
S.F. programmers build alternative to HealthCare.gov [video] - r721
http://www.cbsnews.com/8301-18563_162-57611592/s.f-programmers-build-alternative-to-healthcare.gov/
======
_pius
This looks great, but haven't the big, embarrassing problems been with scaling
the back end? Even if this were a superior UI and flow, it wouldn't address
the issues that made the news.

~~~
hga
Perhaps, and no.

E.g. the front end registration problem is due to a late requirements change
in August that had the effect of preventing window shopping, plus we know
there were changes ordered _though the week before launch_ , and no
integration testing until 1-2 weeks before launch, and that discovered it
locked up if 200 simultaneous login attempts were made or if it had ~1,100
users on it.

So, yeah, those are scaling problems, but not ones we can necessairly blame
the techies for, given that they didn't have enough time, and couldn't do
integration testing (the government's CMS _was_ the integrator and integration
tester, now replaced by QSSI, the ones who did the "data hub"? I think it's
called, which is supposed to be not so bad).

But also no, in that the fix-it czar's #1 declared priority is to fix the
garbage 834 EDI transactions that are being sent to insurers. That includes
incorrect data and incorrect transactions (e.g. multiple enrollments and
cancellations for the same person). Based on that, the front end's problems
have been a blessing in disguise, because the insurers are only getting a few
hundred enrollees a week and that low volume allows the insurers to call each
up and straighten out problems.

An estimated 16 million policies in the individual market, and an unknown
number in Obamacare's interim high risk pool must sign up for new policies by
December 15th or so or they'll suffer a lapse in coverage, which for many of
the latter will be fatal. The _only_ way to get subsidies is through the
Federal system, i.e. the state exchanges use it for that (maybe with
inaccuracies, but it's evidently working for the state exchanges that are
working, but don't judge that for any given state exchange until you find out
which are getting Obamacare and the much larger numbers reported to be signing
up for Medicaid), and that makes sense to avoid fraud, since it results in
direct payments from the Federal fisc.

~~~
jorgem
>> An estimated 16 million policies in the individual market

What percentage of people with individual plans (who need to get new plans)
would actually qualify for subsidies? I don't, so I have more options: (1) I
can buy another individual plan from my insurer (2) I can shop other insurers
or (3) I can buy from california exchange

In none of those scenarios do I actually care whether healthcare.gov is
working. I suspect I am not alone.

~~~
tanzam75
> _What percentage of people with individual plans (who need to get new plans)
> would actually qualify for subsidies? I don 't, so I have more options: (1)
> I can buy another individual plan from my insurer (2) I can shop other
> insurers or (3) I can buy from california exchange_

I don't understand why you're required to use the exchange to get the
subsidies, anyway. Why not let people claim the subsidy directly through an
insurer? Then turn healthcare.gov into a static site that simply displays the
options and redirects to an insurer's web site.

After all, the subsidies are only an estimate. The actual amount is only
calculated on the 1040 tax return. So why should this be any different from
tax withholding?

We don't make everyone pay estimated taxes through a centralized site. We let
employers withhold an estimated amount, and then the IRS balances the accounts
annually, in a batch process.

~~~
hga
Well, as I understand it the subsidies result in direct draws on the Federal
fisc by the insurers, and the latter can't afford to wait till the next
calendar year to get paid. And there's certainly a desire to avoid fraud given
that schedule of payments, if I'm correct about it.

Erk: if you're right about estimates and it depending on that years tax
return; what do you do if you lose your job and can't afford to pay the
unsubsidized rate? What if you earn a lot more money, spend too much of it,
and then get hit with a huge bill next April 15th?

I'm disabled and on Medicare so I haven't been looking into these fine details
... this all sounds unworkable to me at first glance, unless it's
retrospective based on ... the last year's tax return, but, erk, can't do that
either since that don't be doable before the mid-December deadline necessary
to get you into a insurer's system.

WTF???

ADDED: this probably explains why the Federal system has to do this, access to
IRS payments data (e.g. withholding) is required, it's sensitive data and only
they have all of it. Although Experian has a income verification role (people
without credit, like sick young adults who can't leave the nest are at last
count thoroughly screwed because the Federal site isn't handling this manual
intervention well or at all), but I assume that's a double check. Maybe not?
Maybe they couldn't get that info out of the IRS's generally high latency
(often weeks and months, sometimes years) computer systems?

~~~
tanzam75
> _And there 's certainly a desire to avoid fraud given that schedule of
> payments, if I'm correct about it._

But why is it any different than the desire to avoid fraud through
underwithholding of income tax?

If someone files an in incorrect W-4 and underwithholds by $2000, then the
Treasury is out $2000. If someone files a fraudulent insurance application and
gets $2000 of unwarranted subsidy, then the Treasury is also out by $2000.

It's the same $2000, whether the Treasury writes some checks to the insurance
company, or fails to collect it from an individual on his paychecks. Either
way, the $2000 gets paid back on the tax return -- or the IRS goes after you.

> _Erk: if you 're right about estimates and it depending on that years tax
> return; what do you do if you lose your job and can't afford to pay the
> unsubsidized rate? What if you earn a lot more money, spend too much of it,
> and then get hit with a huge bill next April 15th?_

Again, not different in principle from income tax withholding. If you do not
withhold the right amount, then you may get hit with a big bill or receive a
big refund when you file your 1040.

The main difference is that the subsidy does not automatically adjust.
Withholding tends to automatically go up and down with income, because it's
calculated by the employer on the paycheck. Whereas the insurance subsidy
stays constant _unless you make changes_.

If you lose your job, you're supposed to tell the exchange so that you can get
a bigger subsidy. If your income goes up, you're supposed to tell the exchange
so that you can get a smaller subsidy.

~~~
hga
The big difference in the first point is who collectible the debt is. Someone
who underwithholds has to have that money in the first place to do so. Sure,
they may have spent it, but it suggests an ability to earn money commemorate
with the debt incurred.

With insurance subsidies, scamming "insurance" companies can sign up
nonexistant people etc. and collect those payments from the Treasury until
someone catches on months or years down the road. Hence the need to reconcile
everything in one central system.

In the case of individuals committing fraud, many would do so simply because
they can't pay the higher premiums now demanded of their subgroup (there's a
lot of cost shifting), so you have more of a "can't get blood out of a stone",
and the optics for the IRS are _horrible_.

For your latter point, you're saying you make a 2013 enrollment based on
partial 2012 data, and if you've got your act together you adjust with
healthcare.gov or the linked state site as things change. Which I'm familiar
with, the quarterly payments for those who don't withhold ... but I bet
this'll hit a lot of people who aren't used to this sort of thing, but the
automatic withholding of income that HR/ADT/whomever does for your
paycheck....

~~~
tanzam75
> _Someone who underwithholds has to have that money in the first place to do
> so. Sure, they may have spent it, but it suggests an ability to earn money
> commemorate with the debt incurred. ... With insurance subsidies, scamming
> "insurance" companies can sign up nonexistant people etc. _

If you claim an undeserved subsidy, then that means you earn too much for the
subsidy. Which means you earn enough to pay for healthcare. You may want to
spend it on something else, like your mortgage. But then we're back to the
underwithholding situation.

The Social Security Number prevents subsidies from being claimed for
nonexistent people. It's like the "phantom dependents" problem on income tax
returns. When the IRS began requiring an SSN to be provided for each
dependent, the problem went away.

I'm not convinced that fraud would actually be a major problem. It's not like
you get the whole year's subsidy at once. You get it a month at a time.
Instead of running the income-check interactively, run it as a batch process
after the first month of coverage. Then investigate the most egregious cases
-- either individual or insurance company fraud.

If an insurance company is committing fraud, take it out of next month's
subsidy payments. Remember -- we're already trusting these insurance companies
to provide a whole year's worth of coverage, until the next open-enrollment
period. They're around to be accountable.

~~~
hga
" _If you claim an undeserved subsidy, then that means you earn too much for
the subsidy. Which means you earn enough to pay for healthcare. You may want
to spend it on something else, like your mortgage._ "

Your last sentence indicates you know the truth about the statement your
penultimate sentence makes. Which might be better stated as "Which means you
earn enough to pay for healthcare _according to this dog 's breakfast known as
the Affordable Care Act_", which following our version of Newspeak for the
naming of political bills tells us it's unlikely to be always, or maybe
generally affordable.

" _The Social Security Number prevents subsidies from being claimed for
nonexistent people._ "

Good point. Change "nonexistent" to "real people under 65 not in the system"
(the SSA knows the age). Like illegal aliens using other's SSN numbers, a
scammer "insurance" company could just harvest numbers and other ID
information for people who aren't buying insurance through Obamacare (hard to
say, but a selection of young ones should be fairly safe) and those covered by
employer plans, unless and until those people are reported to HHS.

" _[Insurance companies will be] around to be accountable._ "

I'm postulating the creation of new, entirely or partly fraudulent ones (e.g.
Obamacare subsidizes the creation of co-ops), or the subversion of existing
ones. If there's "free money" to be had, it's likely stupid people will try to
grab some, no matter how likely or certain it is they'll get caught.

~~~
tanzam75
> _Your last sentence indicates you know the truth about the statement your
> penultimate sentence makes. Which might be better stated as "Which means you
> earn enough to pay for healthcare according to this dog's breakfast known as
> the Affordable Care Act", which following our version of Newspeak for the
> naming of political bills tells us it's unlikely to be always, or maybe
> generally affordable._

You cut off my actual last sentence in the paragraph, which compared it to
underwithholding on income taxes. This is what I keep bringing up, and you
keep ignoring. This is _not so different from income taxes_.

Someone who earns 400% of poverty level owes $5000 in federal income tax, plus
maybe another $5000 in local property tax and possibly state income tax. They
might want to pay that $10000+ towards their mortgage, rather than to the
government.

Since you're clearly very concerned about the financial burdens imposed on
those less fortunate among us, I hope you'll support eliminating all taxes on
those earning 400% or less of poverty level. We can make up for it by taxing
the rich more heavily. What do you say?

Or perhaps we should do the same for health insurance. Single-payer system,
paid for by progressive taxation.

------
meshko
Not even going to click to find out how stupid people are. Did they implement
integration with data streams from hundreds of national insurance companies?
Didn't think so.

~~~
theg2
It is stunning just how much a lack of education and expertise went into this.
This says nothing about HIPA, security, scaling, data source integration. It's
staggering how much misinformation this PR stunt is going to cause.

~~~
otterley
HIPAA is not implicated in the new health insurance marketplace. HIPAA
protects personal medical information, and under the Affordable Care Act, you
cannot be asked any personal health information on any insurance portals
because insurers are required to cover any pre-existing conditions.

~~~
absconditus
HIPAA covers far more than privacy.

------
danso
From the convoluted articles I've read, not only was the main bottleneck in
the identification process, but the issue seemed to be that the authentication
was necessary to just show the plans, because the gov wanted to make sure you
were 25 before showing you a range of prices...was that the case? If so,
whatever happened to letting people just browse the entire table of
prices....remember when people had to look things up and scan tables once in
awhile, instead of living in a Minority Report world where every piece of info
is handcrafted to the user?

I wonder how much of Healthcare.gov's problems could have been eliminated if
the sign up was more modular...users were allowed to browse before signing up
for anything. Then they could sign up via email and tentatively pick a plan.
Then in 3 days, they go through the full authentication process...this is
similar to how Amazon does things...you can sign up without a credit card, you
can browse without signing up, and you don't go through the processing
bottleneck till the very end.

~~~
hga
The contractors were ordered in August to change the system to require up
front registration and submission of "correct" information on penalty of
perjury, no window shopping allowed, nor checking out "what if" scenarios
(e.g. using the Kaiser Foundation's calculator, someone was unable to find
_any_ scenario where being married wasn't more expensive, and of course
subsidies are based on income, and that can be very flexible for a lot of
people).

Since then window shopping has been allowed, but I don't know if the "under
penalty of perjury" bit was dropped.

As to "what happened", I'll just point you at this _Washington Post_ article
and let you come to your own conclusions:
[http://www.washingtonpost.com/politics/challenges-have-
dogge...](http://www.washingtonpost.com/politics/challenges-have-dogged-
obamas-health-plan-
since-2010/2013/11/02/453fba42-426b-11e3-a624-41d661b0bb78_print.html)

Note also the front end traffic jam has avoided sending the insurers more
garbage 834 EDI enrollment and cancellation transactions than they can
manually clean up by contacting enrollees. That's the #1 thing to correct
according to the fix-it czar.

And I do agree with you, an Amazon system, which I'm sure is based on the BASE
eventual consistency back ends, e.g. you don't get your confirmation email
until it decides who "won" the last copy of an item, would have been a lot
better. But then again the contractors were doing a lot less of that sort of
top level design that you'd think (see the Post article).

------
butner
Seriously -- this tool is equivalent to a cardboard cut-out of computer. It is
embarrassing this is getting attention. They're dumping a publicly available
spreadsheet that contains example age-group pricing... i.e. unless you're 27
or 50, it's giving incorrect information.

------
analog31
I just tried it, and it's great. Nice job, on many fronts: Recognizing a
problem, coming up with a simple, uncluttered solution, and making it work.

In my view, a site like this is useful for a lot of purposes beyond actually
signing up for health care. For instance, I've got employer sponsored care,
but I was simply curious about what my costs would be through the exchanges. I
also want to be an informed citizen, and "how much does it really cost" is an
obvious question that anybody might be inclined to ask. In my view, knowing
the magnitude of the numbers should help provide a reference point for
political debate.

~~~
hga
Have you tried this: [http://kff.org/interactive/subsidy-
calculator/](http://kff.org/interactive/subsidy-calculator/) ?

~~~
analog31
Thanks for that! I had assumed that I wouldn't qualify for a subsidy, and
indeed I don't.

As others have mentioned, these sites don't actually solve all of the
problems, but it seems to me that a few free tools that just help people
gather information would take some of the pressure off of the main system. And
if enough of these tools were to crop up, then none of them would have to be
100% reliable.

Simply making people less nervous about signing up will make the official
process work better.

~~~
hga
" _I had assumed that I wouldn 't qualify for a subsidy, and indeed I don't._"

And having learned that, you could now go to individual insurer's sites, or
various ... marketplaces? like
[http://www.ehealthinsurance.com/](http://www.ehealthinsurance.com/) which
I've also tried, shopped around (that site even integrates "is your doctor in
the network", at least for Humana), and gotten yourself covered.

But _everyone_ was told to go to Healthcare.gov, and right now individual
states are doing a lot of marketing for their own sites, some of which aren't
sufficiently functional....

However a _lot_ of people are due and need subsidies, e.g. see this link I
found using Google right after the Kaiser one:
[http://obamacarefacts.com/obamacare-
subsidies.php](http://obamacarefacts.com/obamacare-subsidies.php)

A smaller fraction of the individual market I'd assume, but I also assume a
rather large fraction of the temporary Obamacare high risk pool, many of whom
could die if they suffer a lapse in coverage (I imagine kludges will be
arranged if Healthcare.gov is not _too_ late in becoming a MVP).

~~~
jorgem
>> And having learned that, you could now go to individual insurer's sites, or
varios... marketplaces?

Yes. That is the message that is not getting thru, I think.

~~~
hga
Well, there's the caveat that the Federal site has the last word on whether
you're really due a subsidy.... If you can't afford, or can only afford a new
Obamacare policy, you'd really like to _know_ you aren't due a subsidy, and
how much do you trust random non .gov web sites???

And I think most of us know why that message "is not getting through".

(Totally unrelated side note: damn it, we really should change standard
legitimate English so through -> thru and leave thorough standing "by
itself".)

~~~
tanzam75
> _Well, there 's the caveat that the Federal site has the last word on
> whether you're really due a subsidy...._

It's worse than that.

You are _required to buy through the exchange to get a subsidy_. The way the
law is written, you cannot get a subsidy if you buy insurance off-exchange.

The absolute worst case is someone who earns precisely 400% of federal poverty
level, buys a policy outside the exchange, gets laid off on April 1, and can't
find a job for the rest of the year. Open enrollment is over, and he's stuck
paying full-price even though he only earned 100% of federal poverty level.

This is the absolute worst-case scenario -- but even less dramatic examples
could still benefit from the exchange. Earn 600% of FPL? Are you 100% positive
that you won't get laid off before August? The optionality is worth keeping.

We've only got 7.5 weeks to go before some plans start expiring.
Healthcare.gov had better be 100% operational by then.

> _damn it, we really should change standard legitimate English so through - >
> thru_

Teddy Roosevelt thought so, too. That was 100 years ago. It didn't really
stick, highway signs excepted.

~~~
hga
Ack, I didn't realize that screw case.

And we've got less time; realistically, the insurance companies need finite
time to process enrollments. The official deadline is December 15th, which
I've been modifying to "mid-December" assuming they do a Maximum Effort if the
exchanges are working well enough to give them a lot of valid enrollments.

And of course a lot of people who don't realize this, got to a subsidy
calculator like the Kaiser Foundation's and satisfy their gut feeling they
aren't due one, will bypass the dysfunctional exchanges and just buy on their
own ... then some subset who hit hard times will get screwed.

Blah. Thanks for the good discussion and bringing up yet another screw case.

~~~
tanzam75
Well, it's not quite _that_ bad. Until open enrollment ends, you could always
drop your off-exchange coverage and re-buy on the exchange. So up until March
31, you only lose a pro-rated portion of the subsidy due to you.

That's why I selected April 1 as the worst-case scenario. When open enrollment
ends, the potential lost subsidy jumps from 25% to 100%. You have to wait
until the next open-enrollment period to change plans.

But that having been said: why should anyone give up even $1 of the subsidy
due to him, because of a failure of healthcare.gov? That's why I think the
subsidy should be claimable off-exchange:
[https://news.ycombinator.com/item?id=6702966](https://news.ycombinator.com/item?id=6702966)

Problem is, the requirement to buy on-exchange to get the subsidy is _written
into the law_. That means that it is not changing. The Republicans certainly
won't want to fix any screw-ups in the implementation of Obamacare.

------
ollymorgs
The government contractors should of just built healthcare.gov as a data
service and asked people like these guys to build an intuitive front-end for
it. Then if people don't like the interface, they can do something about it :)
This may also help to dissipate the traffic load and present the same data in
more relevant ways to different types people. The idea of building apps as
single, monolithic system is out-dated.

Even though I'm a Brit, some governments are making moves to modernise and
open up their data for others to play with, over here we've got a great
government-funded team working on exactly that (called the GDS).
([http://digital.cabinetoffice.gov.uk/](http://digital.cabinetoffice.gov.uk/))

Frankly I think this is a massively expensive and missed opportunity for the
US Government's digital service team.

~~~
drivingmissm
Britain is far worse than the USA -- your health care system just flushed $18
billion down the loo on a massively failed IT system.

[http://www.independent.co.uk/life-style/health-and-
families/...](http://www.independent.co.uk/life-style/health-and-
families/health-news/nhs-pulls-the-plug-on-its-11bn-it-system-2330906.html)

~~~
hga
A closer reading reveals that 11 billion (I assume that's thousand million)
pounds was the projected cost at the time for completion of the system. "Only"
2.7 billion, or 4.3 billion USD, has been spent, although I don't know if
there are contract terminations of serious size to be paid.

Still, it's an epic failure, said to be the greatest single one in government
IT contracting.

(E.g. I'll bet the FAA's eternal quest to upgrade from their 1940's (sic)
technique and '60s or so architecture has cost more over time, but not any
single failed effort.)

------
hsitz
I'm assuming the task these guys have done is tiny portion of the actual work
needed for the website.

I've been wondering for a while, though, why the federal government can't just
buy/beg a copy of software running one of the exchanges for one of the states
doing things themselves. Then they could modify it to work for other states.
Maybe they'd then have to replace existing federal exchange with 26 different
instances (one for each state that's a member of the federal exchange), but I
can't imagine that the technical difficulties of modifying one state
exchange's software to run with another state's data would be as bad as fixing
what seem to the problems with the existing federal exchange website.

~~~
hga
Probably too late for the very hard mid-December deadline for those losing
their insurance, maybe too late for getting enough young healthy people
enrolled before adverse selection forces insane 2015 premium filings from
insurance companies, which are due by the end of March.

They also have only 4 well functioning states' systems to chose from as I
understand it.

The centralized subsidy calculation/verification/etc. process, which the
Federal system does for all the exchanges is another issue, although I've only
heard that some time ago is was known to produce incorrect results under
testing.

Also would require the Federal government to admit a much bigger screwup than
they've been willing to so far, in a process _entirely_ driven by politics
([http://www.washingtonpost.com/politics/challenges-have-
dogge...](http://www.washingtonpost.com/politics/challenges-have-dogged-
obamas-health-plan-
since-2010/2013/11/02/453fba42-426b-11e3-a624-41d661b0bb78_print.html)) until
the last week of last month when CMS was fired and the fix-it czar was
appointed.

If you've been in this game long enough you've seen projects and companies
destroyed by a failure to take decisive action when it could have made a
difference (or read, for example, Churchill's _The Gathering Storm_ , or any
shorter version of how WWII could have been so easily averted by preventing
German rearmament). The odds are pretty high this is going to be another
example of that.

------
aram
Hats off to the guys - good job.

Here's the link to the site:
[http://www.thehealthsherpa.com/](http://www.thehealthsherpa.com/)

------
semerda
For an MVP this is a great start. Front-end code is clean, concise and the
flow far better than the gov version. If the gov is looking for solutions to
their problems these guys just showed what local talent can do vs outsourcing
an important piece offshore and messing up.

------
xbeta
As a Canadian living in the U.S. (SF bay area), I still don't understand why
American make healthcare so complicated. At beginning, HMO vs PPO vs whatever
makes me very confused. Why not just move to a public national health care
that works for all?

~~~
wildgift
money * low information voters * paranoid messages = tea party

Also, around 80% of people are in private insurance plans through a plan at
work. Some fraction of these people are happy with their HMO or PPO. These are
the middle class and upper middle class or rich. They are also politically
resistant.

The support for national health care or even single payer would come from the
uninsured and people who have lower-end insurance (high deductible plans) and
are forced into a kind of expensive PPO (insurance that makes you pay most of
the costs of doctor visits).

Hilary Clinton's single payer plan was demolished by the insurance industry.
So this time around, they kept insurance companies in the reforms. That
negated some of the resistance from the well-insured.

------
willchilcutt
I don't understand how this site works. A few days ago when it was first
posted here, I tried my zip, and it returned

"Plan Results

Found 0 exchange plan."

Today I searched my zip again, this time even messing with the different
options of insurance type, and still zero results. Is this saying there are no
insurances available for people in my area?

~~~
joyeuse6701
Apparently it only works for California zip codes:

~~~
frakkingcylons
Not necessarily, I tried it with Arizona and Texas zip codes and those both
returned valid results.

~~~
toomuchtodo
Worked just fine for my Chicago suburb zip code (60195)

------
chucknelson
A little skeptical of this, as others are. How was this tested? Just because
it seems to "work" with responsiveness and items on the screen does not mean
the info is correct.

Not saying healthcare.gov is any better, but there is just no mention of the
information given and/or calculations done being correct.

------
x0054
This makes me so infuriated! This site is great, it's exactly what needed to
be done, it works, and of course, it was NOT designed by our government,
because it works, and that just makes way too much sense! I used the CA site
before to look at available covarage. It's much more dificult to use, and it
hides from me the more affordable "Catastrophic Plan" for which I do qualify,
because I am under 30 years old. They do not want people to sign up for that
plan, so they just hide it! This is outrageous beyond belief.

All this site now needs is the ability for the insurance companies to upload
information about their plans directly to thehealthsherpa.com and we can
forget about healthcare.gov all together. People signed up for years for
insurance coverage by phone, directly with the companies, and they can
continue to do so. The exchange should be just be an informational tool. This
site does the trick.

I think thehealthsherpa.com should provide links, or better yet, add pages to
the site directly, to explain the different plans and regulations for
different states, so it can be more of an information hub. Great Job!

~~~
greg5green
Why would you want to sign up for the "Catastrophic Plan"? From my
calculations here in Ohio, you could have actual coverage for not much more?

~~~
x0054
For me it comes out to $250/month for Bronze Plan, and only $170/month for
Catastrophic Plan. I don't go to doctors unless I need to, and when I need to,
I can afford paying cash. I can take a $6,350 bet on my health, but I still
want to be covered above and beyond that.

And the question isn't about whether or not I should get catastrophic plan. I
have the right to get it under the new law, and CA's Exchange site should have
the duty to show me it as an option. Instead, they hide it, which is very
underhanded.

------
meerita
They bootstrapped a lot, that's nice :)

------
robomartin
I must admit I have not devoted any time to understanding the real technical
issues behind healthcare.gov. What little I know is from interpolating and
extrapolating what I read here and elsewhere. One impression I got is that
this $600+ million dolar website's authors tried to do it all. I don't get
that at all.

So, here's what I would have done. This is completely sit-of-the-pants. I'm
sure it has holes. Nothing that couldn't be sorted out by applying real
thought to the problem beyond this quick and admittedly faulty definition:

My approach would have been to first develop a specification for an API all
insurers would have to implement. They would be required to have a full
implementation of this API in order to participate in the service. Now you
have hundreds of teams working for you. This would cost almost not taxpayer
money.

The next step would be to develop an automated test suite to test for API
compliance. Open source it and release it. Setup a method through which this
API could be used to certify compliance. Perhaps this would be an insurer's
portal in healtcare.gov. Upon certification they would receive an expiring
token identifying the plans submitted as being fully compliant with the API.
More on this later.

Now everyone knows what they have to do to communicate their plans and how to
make sure their API is fully compliant. No tokens. No participation.

Each plan has a token. The token is also the GUID for each plan.

Unit and regression testing are your friends. Insurers would do their own
testing and they would be forced to continue to guarantee compliance by means
of the tokens expiring at preset intervals (a year?).

Next the API would be released for anyone interested to implement health
insurance browsing sites. Yup, let entrepreneurs battle it out for best-in-
class discovery services. You would have hundreds of sites pop up with all
kinds of really good solutions.

You would then publish another API anyone could use to actually communicate
with government servers and "book" insurance.

Now you have a potential of tens of thousands of people working for you. And
still virtually zero cost to taxpayers.

If that's too open, perhaps the plan browsing sites simply redirect you to a
government site for the actual booking. They pass the token for the plan that
was selected and a secure government site takes it from there.

Not done yet.

I would also hold a pre-release contest with cash prizes in the range of
$1,000 to $100,000 for faults found during penetration testing of the
government booking site. Release the code to the .gov site and let hackers
mount massive attacks from every angle. Do this until top hackers agree the
site is pretty damn hard. Give the top ten contributors cash as well as some
kind of a presidential recognition at the White House. In other words, make it
very public and very prestigious. Money and time well spent.

Once there, load test for something in the order of a million simultaneous
users. The site must be built with elastic capacity as it will have to be able
to manage insane traffic for a few months and then scale down to a more
reasonable baseline.

Then open the doors.

However. This does not happen all in one shot.

Segment the population around data centers. Perhaps a couple of states on the
east coast and a couple on the west. Announce it across all media. Schedule
additional population segments across a period of a few months in order to
average out a reasonable load on the system.

All independent browsing sites would have API access to the schedule. They
could then save your selection and email/sms you when your turn comes up.

In other words, decouple the act of browsing and researching plans from
actually booking it. And, at the same time, utilize a mechanism through which
the rate of booking per unit time might be controlled. The browsing sites
would simply not be able to forward to healthcare.gov unless it is your time
slot. Now you have a situation where you simply can't have a hundred million
people hitting healthcare.gov.

One could further segment booking by implementing time slots based on other
criteria. For example, the last digit or two digits of your SSN.

Yet another approach would be to offer a limited number of booking time slots
per hour. Browsing sites, through the API, would have access to this
information. This means they could provide a virtual appointment system where
you pick the time and date that is most convenient for you to actually book
your plan. If a slot is available you are in. Otherwise you are offered
alternatives. With this you could easily throttle the number of people who hit
healtcare.gov per unit time. Again, healthcare.gov would NOT be a browsing
site. You'd have to go through private sites for plan discovery.

Once booked, healthcare.gov would --via a pre-published API-- forward a
completed and validated application to the insurance company.

I am sure further checks and balances would be required. And, as I said above,
this game-plan surely has holes. It is seat-of-the-pants, I am coming up with
it as I type. No way it is perfect.

However, there is one thing I know: The general idea here is to leverage the
free market and private enterprise in order to delivery a massively better
product. I realize this goes counter to the ideas the current administration
must have about how a country ought to be run. However, if this healthcare
disaster has done anything at all for all of us is to potentially prove, once
and for all, that central planning and management by government is a horrible
idea.

This is exactly how everything is done in government. We simply don't get to
see it and experience it in daily life. With the ACA there was no way to hide
it. This has been and continues to be a very unique opportunity for the
American public to really see how bad government is about specifying,
planning, managing and executing anything at all. If this makes people
understand the fallacies in that school of thought this could very well have
been the best $600 million we ever spent.

~~~
hga
You need to add to your seat of the pants concept how the government is going
to control the payment of subsidies to prevent fraud. Those result in direct
payments from Federal fisc to insurance companies....

Right now the Federal system is doing that for everybody, Healthcare.gov and
all the state exchanges (single point of failure as Verizon's goof
demonstrated). In theory insurance companies will get access, but it's said to
be a _very_ low priority.

Then there's, oh, the straight out fraud problem, i.e. you sign up, pay your
first payment, then come January you or one of your fellow enrolees find out
when you try to get services or prescriptions, the insurer you thought you
signed up with has never heard of you. That pretty much requires starting at a
blessed government site, I don't think your stopping at a government booking
site would work since that could be spoofed, right? So could close the loop
snail mail confirmations from insurers.

~~~
robomartin
That's why each plan has a GUID. This GUID would be authenticated when you go
to healthcare.gov. They would not let you purchase a plan that does not
authenticate. They are the ultimate authority and filter. They'd also handle
details such as subsidies, etc.

In addition to that the transaction from healthcare.gov would, of course,
ultimately reach the actual insurer who would have to further authenticate it,
communicate with you and possibly also send some kind of an ACK to
healthcare.gov.

The process could be full circle with many layers of confirmation and
verification. This does not need to be overly complicated.

The idea is that the free market would handle the implementation of the
massive first layer of a national system such as this one. Get government
involved only where and when absolutely necessary.

~~~
hga
How will people reliably get to healthcare.gov from a friendly scammer's web
site...? The system has to be built for ordinary people who seldom if ever
look at URLs unless entering them.

For your second point, I posit a scammer simulating all of that, right down to
sending out authentic looking enrollment snail mail. Or just disappearing
after getting your first, up front payment.

My point here is that we need something like what you describe in your last
paragraph, with people like you putting on white hats to design the system and
people like me putting on black hats to break it in principle. And of course
trading hats as we see fit, etc. This most damning article yet, from the
_Washington Post_ , points out how unopen, often the point of secrecy, the
process was, even to the point of suppressing release of architecture diagrams
to the state exchanges: [http://www.washingtonpost.com/politics/challenges-
have-dogge...](http://www.washingtonpost.com/politics/challenges-have-dogged-
obamas-health-plan-
since-2010/2013/11/02/453fba42-426b-11e3-a624-41d661b0bb78_print.html)

~~~
robomartin
Yes, yes, I agree. This isn't difficult. Right. I mean, here are two guys
talking it out. Imagine if you put together a dozen real experts, took them to
a nice resort for a week and tasked the with coming out with a complete
definition covering architecture, operations and penetration/scam testing. It
isn't like we are trying to build a Star Trek transporter. There is nothing
about this that we don't have a pretty good handle on. And that's kind of my
point. The government is and was the worst possible project leader for
something like this. It isn't that complicated.

As I said in my opening to the prior post. I know it's full of holes. At the
same time, I know it would be a million times better than what we have now and
it would probably cost $595 million dollars less.

~~~
hga
Works great until that group includes, even if by proxy, someone from IRS IT.

Have you ever dealt with any of them? I suspect not, for it's in my experience
unforgettable, and unique compared to every other governmental IT person I've
ever dealt with.

See this diagram drawn from the first set of hearings:

I have no idea what HHS's computer systems role in this is ... well, tracking,
I suppose. Healthcare.gov is for managing enrollment in plans; does it's remit
even include knowing who has what at the moment?

"SSN" is I assume the Social Security Administration, and I also assume is to
verify citizenship.

IRS in theory has all the relevant income data and is the non-criminal
enforcer.

Equifax is also used for income verification, suggesting IRS isn't up to
delivering all that's needed, or not reliable enough. Not part of the
government, fortunately!

