Not What the Doctor Ordered: Rough first day for Healthcare Exchanges

Author’s Note:  For the sake of this blog post, I have left the politics of the Affordable Care Act (ACA), commonly known as Obamacare, out of the discussion. 

As the White House, Congress, and most of the news media made sure we knew – today is the first day of open enrollment for individual health care plans sold on one of the insurance exchanges.  Regardless of how history books eventually look at the Affordable Care Act and the Federal Government shutdown that occurred concurrently with its launch – from a technology perspective, the first day of ACA open enrollment  on the health care exchanges will go down as a failure.  Starting in the early morning hours, Twitter reports started to surface indicating that people have been unable to register for the federal site and that several of the state sites disabled online enrollment or went off-line entirely.  As I write this, 12 hours after their launch, it continues to be impossible to register for an account, which is required in order to start shopping for healthcare plans.  Some of the sites recommended that citizens call insurance brokers to shop for plans while others were referred to call centers and on-line chat tools.  Unfortunately, those systems are also strained under the demand as the online chat feature was quickly disabled on the Federal Healthcare.gov website and one of the states reported on Twitter that their “Consumer Support Center is presently experiencing unexpected connectivity problems.”

For those of us who have led large technology projects, the day one failure of a project of this size and magnitude was no surprise.  First, the regulations that defined the requirements for the healthcare exchanges were released weeks and months late from the Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services.   Once the regulations were released and development could start in earnest, the complexity of the systems being developed became clear as each state exchange had to interact with dozens of systems from the IRS, Social Security, Centers for Medicare and Medicaid Services, and insurance providers.

Hints of the pending failures were coming for months as the Administration delayed key components of the Affordable Care Act (employer mandate, eligibility verification, small business exchanges, etc.), likely in an effort to shed scope and focus on the individual healthcare exchange for the October 1, 2013 release.  For weeks, there have been news articles about the delays and missed deadlines for the creation of the software supporting the healthcare insurance exchanges.  Delayed requirements, high complexity, and a hard launch date are a combination that often leads to a failed release as software quality assurance and full system & infrastructure testing are condensed or skipped as the timeline compresses.  While there are an estimated 48 million uninsured people in the country, it is unlikely that all of them attempted to enroll in the first 12 hours for coverage that will not begin until January 1, 2014.  The fact that the systems couldn’t handle the load for day 1 launch indicates that it is unlikely that a robust, full load testing process was completed.  As many human resources departments can attest, day one of open enrollment is not the busiest day – the busiest day is the final day of enrollment.  It will be interesting to see if the systems issues can be resolved so that December 15th (last day prior to coverage starting on January 1st) and March 31st (last day for 2014 open enrollment) will go more smoothly than today.

A few key lessons IT leaders can take from today’s healthcare exchange failure:

  • System testing must be designed from the beginning so functional and non-functional requirements (including response time and load) can be confirmed prior to launch
  • Lost development time being made up for by shortened testing is a recipe for disaster
  • Soft launches are a key component to system deployment.  Rather than allowing all citizens to enroll on day 1, CMS should have created waves of open enrollment dates (launch and close) by groups of states rather than all being on the same day
  • Putting application infrastructure “in the cloud”, as CMS did by utilizing Akamai and Terramark, does not guarantee application scalability

While some day, historians may look back on the launch of the Affordable Care Act as a net positive for the country, from a technical perspective, the launch was a failure.  Unlike the government, businesses are competitive – so a day one failure as large as this one could be a significant financial hit and absolutely a confidence hit with your customers and partners.  You may never design a system that has the potential for 48 million users, but the customers utilizing your systems are driving your business.   Is your IT Service Design, including software quality assurance & testing, as well as your IT Service Operations strong enough to ensure that your major system deployments are successful?

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