The countdown is on. In four days, the health insurance marketplaces mandated by the Obama administration's Affordable Care Act are scheduled to open for business. As with any sizable tech project, there are bound to be glitches. But this isn't just any large tech project. It's unprecedented for the U.S. government.
Come Tuesday, every state will have its own online healthcare exchange, where citizens can browse and buy insurance from healthcare providers as if they were shopping for flights on a travel website. Consumers will be able to find out if they qualify for financial assistance and compare plans based on pricing, quality and benefits. The portals will calculate premiums and potential tax credits based on citizens' income, eligibility for subsidies, and other parameters.
Behind the scenes, a number of agencies, applications and data sources must swap information to keep the systems running.
"Homeland Security sends the citizenship information, IRS sends the income information, Social Security sends the Medicare eligibility information, and from the states you get the Medicaid eligibility," says Charlene Frizzera, president of consulting firm CF Health Advisors.
The requirements for data security and privacy are particularly onerous. Yet even before the sites launch, problems are emerging:
" Final security testing of the federal data hub, which links to databases maintained by multiple agencies and containing sensitive personal information, isn't slated to happen until Sept. 30, one day before the rollout. Lawmakers have raised significant concerns about the ability of the system to protect personal health records and other private information.
" The District of Columbia's DC Health Link marketplace announced that it won't deploy on Oct. 1 the function that makes new Medicaid eligibility determinations and calculates tax credits for purchase of private insurance "due to a high error rate discovered through extensive systems testing." Other states have reported similar functional setbacks.
" The Associated Press is reporting that online enrollment for small businesses will be delayed and business owners initially will have to mail or fax their enrollment info.
If technical glitches arise, The Centers for Medicare and Medicaid Services (CMS) is prepared to issue workarounds, industry watchers say. In addition, nobody is expecting millions of enrollments at the start of the six-month open enrollment period, particularly since coverage won't begin until Jan. 2014 -- which could buy some time.
CMS "has designed a system that they've tested to the best of their ability, and they think it works," says Frizzera, who is a former CMS acting administrator.
The agency has identified where they think the biggest risks are in the system they designed, Frizzera says. If a few of those risks materialize, CMS has prepared workarounds to handle the issues, but "they're going to have a harder time keeping up if a lot of those come to fruition," she says.
The unexpected risks are, naturally, unpredictable and potentially more worrisome, Frizzera notes.
There will be a marathon of testing and fine-tuning during the next few days as developers and stakeholders work out the known kinks.
"It's completing the final rounds of testing, it's preparing our production environments, it's thinking about day-one readiness from an operations perspective. Lots and lots of late nights and weekends as people get ready for go-live," says Patrick Howard, who leads Deloitte Consulting's public sector state health care practice.
Part of the crunch is due to tight timing.
The healthcare exchanges are the cornerstone of the Affordable Care Act, President Obama's health insurance reform legislation enacted in March 2010. Since the passage of the law, government agencies, contractors and private insurers have been working on the design of the insurance exchanges. But implementation has only begun in earnest within the last 12-18 months.
"It's a relatively short implementation time for such a big project," says Frizzera, who was responsible for executing the design and implementation plan for ACA while she was at CMS (she left the agency in 2010).
"I think everybody would have liked to have more time," says Deloitte's Howard. "More time is always a good thing. That being said, the majority of systems I've been exposed to are very, very stable and ready for day one."
Deloitte was hired to build healthcare exchanges in Washington, Kentucky, Rhode Island and Connecticut -- four of the 16 states that opted to build and run their own exchanges. Seven states are partnering with the federal government in a state-federal joint effort, and 27 relying on the federal government to operate their exchanges.
Leading up to the launch, "there has been rigorous testing of these exchanges, starting as early as May in many states," Howard says. "We're talking about thousands and thousands of scenarios."
"The states are very prepared," Howard says, "but with all that said, if you tested for two years, you're still going to find things in real life that you just didn't catch, that you never expected to happen."
As in any typical tech-support scenario, "day one will be all-hands-on-deck, people will be watching carefully what's happening, there'll be operations rooms for every one of our clients," Howard says. If something unexpected happens, people will figure out what needs to be done to fix the problems.
Adding to the complexity of the marketplace launches are the transactions themselves -- shopping for health insurance is no ordinary ecommerce transaction.
"It's different from a typical shopping-cart experience when you add in the complexity of financial eligibility, determination of tax credits and Medicaid," Howard says. "That adds quite a bit that you wouldn't see in a normal shopping experience."
The federal government can draw on its experience with Medicare Part D, a federal program to subsidize prescription drug costs for Medicare beneficiaries. Medicare D necessitated data sharing and coordination among government agencies and "provided a good foundation for this," Frizzera notes. "We learned a lot about how difficult that is -- though this is obviously bigger, because there are more agencies involved in the transfer of data."
Some are viewing the Oct. 1 opening of the exchanges as a soft launch, since coverage doesn't begin until January. That in-between period might provide tech teams the buffer they need to work out the kinks and glitches that surface after the launch.
"I've been doing this for probably three years now, and the primary question on my mind all along that path is: What happens on October 1?" Howard says. "It's very unclear, because we've never had an experience like this ... we don't know how many people are going to use it on October 1."
There's been a lot of publicity about the Oct. 1 launch, and anticipation is building.
"There's a lot of pent up curiosity," Howard says. "Let's say I make $40,000 and have a family of four. How much would it cost me to get health insurance through the exchange? How much will my tax credit be? What kinds of plans are out there?"
"I think a lot of people will go online and browse. Over time, people will start to get to a mode of, ok, I've seen enough, it's getting close to January, and I want to lock in my plan.' My guess is we'll get lots and lots of activity around the Thanksgiving time frame," Howard says.
"We can learn from those early adopters to make the experience better for the majority of the population."
In the meantime, "everybody has been working hard, and everybody's tired," Howard says. "But when you see 10/1 coming, there's that extra adrenaline rush that keeps you going. Everyone is excited to see these systems go live that they've spent a year, year-and-a-half building."
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