The website for the 36 states that did not sign up to run their own exchanges — healthcare.gov — experienced many technical problems during October, and these problems are still continuing, with the contractors blaming one another and the federal government. But changes are being made, and people will be able to enroll, according to the federal Centers for Medicare and Medicaid Services (CMS), the main “client” for the contractors developing the website. This week ADAW interviewed treatment advocates who support the Affordable Care Act (ACA), which is expected to bring thousands of new patients with insurance coverage to treatment programs starting in January, as well as a technical expert in website development. The bottom line: the biggest problems were in the linkages between healthcare.gov and the insurance companies.

Let’s start with the technical expert — Andy Swindler, president and founder of Astek, a Chicago-based website development company (full disclosure: Astek develops websites for ADAW’s publisher). While he’s not privy to the details of the development of healthcare.gov, he told ADAW in a October 24 interview that as he understands it, each contractor “had a different piece of the puzzle, and they weren’t coordinating together.”

At a House of Representatives hearing on October 24, this appeared to be the case, with the contractors, including lead contractor CGI Federal, blaming one another and their client — CMS — for the problems. “There are a lot of connectivity issues,” said Swindler. The “systems integrator” — the coordinator of all of the systems and contractors — was supposed to be CMS. “I’ve been involved in this before, where you’re one of many vendors, and you need someone to coordinate everyone, and that someone should be independent,” he said. “It’s like any project — you need someone to tie it all together — and in this case, you’re trying to get robots to talk to each other.”

And in a different committee hearing on October 30, Kathleen Sebelius, secretary of the Department of Health and Human Services (HHS), the parent agency of CMS, accepted full blame for the glitches. It was also revealed that CGI Federal had warned the federal government about problems in early September. CGI said that the testing time frames were in fact “not adequate to complete full functional, system, and integration testing activities.”

Systems integration

What makes systems integration difficult in this case — and is ultimately what needs to be fixed on healthcare.gov before it can really function — is the integration with insurance company systems. “What makes this so complex is that not only do the contractors’ systems have to talk to each other, but somehow they have to talk to each insurance company,” said Swindler. “And every insurance company has its own system.”

Particularly with healthcare.gov, where the system has to operate within 36 different state systems — states regulate insurance — it would have been very difficult to coordinate all of the systems, said Swindler.

Ultimately, Swindler said what healthcare.gov needed was more testing. Swindler mentioned the experience of fellow Chicagoan Harper Reed, a computer programmer who led President Obama’s 2012 digital campaign. “He’s a tech guy, but what’s amazing about what he did was to put together a volunteer army” of engineers who were committed to getting Obama re-elected, “which is a lot more exciting than running a healthcare website,” said Swindler. “Here’s what he says about testing — ‘We don’t practice until we get it right; we practice until we can’t get it wrong.’” For 30 days before the election, Reed’s team practiced failing, said Swindler. “Every day they set up a new scenario and they practiced how they would handle it when things went wrong,” he said. That is a “brutal” way to test a product, but it paid off. “The Amazon cloud, one of the biggest backend providers, failed during the election,” said Swindler. “But the Obama team wasn’t affected by it, because they had prepared for that contingency.”

Testing, testing

“All of us in the software cycle wish that there were more time to test,” said Swindler. This is especially problematic when, as happened with healthcare.gov, the requirements changed just weeks before launch. Instead of being a site where people could browse, it was decided that it should be a site that required users to create an account first. “That’s a huge change,” said Swindler. “We would push back hard” on timing if a change like that were made. “That’s a totally different type of website.” At least, he said, the client — CMS — should have been warned. “We are always trying to educate our clients about how much time is really needed for testing,” said Swindler.

And it’s important for testing to be done not by the developers, but by the potential end user, said Swindler. “When you’re in the trenches as a developer, testing isn’t just about ‘Does this work as we planned?’; it’s about observing someone who wasn’t in on the development, because they’ll go down a different path.”

Effects on treatment

Healthcare.gov, like the state-run exchanges, has four “metal” plans — platinum, gold, silver and bronze — that people can enroll in. If they make 137–400 percent of the federal poverty level, they can get subsidies for the premiums. But the links between these websites and the insurance companies still need to be fixed in many cases, so insurance companies know who is actually enrolling.

“One of the great challenges that the metal exchanges face is the fact that many of the key staff that were working with the contractors were furloughed when the marketplace first started,” said Mohini Venkatesh, senior director of public policy for the National Council for Behavioral Health, referring to the government shutdown October 1, which, in a story full of ironies, was triggered by congressional Republicans who refused to fund the government unless Obamacare were defunded. “This put incredible pressures and challenges on the marketplace,” she told ADAW. (Another irony is that it is the same Republicans who are now criticizing HHS and CMS for problems people have in enrolling in Obamacare.)

The state-run exchanges are “leap years ahead” of the federal exchange, said Venkatesh. They were proactive, they started earlier and they embraced the whole concept of healthcare reform. The other states not only did not expand Medicaid but were opposed to Obamacare in the first place, many of them suing in Supreme Court to shut it down. Forcing the federal government to run the exchanges put an “incredible burden” on the website development, said Venkatesh. “This is going to have to be endlessly tweaked,” she said.

Making sure that addiction treatment is included in the networks — a requirement of the law — is still problematic, said Becky Vaughn, CEO of the State Associations of Addiction Services. “It varies greatly state by state, and it will continue to vary even as we go into the next year,” she said. “If you ask [officials] what’s keeping them up at night, it’s making sure that they have adequate services for addiction,” she said. “Everyone is trying to figure out how to make sure their network is adequate.” As always, said Vaughn, providers should be proactive and try to get into networks on their own. “Don’t wait for someone to come to your door and invite you,” she said.

Fewer problems with Medicaid

There have been some smaller problems even in states that are running their own exchanges, said Vaughn, who has been traveling the country tirelessly over the past few years urging providers to get on insurance networks. “There’s a separate process for enrolling in Medicaid, and that is working much better” than healthcare.gov, she said.

“I don’t think any of the providers have seen this as a huge glitch,” Vaughn told ADAW of the website problems. “We know it will get fixed, and we know that the providers will help anybody who walks through their doors to get enrolled.”

Many community mental health centers are helping patients enroll in insurance — Medicaid or private insurance — on the state and federal marketplaces, just as they have always helped patients enroll, said Venkatesh. They are not “navigators,” who received federal grants and who have strict reporting requirements. “Many community-based provider organizations, whether in behavioral health or addiction or hospitals, have been doing this work anyway,” she said.

For the report from CGI to CMS, go to http://i2.cdn.turner.com/cnn/2013/images/10/29/redacted.cgi.monthly.report.to.cms.pdf.

Bottom Line

The website for the Affordable Care Act, healthcare.gov, may not have been ready for its October 1 launch – at least, it was not always able to connect to the insurance companies.