How States Launched Successful Health Exchanges

Testing of the Minnesota exchange in St. Paul on Sept. 27, four days before the site launched.

Testing of the Minnesota exchange in St. Paul on Sept. 27, four days before the site launched. Jim Mone/AP

Minnesota and D.C. marketplaces suggest HealthCare.gov’s disastrous first month wasn’t inevitable.

In the second half of August, six weeks before rollout, the best tech minds building Washington D.C.’s Health Benefit Exchange gathered to test the system end to end.

This wasn’t the first testing the system had undergone. Contractors and employees had spent much of the past several months combining different parts of the system for load testing and stress testing, adding updates to different components as they became available.

At one point, there were between nine and 11 testing environments running simultaneously, the exchange’s executive director Mila Kofman said.

It was six weeks before launch, though, when the full system came together and the exchange staff began to see how it ran.

“Essentially, most of my office, the folks who are the experts here, we sent them to our IT site to be there all day, every day testing the portal for functionality,” Kofman said. “We wanted to make sure it worked the way we wanted it to work and that it did what we said it did.”

There were a few surprises. For instance, a premium calculator that was supposed to give people eligible for premium reductions an early estimate of what they’d pay was only getting the numbers right about three-fourths of the time. Kofman decided to turn that system off rather than try to fix it under a tight deadline or give some consumers bad information.

All told, though, the capital’s Health Benefit Exchange has performed very well since its launch, a stark contrast to the troubled federal exchange, HealthCare.gov, which has suffered from numerous glitches and backend failures that have kept the majority of insurance seekers from enrolling in plans through the site.

HealthCare.gov only underwent two weeks of end-to-end testing before its launch, according to contractors’ testimony, much less than the months of testing they said other large government Web portals have undergone.

More than 12,000 District residents had created accounts on the D.C. Exchange as of Oct. 21. There’s no good way to compare those numbers with HealthCare.gov because the White House and the Health and Human Services Department have declined to release metrics for the site, saying they’d be inaccurate or misleading at this point.

According to documents provided to congressional overseers, though, only 248 people in the 34 states that rely on HealthCare.gov for their insurance marketplaces had enrolled in a plan through the site by its second day online.

Technology is notoriously fickle. There’s no way to guarantee a new Web system will operate as it’s supposed to and the online health insurance marketplaces, built by the federal government, 14 states and the District, are among the most complex systems government has ever built.

A review of some practices employed by successful state exchanges, though, suggests HealthCare.gov’s disastrous first month wasn’t inevitable.

By testing early and often, setting achievable goals and ensuring regular communication between contractors and government staff, the Washington D.C. and Minnesota marketplaces were able to launch cleanly and successfully.

Here are some other strategies they used.

Know Your Limitations

“We had a long wish list of things that we wanted the portal to do eventually,” Kofman said of the D.C. exchange. “We wanted to make it as user friendly as possible. But we were also pretty pragmatic, recognizing that you can’t just build the wish list. We decided there was some functionality we just weren’t even going to try to have built for Oct. 1.”

For example, the D.C. marketplace will ultimately have a system that allows consumers interested in a particular plan to search the provider directory for that plan with just one mouse click, Kofman said. Now it takes a few clicks to see roughly the same thing.

The designers decided the consumer benefit from the one-click option wasn’t worth the added risk of introducing new complexity to the exchange before its launch, so they delayed that part until 2014.

Get Everyone to the Table

A massively complex system, multiple contractors and a short timeline to launch meant Minnesota’s information technology agency needed to be more than just thorough. It needed to be nimble, said Jesse Oman, MN.IT’s assistant commissioner for projects and initiatives.

“What you want on a project like this is a true, seamless partnership between your [consumer off the shelf products] providers, your internal IT staff and your business partners,” Oman said. “It’s not like you’re off in your little siloes. You need to be working together in true project fashion, all at the same table.”

That relationship between state officials and contractors proved essential when the team had to make quick decisions in response to new federal regulations and couldn’t wait for a weekly or monthly meeting.

“Looking at the narrow time frame, we understood we couldn’t admire the problem very long,” said Tom Baden, MN.IT’s CIO for the state Department of Human Services. “We had to get right out of the gate and make clear, concise, actionable decisions to get the site up on time.”

Scale Early

One ace Minnesota had up its sleeve was the MN.IT cloud, a state-owned computer cloud where government agencies store many of their new systems. Clouds can scale up and down the amount of computing power supporting different systems as they surge and ebb in use.

By housing the MNsure marketplace inside the state government cloud, MN.IT officials knew they could meet extra demand if the marketplace got a rush of visitors in its first days or as deadlines approached by borrowing capacity from other state systems, Baden said.

HealthCare.gov’s data hub is housed inside a Verizon cloud that can similarly scale up and down, but other parts of the system are housed elsewhere.

Iterate Often

Before their systems went live Oct. 1, Minnesota and D.C. had both scheduled several post-launch updates for maintenance, add ons and feedback they received from consumers.

“This isn’t a one-and-your-done launch,” Oman said. “You have to be prepared for and open to feedback from a lot of different people. You’ve got to be able to respond and continually enhance based on that.”

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