My basic understanding of this controversy is that there are real aggravations and problems with the website that are being vastly overhyped by the Republicans and the still-wired-for-Republicans Beltway media. I think it's exceptionally important for Democratic Administrations to present a reality of competence and, as far as the politics will allow them to, a clear appearance of it as well. So it's a high-level but probably accurate criticism to say they should have given more attention to the initial rollout of the website.
But that would have probably had to have been part of a much better marketing project for the rollout of the full-blown program. I continue to think asking Bill Clinton to be the public face of that effort would have helped a lot. Selling this kind of thing and slapping back Republicans criticism is right up Clinton's alley.
Part of the problem continues to be Obama's seemingly chronic habit of trying to sell his policies in the context of Republican framing. Since the ACA is largely based on previous Republican ideas and programs, very significantly including "Romneycare" in Massachusetts, that's perhaps understandable. But still not acceptable. They needed to anticipate obvious targets of potential Republicans attacks and disinformation like the website. Part of the reason that I can't get too excited about the website issue is that progressive Democrats are way too familiar with this Administration underestimating the toxicity of Republicans hostility to be much surprised by it.
Also, some of the distress is caused by greedy grasping by the insurance companies themselves, as Digby discusses once again in Misleading insurance companies? Say it ain't so! Hullabaloo 11/04/2013. I happen to think this is not the smartest thing that insurance companies should be doing from the viewpoint of their own interests. But they haven't asked me for my advice. Since the ACA is a huge boon to the private insurance companies, who have a vast pool of new customers, many of whom will be subsidized by the federal government to buy their products, you might think they would try to be as cooperative and helpful as possible on the rollout of this thing.
On the other hand, they can be reasonably sure that Obama won't have the kind of reaction that Jack Kennedy had when steel executives jacked him around or that even Angela Merkel had when nuclear energy firms did the same to her. Would Obama ever utter words about the insurance companies like Kennedy used in 1962: "The facts of the matter are that there is no justification for an increase in steel prices"? I certainly can't imagine it. Much less his reported private remark, "My father always told me that all businessmen were sons of bitches, but I never believed it until now."
Charlie Pierce has, as usual, stated this more imaginatively and colorfully than I could manage (There is Gambling Going On Here Esquire Politics Blog 11/04/2013):
There always has been a kind of tacit agreement within the elite media concerning the Affordable Care Act not to mention the fact that the whole gimcracked structure depends vitally on the health-insurance companies not behaving like the greedy bastards they always have been. There is talk about Democratic sellouts and Republican intransigence, and who's up and who's down but the fac[t] remains that the president needed the involvement of the health-insurance industry to get the thing passed, and that the latter was grumblingly willing to go along because a) they'd get more customers, and b) because they believed that the PPACA would turn off the general enthusiasm for a more aggressive government-insurance solution on the order of the late, lamented public option or the glorious liberal pipedream of Medicare-for-all. The mistake came when people started to believe that these two elements would be motivation enough for the health-insurance industry not to behave the way it always has behaved. Even now, with Glitchghazigate, and the Oh-noes-Obummer-lied scandalpaloooza, still running wild, the health-insurance companies are maneuvering the way they always have. Leaving corporate profits at the heart of the system was always going to be a problem. Now it is. It would be nice if so many people who are doing their end-zone dances now -- many of them at the five-yard line -- would acknowledge it. [my emphasis]Getting back to Ezra Klein's piece, I notice that one of his arguments for his central point doesn't really make sense even on its own terms, something unusual for him.
The saga of healthcare.gov has been a symphony of government inefficiency. The effort, directly overseen by the IT department of the Centers for Medicare and Medicaid Services, involved no fewer than 55 contractors. The process was thick with lawyers and political interference. In violation of current best practices in the software world, the code was kept almost entirely secret; other engineers weren't able to point out its flaws, and it wasn't tested rigorously enough. The Obama administration has been assailed for not calling in Silicon Valley’s top minds to collaborate, but that misses the fundamental problem: The best coders in the Valley would've never agreed to work under such deadening, unpleasant conditions.The Guardian editorial isn't linked, but it seems to be NHS database: Digital disaster 08/03/2011:
The flawed product poses real dangers to the law's success. The front-end shopping experience — which is what people mean by "the website" — is busted, but there are also persistent errors in the systems that authenticate users, determine eligibility for subsidies or for Medicaid, and hand off purchase information to insurers. Obamacare’s coverage expansion sits atop a complex digital infrastructure, and that infrastructure is failing.
For all its deficiencies, healthcare.gov isn't the worst disaster a government has experienced on a major IT project. That distinction belongs to the U.K.'s endeavor to create an electronic medical records system for its National Health Service. The effort, which began in 2002, tore through about $10 billion before the government admitted it simply couldn't be salvaged. In an editorial at the time, the liberal Guardian newspaper declared, "The government is an inept purchaser of private services: indecisive, ponderous, overambitious, and wasteful. Mass centralisation does not reduce costs, but it kills flexibility."
“NHS just got tremendously burned by the rollout of electronic health record systems,” says Fred Trotter, the founder of health-care software developer Not Only Development and the co-author of Hacking Healthcare. "It's probably the biggest catastrophe before healthcare.gov. They also had a big-bang, all-at-once, one-big-vendor strategy. That did not work."
There are lessons in the report for all policymakers. As the failure of the NHS private finance scheme has also shown, the government is an inept purchaser of private services: indecisive, ponderous, overambitious and wasteful. Mass centralisation does not reduce costs, but it kills flexibility. Under the national scheme, NHS professionals were given expensive systems with little discussion of what would actually help them do their jobs. The project was carried along by the momentum of its scale and the sense that having spent so much it would be wrong to pull out (pressures that have also wrecked the defence budget, as a report from the defence select committee reminded people on Wednesday).Both the Guardian editorial and Ezra in his use of it seem to be saying that Government in the abstract is a poor customer for "private services," although that could also be read to mean that relying too much on private services purchased was a key problem.
Most of all, though, the PAC report challenges the current government. The problem began under Labour but it has continued under the coalition. The committee suggests that £4.3bn might be better spent elsewhere and that perhaps the programme should be scrapped. It also warns that the planned NHS reorganisation will only make things worse, since it proposes abolishing the organisations currently managing the programme. Past failure, current failure and future failure: a warning for all governments that big ambitions and bigger budgets do not automatically deliver big success.
And I'm puzzled by the comment, "Mass centralisation does not reduce costs, but it kills flexibility." That's the kind of careless generalization that too often gets tossed around. Corporate mergers are typically justified on the assumption that some kinds of centralization are indeed able to reduce costs. The fact that many mergers don't live up to their cost-savings hype does not in itself mean that economies of scale aren't to be had in mergers. It does suggest, though, that whether or not centralization saves costs isn't a particular function of whether its a government or a private business doing the centralizing. It depends on what you're centralizing and why and how well it's managed.
But then Ezra proceeds to make what sure looks like to me the opposite point:
The British learned from their mistakes. The disaster empowered Francis Maude, the minister for the cabinet office, to bring in technologist Mike Bracken to overhaul how the British government did IT. Today, gov.uk is something of a wonder. It's a single, centralized portal to pretty much everything the British government might be able to do for you. It/s designed for users. It's nominated for awards. With the deep admiration of Silicon Valley boosters, Bracken is working to change everything about the way the British government builds technology. His keynote speech at the October Code for America conference received a standing ovation.So, Government in general is "indecisive, ponderous, overambitious, and wasteful," at least on tech projects. Except that the British government now has set up a "centralized portal to pretty much everything the British government might be able to do for you" that "is something of a wonder."
I'm now officially confused.
Yes, tech is hard. Having had experience as a financial manager with large tech efforts in various contexts both public and private, I'm at a loss to identify what Ezra is trying to say here. Both the business managers and the tech staff need to manage projects responsibly. And sometimes large projects prove unworkable, or have portions of the coding that need to be discarded, business priorities change, competition goes in a different direction that requires a different response, and so on.
It's easy to guess that the overall project management was deficient in monitoring the program in some way. But based on what I've seen so far, including in Ezra's article, I'm not at all clear on two very basic things: (1) How systematic and serious have the problems been on this thing really? Are we talking mainly about capacity issues or about bad information? What portion of the users are encountering the most serious problems? How does this compare to similar web rollouts? (2) Were the flaws the result of faulty design? Insufficiently analyzed business requirements? Or failures in prioritizing the particular features to be available on Day 1?
Ezra does say "it wasn't tested rigorously enough," and that's entirely believable. Skimping on the UAT (user acceptance testing) is always a risky thing to do. But his analysis doesn't even tell us why that occurred. Typically, UAT is shortened because other phases of the project aren't running on type. But managing that is also a key part of project management.
Even the fact that 55 contractors were involved doesn't in itself tell us anything. The federal government is big and the ACA involves a lot of factors. Was 55 the right number? Was it too many? Too few?
I suppose you could say it's easy to nitpick. But these factors aren't "nits" when you're talking about evaluating a major system rollout.
Even Ezra's opening premise is odd:
In the 2008 election, President Obama’s advisers talked of their boss’s belief that it was time for an "iPod government." Obama, a technology addict who tools around on his iPad before going to sleep and who fought the U.S. Secret Service bureaucracy for the right to carry a smartphone, would be the first president truly at home in the Digital Age. That put him, he thought, in a unique position to pull the federal government into the Digital Age, too. His administration wouldn't just be competent. It would be modern. And it would restore America's faith that the public sector could do big things well.I wonder if pollsters were to ask voters what role hoping for "iPod government" had in their votes for Obama, there would be an awful lot of "huh?" responses. Even for a news junkie like me, I didn't remember seeing that particular phrase before this article.
And was it really a prominent goal of this Administration to "restore America's faith that the public sector could do big things well"? It seems to me that the Obama Presidency has focused more on the promotion of austerity economics and the supposed limits of doing "big things."
He also says early on in the piece, "Obamacare was supposed to be the model for a 21st century social program, not a replica of programs built in the 20th." But int he very next paragraph, he introduces an odd quote from former Obama economic campaign advisor Austan Goolsbee, "This plays into the suspicion that resides in really all Americans that, outside of narrow functions they can see and appreciate like Social Security and national parks, the government just can't get it done." If what people have faith in the 20th-century programs like Social Security and national parks, maybe not everything that is new is better.
But our journalism is littered with quotations like that which don't make much sense when you think about them for a minute. For one thing, Medicare and Medicaid are also very popular and well-run programs that are highly effective within their scope of operation.
And after over a decade of idolatry and adulation directed at the US military - despite their lack of ability to win anything that looked like clear-cut victories in Iraq and Afghanistan - can we really say that Social Security and national parks are the only thing people in America have faith that government can do well?
Ezra ends his piece with this question that could have been a punch line in a Republican politician's speech, "We live in an age when machines can learn. Can government?"
The thing about writing on government competence is that the Republican Party since half past forever has been griping about the alleged lack of competence in government. You know, the unholy trinity of "waste, fraud and mismanagement"? There's an old saying that I believe I first heard from John Kenneth Galbraith that Republicans campaign complaining that government doesn't work well, and then they get elected and set about proving it. So any serious reporting on government competence, aka, one substantial enough that Megan McArdle wouldn't be quoting it in approval, needs to be clear about the actual problems and dispense with throwaway Republican talking points like, "We live in an age when machines can learn. Can government?"
Tags: obamacare
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