A Pragmatic Fix for Healthcare.gov & the HIXs

By now even those of us who originally thought that we were seeing minor teething troubles are no longer deluding ourselves. Healthcare.gov, the federal health insurance exchanges (HIXs), and many of the state HIXs are in deep trouble.

One summary of many articles about this is up at ProPublica. But now that the House Republicans have stopped trying to destroy the country and themselves, attention will turn quickly to this problem, and–much worse–beyond the politics, there is now only eight or so weeks to get ready for actual enrollments for Jan 1, once you take out Thanksgiving and the Christmas holiday. Getting ten or twenty million new customers on board, not to mention the small businesses who want to move from their current insurance onto the exchanges, seems like an impossible task.

But, if we can muster the will, there may be a solution. (And yes, I want it to work, faut de mieux). Quietly last summer two private online insurance brokers, eHealth which runs the eHealthInsurance.com site, and GetInsured, struck deals with HHS which allowed them to enroll individuals in plans that qualify for the mandate under the ACA, and more importantly, connect with the “Health Exchange Data Hub” that figures out whether the enrollee qualifies for a subsidy (theoretically by connecting to the IRS).

That part of the transaction, though, could be done by attestation and dealt with later. In other words, someone buying health insurance could state what their income will be in 2014 (or was in 2013) and if it ends up varying dramatically on their 1040 then in 2015 they will pay or receive the difference. Essentially this is something all Americans recognize–the IRS asks you for more or gives you a tax refund well after the fact, and H&R Block and their competitors make a business of giving you the refund right away (and of course charge you for the privilege).

That is important because what seems to be crippling the HIXs right now is not the back end, it’s the front end. (Go to this Reddit thread for lots more deeply technical conversation about that). Showing people options, comparing plans, setting up accounts–that’s all standard web stuff and most of the HIXs can’t do it. Those private brokers have both smoothly done this for years and at least the two I mentioned have built comparative tools for the new insurance plans. (Both were demoed at Health 2.0 on October 1).

So why can’t we put prominent links to eHealthInsurance.com and GetInsured on the Healthcare.gov site and move people over there? I asked both company’s CEOs. Here’s what GetInsured’s Chinni Krishnan said.

As you have observed,  Getinsured and other private health insurance exchanges are already certified by CMS to sell federally subsidized coverage on their sites and can soon play a significant role in enrolling uninsured Americans in states covered by the Federally Facilitated Marketplace.

As for timing – not just yet but we are near completing final testing with healthcare.gov and will turn on our shopping experience very soon. Once we do, we will absolutely offer the high-quality customer experience that we have always provided to individuals and families buying health insurance. Once this happens, I would envisage additional forms of cooperation such as the one you have visualized.

And eHealth’s Gary Lauer basically agreed but went further to say that the state HIXs, too, could join in.

For non-subsidy eligible consumers in the 36 FFM states, yes, a redirect to eHealth would be easy and quite workable. Prospective subsidy-eligible consumers could be provided the same eHealth option as soon as eHealth is able to connect through the FFMs to allow subsidy applicants to validate their subsidy eligibility.

The same access capability should be provided on the state exchanges as well – the result is more enrollment, which is the overall Affordable Care Act objective and purpose. Perhaps the states need to be reminded of the real ACA objective – maximum enrollment.

Basically they are both saying, “we can handle a lot of traffic right now, and although we’re not set up with the Hub yet we soon will be”. But even that need not be a problem. If consumers were allowed to estimate their incomes and get an appropriate subsidy without the connection to the hub–so long as they were made aware that they may have to pay some money back later just like underpaying your taxes–then the connection to the hub could be turned off until everyone is sure it’s working.

So why not? I know this wasn’t the original intent of how the exchanges were supposed to run, but we are in a desperate position and for the good of the Administration. and more importantly the good of the millions the ACA was designed to help (like this guy), we need to act fast.

How about it, HHS?

24 replies »

  1. @ Mr. Holt:
    “and more importantly the good of the millions the ACA was designed to help” & “We are talking here about insurance enrollment into private health plans…”

    Always remember, The ACA was never meant to function.

    But, I do believe everyone should recall the stated goals of those pushing the “Act”. To facilitate insuring the uninsured (the good of the millions the ACA was designed to help) and lowering overall health care spending (aka bending down the cost curve). Why not insist that this is the benchmark to measure success or failure of The Act and the exchanges? When it turns out 75% of the exchange enrollees are actually Medicaid beneficiaries (welfare not insurance) most of which were already eligible for Medicaid prior to The ACA but too busy (or lazy) to bother to enroll and 15% of the enrollees actually were previously insured but looking for a better deal through subsidies and cost shifting to the young and healthy, or were previously insured but their plans were outlawed, and the balance is made up of the young people just kicked off their parents plans due to age or cost or the parent’s plans were canceled, and the overall cost do not go down $2,500 per family or at all and the country ends up with the same percentage or more people uninsured, cannot we agree the ACA failed and more importantly can’t we agree not to reward the perpetrators of this waste of money, distraction, single payer, stepping stone with their ultimate goal? Just sayin’.

  2. A gross failure by the president, congress and the media to read and understand the consequences, loop holes and problems they were creating. Being manipulated by the insurance industry and others. They failed to read and understand their own regulations and laws. What’s going on with people promised they can keep their insurances and physicians? Losing plans for patients and physicians being de-enrolled. Let’s have government do something about that now.

  3. Rebecca M., name calling such as “Obozo” and “Obozocare” damages your credibility and reflects poorly on you. Also, the fact that you’re not even aware that “Pelosi, Reid, and the rest of them” ARE required to participate in Obamacare further damages the credibility of anything you say. If you want to be taken seriously, use facts.

  4. It’s refreshing to hear you critique and suggest without being a critic. As a health literacy person studying the enrollment process from the perspective of low literacy/low health literacy consumers, many have conveniently forgotten that continuous quality improvement and revision based on useability testing is key to all good e Tools, healthcare.gov included. We just need time, expert input and receptive designers & IT folks.

  5. They should have enrolled everyone on form 1040 or 1040 A. Either extract the penalty or extract the premium. Require everyone to. Use the in place infrastructure instead of building a new one.

    Enforcement is thru the IRS, afterall. Why not make it easy for them?

    The crap that is called i

  6. Signing up is only a temporary hassle. Now that you have a choice, the money is in picking the right plan to sign up for. Your claims history is a good place to start.

    Private and public HIXs that could access the state All Payer Claims Database on your behalf via BlueButtonPlus would be able to tell you your total out-of-pocket cost for each of the plans on the exchange. That would be an informed choice.

    More: https://thehealthcareblog.com/blog/2013/10/18/state-surveillance-endangers-the-affordable-care-act-a-case-study/

  7. “Obozo needs to be Impeached for the good of our country.”

    How creative. Why don’t you go back to the Yahoo Boards where you belong. Matthew has put up a serious post addressing an exigent problem that needs a solution. Take your bumper sticker elsewhere.

  8. LOL! Yea…the GOP likes to do their corrupt contracting with defense companies! (and I’m more fiscally right of center so this is painful to admit) 🙂

  9. At the time he was 59. Still young in my mind and non smoker. When I went to Ireland and met him, he was still pretty active. I just ranted because I heard Obama mention “Socialized medicine” this morning on TV, and the subject regarding the “throwing” granny off the clift”. My younger sister is a surgical RN here at Methodist in Houston and she has talked about how many of the Doctor’s plan on cutting back or retiring from medicine due to the new laws that will come about.
    Obozo needs to be a President of the USA and quit trying to run our healthcare. If Obozocare is going to be so good, Pelosi, Reid and the rest of them should have to have it also.

  10. Basically CGI is using a lot of Oracle technologies to include the ID Access module that Kaiser uses..yes it depends on the configuration for sure..and this is one big huge configuration for sure..


    The California exchange used some CGI too but under the direction of Accenture, a long established Oracle partner..and I wonder too if the turnkey Oracle “state” insurance exchange module was used as well, heck of a lot less code to write and I would think the Access and ID manager from Oracle would be better configured to integrate..oh well. Microsoft built a turnkey exchange platform too.


    I said also they should call it a “beta” to get some additional patience and forgiveness from consumers and the media..I told my readers be prepared for a manual method if you have too and pick up the phone and get enrolled even though that might not be pleasant either but use a method that might work.

    California exchange folks did a good job in a short amount of time though when you look at other IT issues the state has, like 20 years and millions in trying to get a new state payroll system on board, and I think they are suing SAP now as the latest vendor to give it a try with a contract:)

    Yes indeed this was one of if not the biggest integrated projects every attempted and you have those old COBOL legacy servers at the government so middleware needed there too for scalability to kick in..

    Like I said in 2009, get someone with “some” IT background to run HHS as HealthIT was going to eat her up and she would be duped and duped again..not personal as SEC and DOJ have same issues..


    Gov needs some real Quant and Actuary Sleuths on their side to explain the fact of life with math modes and how the insurers put the government behind the 8 ball as reactionary all the time. I have a collection that explain this to the layman on the Algo Duping page and consumers and the government has learned a real cold hard lesson on IT Infrastructure complexities today, and yeah I liked the old days better myself before platforms as I had more control, but not the case today. Algo Duping 101 and the resultant Killer Algorithms..video by people much smarter than me..some very intelligent quants and this is important to understand as insurers now have a few hundred quants on board too so not just the banks with models elevating or decreasing risk for profit anymore and all that comes in to play with pricing and their data mining in here too.


  11. How old was the father?
    It’s true that a 90 year old uncontrolled,cigarette smoking CRF patient may not be a transplant candidate in a health care system that is totally subsidized by the taxpayer.
    Its news to me that a CT scan is the test of choice in deciding upon an appropriate donor kidney.I though HLA tissue typing played that role?
    Verifying your facts will make your posts more believable.


  12. Margarit – Surely you must be joking.

    Corrupt contracting on almost anything related to Big Government contracts is a bi-partisan “way of life”. The only agency that makes a feeble attempt to curb this is the GAO

    Rick Lippin

  13. Rebecca. You’re wrong but that’s a longer discussion. But much worse, you’re irrelevant. We are talking here about insurance enrollment into private health plans….

  14. I am a long time RN. I can see the train wreck coming with OBOZOCARE. I worked with several Irish and Canadian RNs when I was working three years in Saudi Arabia. After the first 3 weeks of being there I had made good friends with an Irish RN and another RN from Canada. Over lunch one day I asked what medicine was like in their countries. The Irish RN told me ” Well it’s GET IN LINE AND WAIT!” Then she explained that her father had become ill and needed a kidney transplant. She was going to be the donor but it took the Government run healthcare system 6 months JUST TO DO THE CT SCAN TO SEE if it was a fit! I was told by both nurses that the government drags its feet hoping the person dies when it is an older person needing medical care because of cost. So yes, pushing granny over the cliff is well known! Obozo needs to be Impeached for the good of our country.

  15. There are lots of things you can blame the GOP for (and believe me, I do blame them for most), but corrupt contracting with shoddy software bandits is not one of them.

  16. That is a great idea, Matt. None of this should have been this hard, and this simplifying fix would go a long way to dealing with a problem created by an Administration working under political siege, well beyond the capacities of any government agency.

    Along with benefitting greatly from the streamlining you suggest, this whole mess would have been avoided if (1) all the states had participated in the implementation of a law that was duly passed by Congress, and (2) we had been able to leverage the private exchanges the way you suggest across all states – and thus avoid having the federal government reinvent the wheel. We have had private exchanges in place and working for years, and not just the two you cite, but several others operated by benefits companies – and of course ExtendHealth, which has been enrolling Medicare beneficiaries for nearly a decade.

    The fact that the Fed had to scramble to put a crappy exchange in place for 36 refusenik states is one very tangible example of what happens when people put politics ahead of policy – when making the President look bad becomes more important than making things work.

    There are numerous technical reasons the Federal exchange is working like hell, when it’s working – but the underlying reason is political sabotage, plain and simple – from the same types who not that many days ago were willing to bring down the entire economy to make a political point.

  17. What’s with the fetish of enrolling via the internet? There are tens of thousands of licensed life, health and disability agents who could facilitate the sale of ACA compliant plans. If licensed agents were allowed to act as navigators we would already have hundreds of thousands enrolled.

  18. Ken, You must get the bulk of your news from the NYT and MSDNC. Have you heard about some of the policy prices, deductibles, and spending cap issues with ACA-compliant policies? You can rest assured that enrollment will not produce immediate satisfaction/happiness for the bulk of purchasers. For those who’ve been unable to previously access health insurance, or have health conditions that correspond to high premiums, sure. Otherwise, not so much.

  19. “for the good of the Administration.”

    Are you kidding me? Who the hell cares how “the administration” comes out on this? Besides, of course, “The administration!”


  20. The back end may not be “crippling the HIXs RIGHT NOW” but that’s only because the “back end” has not even been exercised in any meaningful manner. And the issues with the backend – except for perhaps the APTC and CSR impact on premium calculations – won’t be visible to enrollees until their premium statements and eligibility is screwed up. Why not just ask anyone working on the backend pieces how all those 834’s and 820’s are working out? 🙂
    In my opinion, the FFM is hosed and the pragmatic cynic in me is telling me that Obama will grant the one year extension to the individual mandate before Thanksgiving – to lay the blame on those who built the FFM.

  21. This is a marvelous idea, and I sincerely hope that HHS is listening. There’s no point in lamenting that $400 million has been spent on a failed system or that one reason for the failure is that the contractors were more politically connected than technologically astute. At this juncture, what we need to do is get the exchanges moving and make it easy for the people who need health insurance to enroll. Once they do, and they’re happy with their insurance, the Republican assaults on Obamacare will start to fade away because nobody will be listening.

  22. Thanks Matt-

    I’m not surprised at all by the failures of the Healthcare.gov website. Believe me I have lived in a world of failed large Government websites including Health Related websites. Appreciate your practical fix suggestion.

    But in my opinion at least 3 dynamics are in play here. 1) Anything this big is inherently overly complex 2) IT Vendors routinely overpromise functionality and reliability 3) MOST IMPORTANTLY- A failed IT system is NOT a failed affordadable health care for all national imperative.

    Dr. Rick Lippin

  23. I can think of a reason or two why not. Wouldn’t a hand-off to the private sector, after a $400 million investment, be a sad admission that government can’t do big things well, if at all? And on a related note, if they can’t get the front end of a website right, why on earth would we trust them to get the rest of it right — you know, the really hard stuff like restructuring insurance markets, creating new models of care delivery, and handling huge volumes of confidential client/patient financial and health information?