particular, you know, period of time -- and that's just a comment. So the question I have is if you look back on the introduction of other government programs, let's say pre-digital, you know, Medicare, Social Security, unemployment, I mean, don't all of these things take 5 to 10 years to sort of work through their kinks?
HUGHAnd isn't it sort of a political issue here where, you know, the government had to get this thing up and running in order to deal with the political issues because if they had said we're going to delay it, then this thing would have been more susceptible or vulnerable to attacks on the political side.
HOWARDWell, let's take each of these questions by turn. I'll take the latter one second. Caller is completely correct that rolling out large-scale government entitlements, whether it's Social Security, Medicare, Medicaid, the Part D addition, has been hugely challenged. If you look at the history of these things there's no question that the implementation has taken years to "work the kinks out," as they say. And that's going to be true with this, as well. It's important to echo what people are saying, that the ACA is not a website. So issues with the website should not be conflated with issues of the law itself.
HOWARDThere may be, in fact, issues with the law itself or the policies around it, the implementation of those policies by various administrators state by state, agency by agency. And they have to be taken and examined on their own. And my sense is that it's going to be awhile before that gets worked through. We're going to have major choices that are going to be quite politically charged about individual mandate. Obviously the mandate for businesses was delayed. On the technical side, with regards to scaling, yes and no.
HOWARDIt is true that commercial sites that launch might not have had the kind of scrutiny this did. At the same time, this is something that happens all the time to start-ups. They might launch, they get a lot of press coverage, they might go down under a deluge, but with the way that modern cloud architectures are set up, your host, say an Amazon's cloud, you can just add in more capacity. The issue with this site, I think, is that was hosted on premises in a data center using technology they couldn't scale.
NNAMDIOnly have about 30 seconds left. People who want insurance need to sign up by December 15th. Do you think the site will be fully functioning by then?
HOWARDMaybe. (laugh) I can't go on the record on that one. We'll see.
NNAMDIThat's the best he can do for right now. Alex Howard is a fellow with the Tow Center for Digital Journalism at Columbia University. He's the former government correspondent for O'Reilly Media. Alex, thanks for dropping by.
HOWARDIt was a pleasure to join you, as always.
NNAMDIAnd thank you all for listening. I'm Kojo Nnamdi.
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