The news will be full for a while with stories about the ongoing Obamacare Exchange fiasco. Blame will be spread on all the usual suspects. It's more nonsense. This is classic hubris. The nature of the problem and the nature of the hubris is clear if you compare the Obamacare exchanges with the Romneycare exchange launch in Massachusetts. The Massachusetts launch was traumatic, full of problems, and took a couple years to fully stabilize. The current Obamacare problems are only the tip of the iceberg that is being hit.
First, and importantly, the basic underlying problem for Obamacare is larger.
- Massachusetts had 7% uninsured, which translates to about 500,000 people. Massachusetts also took significant steps to reduce the number that would use the computerized insurance exchanges to 200,000.
- The US has 40-50 million uninsured, and no steps were taken to reduce the number that would need to use the exchanges.
Then the hubris starts. Massachusetts took steps to reduce the burden on the exchanges.
- MA decided to automatically enroll everyone who was already qualified for public assistance. These were generally uninsured because of mental illness, incompetence, drug addiction, homelessness, etc. For various reasons they would not do the paperwork to become insured under public assistance. MA just automatically enrolled them on their next medical visit. This reduced the number that would need to use the insurance exchanges to 200,000. So MA had a problem that was only 0.5% the size of the Obamacare problem. There are real differences between a system to handle a load of 200,000 and a system to handle a load of 40,000,000.
- MA went live 9 months before the deadline. This allowed lots of time to fix problems, and there were many problems to fix. Going from zero to 200,000 users in 9 months is hard. Going from zero to 40,000,000 in three months is absurd.
- MA invested in massive educational efforts during those 9 months. You couldn't escape the information efforts that were all over the local media.
The US did none of those. They decided to go from zero to 40,000,000 users in three months. They ignored all the experiences earlier efforts and ignored the problem reports from their test runs. They refused to delay the deadline. That's hubris.
Then there are design decision differences:
- MA paid attention to the experience of web commerce sites. They made the exchange sites open to everyone. There was no attempt to establish identities or qualify purchasers until after the shopping cart was full and a purchase decision had been made. This enabled use of off the shelf web commerce tools.
- MA decided to use audit control rather than access control. They simply accepted all the claims about income and qualifications made by purchasers. This came with some really big warnings about lies. Any lies were going to be processed as income tax fraud and hit with heavy criminal prosecution. Everyone was warned that purchasers' income tax returns would be compared with the insurance applications, and the tax auditors would go after any lies that they found.
These decisions made the site design immensely simpler. It was pretty much the same as any other web commerce site. The entire public could look around, which did increase the computer load, but it also made it easy for people to get help using the site. There was no need to reveal any personal information until the final purchase step. The use of audit control meant that you could go all the way to the final confirmation with fake information and then cancel. This makes it easy to learn, explain, and explore.
The US did none of these. They decided to do an intrusive identification process before allowing access. They decided to use access control, which greatly increases the web site complexity. These increased the overall problem difficulty by a factor of ten, and ensured that ordinary off the shelf web commerce tools could not be used. That's hubris.
Hubris is common. The word originates with ancient Greek. It's easy to find in any time and any place. It's not unique to the Obamacare exchanges. It's found in ridiculous two month deadlines for developing healthcare standards. It's found in many government procurements. It's found in absurd corporate project plans. It's not universal, but it is commonplace.
The future iceberg is the problems that are about to hit the rest of the system. MA had huge problems with processing all the new people entering the insurance system. MA had huge problems with providing service to people who now had insurance and expected healthcare services. The overloaded doctors and clinics became even more overloaded. It took a couple years before most people had switched from using emergency departments to using a personal physician. There are still ripple effects. And MA was dealing with a much smaller problem.