I’ve been following the stories about healthcare.gov. The managerial aspect of the discussion has focused on what was wrong with the site when it went live on Oct. 1 and what caused these problems. The political aspect has dwelt on the question of oversight, who at the political level should have been monitoring the development of the site before October 1, and whether these who were asleep at the switch merit dismissal.
I’m reading these stories through the lens of my own experiences as a board member for the Ontario Transportation Capital Corporation (OTCC), which was responsible for putting in place a major IT project, the electronic tolling system for Ontario’s Highway 407. At the time of its creation in the mid-Nineties Highway 407 was the world’s most advanced electronic toll road, intended to seamlessly integrate recognition of vehicles with transponders with videoimaging of the license plates of vehicles without them.
As the system was being built, there were numerous software glitches, especially at the back end, which involved matching trip records with license plate data and sending bills for the use of the highway. In the months leading up to the highway’s planned opening date of March 31, 1997 the OTCC’s professional staff as well as the deputy minister of transportation (the permanent head of the department) were monitoring the situation daily and were in frequent contact with the project’s four contractors. OTCC was also making contingency plans in the event the tolling technology could not be made to work as intended. The highway itself opened in June 1997 because it was impossible to keep people off the completed roadway. The tolling system software was not ready, however, so Highway 407 became a freeway until the tolling system became operational the following October.
The period from June to October was acutely embarrassing for OTCC and the government because it was obvious to the capital market and to the general public that they were not delivering an operational toll road. Running it as a freeway, however, had the marketing benefit of introducing drivers to the road. In addition, it allowed the software developers unobtrusively to test the system by videoimaging and producing dummy bills for the owners of a far higher volume of license plates than would be the case when Highway 407 became a toll road. This also meant intentionally installing excess computer capacity. These circumstances were far more favorable than those faced by the healthcare.gov team. The Highway 407 experience nevertheless has some implications for the health care website.
The stories that have been published about healthcare.gov cite a number of similar managerial challenges that were handled inadequately. These include the selection of providers for different parts of the system (CGI Federal, the US subsidiary of Montreal-based CGI; Quality Software Services Inc., Oracle) whose products were, if not incompatible, then certainly difficult to interface; the decision by the Center for Medicare and Medicaid Services (part of the Department of Health and Human Services) not to hire a systems integrator; lack of testing, particularly at the back end of the site; and the lack of computer capacity for the system. These were all managerial failings, rather than the result of a project of intrinsically unmanageable complexity. As President Obama said in a meeting at the White House on Oct. 15 (reported by Stolberg and Shear in their comprehensive background analysis published in the New York Times on Nov. 30), “we created this problem we didn’t need to create.”
Managerial problems are ultimately leadership problems, or, put differently, problems created by the lack of leadership. While the political leadership, including President Obama and HHS Secretary Sebelius, were furious after Oct. 1 at the managerial problems, I think it is important to ask what the political leadership was doing before Oct. 1 to prevent these problems from occurring. It seems that the answer is very little.
When President Obama and his advisers woke up the morning after his re-election on Nov. 5, 2012, they should have begun thinking about what would be necessary to make his second term a success. Very high on that list should have been the smooth implementation of the Affordable Care Act, which required a smooth rollout of healthcare.gov. Someone at the political level, for example HHS Secretary Sebelius or the president’s chief technology officer Todd Park, should have been monitoring the development of the website on a day-to-day basis, making sure the necessary leadership (a systems integrator) was provided and sufficient resources (computer capacity) were put in place.
Secretary Sebelius has now asked her department’s Inspector General to review the development of healthcare.gov. He will likely identify the sins of commission at the technical level. He is far less likely to identify the sins of omission at the political level. But I am quite certain that had the sins of omission not occurred, the sins of commission could have been rectified before October 1.
The Republicans are calling for Ms. Sebelius’s resignation. In a parliamentary democracy it would be expected that a minister would monitor her department’s key initiative and be held accountable to parliament for a failure to deliver it. But the US is not a parliamentary democracy, in which a prime minister can readily appoint a new minister from his party’s caucus. Even if the Senate has recently changed its rules to prevent filibusters in confirmation hearings for presidential appointments, the Republicans would use the confirmation hearings for Ms. Sebelius’s successor as an opportunity for blaming and shaming. Regardless of her responsibility for sins of omission, it is unlikely that President Obama will fire her.
This sorry episode speaks to an ongoing failing of political leadership in the age of Government 2.0. Many politicians, President Obama included, are now IT-savvy when it comes to using a personal device (remember the presidential BlackBerry) and participating in social media. They are far less savvy about understanding IT’s back room and making sure that the mundane electronic plumbing that supports bold new initiatives like healthcare.gov works effectively. This political failure on the part of President Obama, his advisers, his cabinet secretary, and his cabinet secretary’s senior politically-appointed staff has damaged the implementation of President Obama’s intended legacy initiative.
The fact that the site is now working well makes clear that the problems experienced before October 1 were not insuperable. But the ongoing and critical legacy of these problems may be lower than hoped-for enrolment in health care plans by the IT-savvy young adults who are essential to the overall success of the Affordable Care Act.
I’ll conclude with a story told to me by former Saskatchewan Premier Allan Blakeney. Soon after the social democratic CCF party was first elected in 1944, it passed legislation to create a universal hospital insurance plan, the first of its kind in North America. Premier Tommy Douglas wanted the plan in operation on January 1, 1947, so that it would be working reasonably well before the 1948 election. The implementation team, feeling they could not achieve the deadline, met with Premier Douglas. Premier Douglas thanked them for their efforts, told them he enjoyed working with them, and regretted that he would be losing them. The team got the message, redoubled their efforts, and met the deadline.
If President Obama and his political appointees had had equally frank, if not brutal, discussions with the healthcare.gov team well in advance of October 1, 2013, perhaps its implementation would have been less troubled.