History of the Federal Health Marketplace Site
The federal website HealthCare.gov launched on July 1, 2010, a few months after President Barack Obama signed the Patient Protection and Affordable Care Act (PPACA) into law. In its early years, the site served as a resource for all things healthcare, including preventive healthcare education, how to find an insurance plan in your area, definitions of terms introduced by health reform, and other information on the law, coverage and staying healthy.
The site was met with positive reviews, as its simple, functional interface helped connect people with insurance eligibility information after a few questions about location, employment status, and health.
At the time of its launch, HealthCare.gov directed visitors to enroll in the Pre-Existing Condition Insurance Plan (PCIP) if health issues prevented them from obtaining traditional coverage. Medicaid and Medicare information was also available, directing eligible individuals to respective government sites to obtain application and program details.
Providing visitors with resources on how to improve personal health, understanding the health law and it’s impact on insurance and medical care, and the importance of quality in health services, the site became a straightforward, user-friendly go-to for health reform information and more. Todd Park, Chief Technology Office of the site noted that HealthCare.gov presents “both public and private health insurance options across the nation in a single place,” upon its 2010 debut.
HHS Secretary Kathleen Sebelius wrote that the site “provides unprecedented transparency into the health care marketplace” and “will help take some of the mystery out of shopping for health insurance,” in a White House blog when the site launched.
When the site launched, it held about 500 pages of content. It had quite a bit of data on the private health insurance market, including plan and eligibility details for over 1,000 insurance companies, product information for 5,561 available policies including 2,030 individual health products and 3,531 small group plans.
The site also emerged as a comprehensive source of Medicaid and CHIP information, providing details on these public programs in each state.
Navigating the site between 2010 and early 2013, you could also find information on PCIP plans in each state. A key feature was the coverage finder tool that automatically sorted through a catalog of private and public insurance plans.
Many of these features remain today, though PCIP has closed, the site no longer suggests off-exchange health plans to individuals or small businesses, and is primarily the portal for the health insurance exchanges.
Reviews were good, yet also constructive. Kate Pickert of Time said the “site is amazingly easily to navigate”. The Tech President’s Nancy Scola remarked that the site was lacking in some areas even within the first week of its launch. “A key piece of information is, at this point, missing. HealthCare.gov is slated to have pricing information on each plan option by October of this fall, but it’s not there yet,” Scola wrote in July 2010. At times, the site also directed users to an unfruitful end result to their insurance quest: a page instructing visitors to contact their state insurance department for details, with no contact information.
The Washington Post’s Ezra Klein noted that building the site to compare health insurance options in 2010 was “a bit odd”, but that “the obvious advantage of starting the site this early is that there’s a lot of time for the tech team to play with it, improve it, and get comfortable with it before 2014, when it really needs to be working.”
HealthCare.gov and the Exchanges
Ultimately, the site would serve as a portal for the health insurance marketplace created by the ACA, but for the first three years acted as an informative tool and introduction to the health law. According to the health law’s initial plans and deadlines, the health insurance plans often dubbed Obamacare would be available for sale nationwide on October 1, 2013, some of which would be sold through HealthCare.gov.
When the law was penned, its authors had hoped the majority of states would elect to operate their own exchanges, creating localized markets under the law with the needs of residents in mind.
The ACA gave each state the ability to choose from three options when setting up the marketplace:
- Accept federal funding for a state-run exchange, organized by state officials and insurers on a local level.
- Enter a partnership exchange with the federal government, in which states split responsibilities with federal departments.
- Default the entire state’s health insurance marketplace to be run by the federal government.
By the time states had to make a decision on how to proceed, the majority chose either partnership or federal, leaving a large amount of responsibility to the unprepared Centers for Medicare and Medicaid Services and the U.S. Department of Health and Human Services. A total of 36 states left control of their marketplaces up to federal powers, while 14 states and the District of Columbia chose to set up their own exchanges before the October 1, 2013 deadline to begin enrollment.
As states had until mid-2013 to decide on their approach to the exchanges, the government did not provide itself ample prep time for the first year of open enrollment. Like other aspects of health reform, deadlines were delayed, leaving too small a window for HealthCare.gov to undergo the major transformation it needed.
Becoming the Marketplace
HealthCare.gov represented the implementation of health reform in a sense, as the insurance marketplace was by far the most significant, tangible change introduced by the law.
The task of transforming the introductory site into the Amazon.com of Obamacare health insurance, capable of supporting millions of shoppers and their personal data, was outsourced to multiple contractors, including CGI Federal, a subsidiary of Canada-based CGI Group, for back-end services, and Development Seed, a small firm in D.C., for front-end work.
Additional contractors were hired for security systems, such as Experian for digital identity authentication and Quality Software Services, Inc. (QSSI), a UnitedHealth Group company. According to the GAO, a total of 55 contractors were hired to help build the marketplace.
Obamacare’s Garage Band
Development Seed started working on the site in March 2013, mainly the home page, over the course of four months until the large contractors stepped in. Sarah Kliff of the Washington Post wrote that it may be surprising for many to discover who built the landing page of HealthCare.gov. “Their offices are in a garage, and they wanted to use the site to buy themselves health insurance in 2014,” Kliff wrote.
This grassroots approach to the site correlates with the health reform and recession recovery initiatives to support small, local businesses, and proved successful. The updated face of HealthCare.gov and its elements created by this company have been running smoothly since June 2013.
The firm used Jekyll, a Ruby-based open-source software project that originated at GitHub in 2008 designed to generate static websites. To promote ease of use when publishing content to Jekyll on GitHub, Development Seed created Prose.io, a web-based content editor. Pairing Jekyll and Prose.io “enable building simple, flexible, and reliable sites without the overhead of dynamic CMSs,” said Eric Gunderson of Development Seed.
The agency’s work has been commended for using smart underlying technology, a clean responsive design, a developer-friendly API and an open source project. The firm has since removed the HealthCare.gov code from public view on GitHub.
Enter CGI Federal
After Development Seed created the front end of the health insurance marketplace, they sent their files to CGI Federal, who then took over. The two teams were completely separate and thus responsible for two very different parts of the site. Different technology was used to construct each of their contributions, and therefore links to front end versus back end elements send you to sites that basically speak different languages.
CGI Federal was chosen to work on HealthCare.gov as they were one of 16 companies awarded a $4 billion “indefinite delivery, indefinite quantity” contract to upgrade the systems for Medicare and Medicaid in 2007. The company received a total of $678 million for various services under a Government-Wide Acquisition Contract, which included the $93.7 million provided for building HealthCare.gov, according to USASpending.gov.
CGI Federal wasn’t given the marketplace contract until late 2011, and their work didn’t begin until June 2013, a mere 3 months before the site’s launch. CGI, which stands for Conseillers en Gestion et Informatique, loosely translated into English as management consulting and IT, was the primary contractor for HealthCare.gov.
Their contribution included building sites for states with federally-facilitated exchanges, ensuring the federal data hub created by QSSI, the user interface made by Development Seed, and Oracle’s identity management software work together flawlessly, and otherwise the glue for the HealthCare.gov’s various pieces.
Opening Day: October 1, 2013
The federal marketplace for guarantee issue health insurance opened for business on the initially projected date of October 1, 2013. Despite warnings from insurers, state officials and other insiders, the Obama administration decided to move forward, instructing millions of Americans to sign up for coverage on that date.
Avoiding the warning messages backfired, as so few people were able to buy coverage or even fill out an application past the overwhelming amount of glitches that the White House didn’t release sign up data until six weeks after open enrollment began.
The government shut down for 16 days immediately after open enrollment began, supposedly on the grounds of party dispute over the exchanges and the ACA. The site was so flooded with traffic, it “collapsed”, and most visitors had trouble getting past the first step of creating a user login.
The New York Times said of the site, “thanks to HealthCare.gov, [Americans] know what a ‘virtual waiting room’ looks like,” in an article entitled “Why the Government Never Gets Tech Right”. The media exploded in subsequent months, tracking the progress of the site and making the word “glitch” more popular than ever.
The sites numerous flaws since day one included getting stuck on the same page, not getting past a certain stage such as answering security questions or being asked continually if you wanted to add another family member to your coverage, and of course, most people couldn’t even get that far and simply saw “The System is down at the moment”. It was a monumentally upsetting time for Obamacare.
Glitches and Repairs
President Obama publicly apologized for the broken website, a historical first, like many other moves during his tenure. He is also the first president to create a website under a federal law, which gives HealthCare.gov an important place in history.
But according to research from the Standish Group, about 94 percent of major federal IT projects between 2003-2013 had not gone smoothly, either, so the marketplace project was not alone in its glitchiness, just more widely discussed than previous .gov flops.
HealthCare.gov also holds more significance to the people, as the website represents the health reform law created by a transformational leader promising hope, progress and affordable health insurance for everyone.
HHS Secretary Sebelius had to testify before the Senate Finance Committee about the site’s malfunctions. CGI Federal, QSSI, Equifax and Serco were also questioned at the House Energy and Commerce Committee’s “PPACA Implementation: Didn’t Know or Didn’t Disclose?” hearing.
Each party blamed for the errors pointed the finger elsewhere, but most agreed on one major fault: a lack of time and funding, the latter of which could be disputed after billions were spent on this site. Regardless, after input from various information technology professionals, it was evident the site was constructed poorly, making it difficult to use — and difficult to repair in time for coverage to begin on January 1, 2014.
Construction to repair the errors began shortly after the site went down, as hundreds of thousands of visitors continued attempting to use the site. The swell of traffic died slightly after the news of glitches bombarded consumers, but by early November, after more than a month of low enrollment successes, a major repair effort went into effect.
The site’s errors led to a mere 27,000 purchased health plans, 106,185 enrollments with plan selection that had yet to pay, and 846,184 completed applications across 36 federally-run exchanges in the first month of going live. The reconciliation project was headed by Jeffrey Zients, U.S. Chief Performance Officer in Obama’s first term, and didn’t involve any of the former contractors.
With a few years of residency on the web, Healthcare.gov has had fewer catastrophic, newsworthy glitches. However, the website remains a comedy in which delays, system updates and outages are now just part of the Marketplace “experience”.