My Experience with Healthcare.gov

I’m a geek – so of course I wanted to test out the healthcare.gov site immediately after it launched – and failed. First I wasn’t able to connect to the site and eventually when I did connect to the site it would let me go through the profile process but once it attempted to verify my identity it would drop me into purgatory and leave me there – forever and ever and ever (literally, I could leave the site and come back days later and I’d still be stuck there).

Screenshot of Healthcare.gov upper front page.
Screenshot of Healthcare.gov upper front page.

I tried a couple times creating, deleting, recreating, on various days and over various months – no luck. Finally I decided to call the phone number and admit that I, an IT guy, couldn’t get the site to work for me. The phone was picked up fairly rapidly and I was led somewhat painfully through providing all the information I had already provided numerous times via the site. At the end I was given an application ID number which the representative informed me I should “enter on the site” and it would show my enrollment – but that sometimes it took up to 24 hours for the change to happen on the site.

I grimaced at the 24 hour statement. While I was on the phone I attempted to pull up the application and of course it didn’t work. I had a pretty good feeling that if it didn’t work then it wasn’t going to work in 24 hours – and I was correct. The next day it still couldn’t find my application ID and weeks and even a month or two later it still could not find the application ID.

People have been noting how few younger people have been signing up through healthcare.gov and I wonder – does the system, for whatever reason, have problems with younger individuals? I don’t mean that it is intentionally discriminatory, but that the data about older individuals is more readily available, organized differently, etc. For example, it may be that older individuals already are “known entities” to the system b/c they have utilized services like Medicare. Just a thought.

Today I tried again…I successfully walked through the process from start to finish. I still don’t like the site design (it is using funky and complex functionality to display the forms, which I found to be jerky in transitioning…) and the site still managed to leave me with a few “what do I do now?” moments…

But it is all done, I’ve signed up for the Keystone Health Plan East HMO Silver Proactive. Cost is less than $230/mo. (unless the premium changes, which I have heard happens…). This may be a decent jump for young folks in good health compared to pre-Obamacare, but for me it is a huge drop. Since I have pre-existing conditions Keystone would have charged me around $600-$700/mo. for health insurance…which was just impossible for me (and thus I have been without health insurance for over a year now).

Ohh, but the real reason I wanted to tell you about this is b/c something bad happens if you don’t have health insurance by the end of March…which I think most people know (I know a fine…and I think “open enrollment” closes which means you can’t get healthcare until the next “open enrollment” occurs – which might not be for a few months), but perhaps more important – if you want to have coverage as of April 1st you need to be enrolled in a plan by March 15th. If you are registered after March 15th, your insurance policy won’t “start” until May 1st!

Why the Healthcare.gov fiasco SHOULD teach us to Open Source Government Application Development.

We Spent How Much?!

According to The Daily Beast the United States Government has spent $118 million to build Healthcare.gov and another $56 million in fixing it…and based on the fact that the site isn’t expected to be fully patched for some time yet I wouldn’t be surprised if the total cost in “fixing” exceeds that of building the system in the first place.

Image courtesy of OpenClipart.org and Iwan Gabovitch
Image courtesy of OpenClipart.org and Iwan Gabovitch

I’m not going to take a position on the Affordable Care Act (ACA) – I try to avoid speaking publicly on controversial issues…but I would like to suggest a lesson we can learn from the ACA that I don’t think will be (very) controversial across party lines – that the Government should utilize open source in the development of applications as a standard rule.

Now, I’m not particularly interested in arguing that every government project should be open source – I’ll be happy if 95-99% of them are. I understand that some people rightly or wrongly believe that using open source in sensitive areas could cause security risks. I’ll let Kevin Clough and perhaps Richard Stallman[1] argue that point.[2] But for the vast majority of projects (Healthcare.gov for example) I can see no reason why the development should not be open source and believe there would be significant advantages to such a course of action.

Lets take a look at the specific ways in which open source development could have reduced or eliminated the issues involved in the Healthcare.gov launch:

Transparency

The government (not just one department, but its entirety – e.g. the white house and congress) and the public could much more readily have seen that issues were arising, deadlines were slipping, etc.  and made necessary adjustments.

It is a constant problem within organizations that individuals at higher levels make decisions without the proper knowledge base upon which to make such decisions. This can result in unrealistic timelines and even if the timelines are realistic, if unexpected issues arise and there is slippage, there is a temptation to “gloss over” the setbacks and “hope” that the timeline can still be met.

This oftentimes results in extreme pressure on those actually working on the application as they are pressured to produce more, quicker – which, especially in the case of programming – is unwise. The more you pressure programmers the more likely they are to make mistakes, to take shortcuts and the more hours you demand of them the less productive they will become and, again, the number of bugs will grow exponentially.

Bug Fixes

Open Source software is oftentimes very stable and secure because of the number of eyes looking over the code. Further, individuals who are amateurs can make small contributions that allow the programmers to development on system architecture and bigger issues instead of stomping out bugs and making aesthetic improvements.

It would make sense for the Government to take a similar approach to Microsoft, Google, and Yahoo! on this front – each offers cash rewards for the discovery of issues. This is a relatively inexpensive way to get folks to pour in their energies – and individuals receive (for them) a significant compensation (hundreds to thousands of dollars – depending on the issue discovered).

Load Testing

The failure to properly load test the Healthcare.gov site is shocking. An open source project still needs robust methods of load testing performed by the core team – but it also benefits from other individuals and organizations implementing the application and discovering bottlenecks.

An open source, distributed team, also could have easily simulated the significant load that the site experienced upon launch – exposing the load issues early enough for remediation.

Code Reuse

When a project is open source the code can be reused by others for all sorts of purposes. The code to this project would certainly have applications in other government projects as well as the private sector. Reuse of code can significantly streamline development timeframes and even if someone in an entirely uses a portion of code for an entirely different project in a different industry – they will oftentimes contribute their version of the function (with enhancements/bug fixes) back to the original project (resulting in better, more flexible, secure, and robust code).

Cost

I really am just spitballing here – but I have a hard time believing that the development of an open source system to perform the Healthcare.gov functions would have cost anywhere near the costs expended thus far upon this closed source system. I’d guess that $10 million could have completed the project in a more robust and timely manner via open source.

Lesson Learned?

Please, let us take a lesson from this fiasco. We want more affordable healthcare – we can start by not wasting millions developing an application as a closed system which lacks robustness and stability.

I know some areas of the Government are already working with open source (and that is great) – but this needs to be a greater emphasis. Perhaps (I don’t know) there should even be some legislation that makes the (required) standard for new applications be open source and any applications which are desired as closed source systems should require review by a panel to determine if there is actual, substantial reasons for developing in a closed source system.

[Apparently I’m not the only one to think OSS could have made a huge difference. See this article by Christina Farr over at VentureBeat. Not directly related, but still interesting is Dylan Tweney’s article “Healthcare.gov costs show that feds have literally no idea how to build a big web site” also on VentureBeat. Another article comes from NBC News staff writer Gil Aegerter and can be found here.]

[11/4: Good article from Matt Asay entitled, “Sorry, Open Source Isn’t the Panacea for Healthcare.gov” on ReadWrite.]

  1. [1]Though Stallman would argue for free software rather than open source, but I leave that semantics argument, however important it may be, aside for the time being to focus on an area in which a relatively minor change in procedure (moving to open source development) could make a significant change in cost and efficiency.
  2. [2]There are some excellent arguments on how and why open source technology can be more secure than closed source technology. Specifically, the additional security in closed source systems usually isn’t b/c the systems are actually more secure but a function of “security by obscurity” – in other words, security holes exist, no one knows about them (including those who wrote the software). But I digress…

HealthTap – Real Doctors, Real Free.

HealthTap is a pretty cool site (and phone app) I discovered a while back and have been using on occasion and also recommending others to when they have health problems.

This image thanks to openclipart.org and johnny_automatic.
This image thanks to openclipart.org and johnny_automatic.

HealthTap offers a bunch of services – but the one I find most interesting and exciting is the “Ask Doctors” option. They have a huge number of doctors (thousands?) who are willing to answer questions.

The doctors answer the questions for free within a few hours. You can also donate $.99 to a non-profit cause via HealthTap and your question is “expedited.” The doctors I’ve had respond provide real answers – not just, “Go see a doctor.” Though that is oftentimes part of their advice (and they usually suggest a specialist for whatever the likely issue is).

So, if you don’t have health insurance, don’t want to try getting hold of your doctor, and for just b/c you are curious – HealthTap is a great and free option…I’m excited to see where innovative companies like HealthTap will take healthcare in the next few years. I have a lot of hope that innovations will result in healthcare reduction costs and improvements in healthcare that will reverse our trend of out-of-control increases in health care costs.

DIY Health Reform: Employers Solving Healthcare Crisis One Onsite Clinic At A Time | TechCrunch

Dave Chase writes in a recent TechCrunch article, “Led by IBM’s study of their $2 billion annual health expenditure, the overwhelming evidence comes to a surprisingly simple conclusion: more primary care = healthier population = less money spent. Ben Franklin was right. An ounce of prevention is worth a pound of cure.” He then notes a growing trend amongst large companies – providing primary care in-house to assist in preventing health crises rather than simply managing or paying for them. Read the rest in DIY Health Reform: Employers Solving Healthcare Crisis One Onsite Clinic At A Time | TechCrunch.

Healthcare Reform and Technology.

Human blood magnified 600 times
Image via Wikipedia

Disclaimer:

When it comes to discussions about nationalized healthcare, cost reductions, and other major political issues – I generally don’t feel qualified to comment. With this post I’m stepping out on a limb – and my qualifications[1] for doing so are probably still lacking. I welcome your feedback. I’m more than happy to be proved wrong – this is just want seems logical (and obvious?) to me.

Delimiters:

In this post I am not going to argue for or against nationalized healthcare, rather I am will discuss alternative methods of reducing costs/improving treatment. This is not because I disagree with nationalized healthcare[2] but rather because I see these steps as being a natural starting point in any attempts at cost reduction/treatment improvement.

Automation:

Each year I (try to) go for a physical with my doctor. I don’t enjoy it – but it allows me to find out if there is something major and obvious wrong with me. It takes a lot of time to see a doctor. After setting up the appointment one generally has to leave work and travel to the doctor. Being the anti-travel person that I am, that isn’t too big of a hazard – my doctor is five minutes drive from my house, ten from work. Still, its a nuisance.

Once I arrive, no matter how early or late, I always end up waiting and waiting (and waiting and waiting). Generally I am surrounded by others like me who are healthy and present for routine maintenance as well as those who are ill. Unfortunately, this means I am in a enclosed space with several individuals who are hacking and sneezing – throwing contagious germs around the room. I don’t harbor any hard feelings – I do the same when I am ill and I go to the same place to get treatment…but still, the risk is that I will leave with more wrong with me than when I entered.

The doctor’s examination includes fairly routine processes. He checks my height and weight. Checks my blood pressure, listens to my heart beat, pays attention for any abnormalities in my breathing, checks my mouth, ears, and nose – amongst other questions and proddings. Much of this process is actually carried out by one or more nurses (including the occasional bleeding for blood tests).

Now, my suggestion is simple, why not work on devices like the Zeo[3] which can perform most of this sort of monitoring automatically? Granted, the Zeo is only for sleep – but why can’t we make multi-functional devices that can monitor our blood pressure, heart rate, breathing, and any of dozens of other health factors? It seems that both the Apple iPhone and the Verizon/Motorola/Google Droid would be able to serve as perfect multi-functional devices for such a purpose (in addition to their many current uses). I’m not a big fan of having something implanted in me but I see no reason why such devices could not be used once a day/week in a few moments or with a small wireless band-aid type patch to monitor our health.

This automation would provide us with numerous benefits such as:

  • Reduced visits to doctors for regular physicals, increasing our work productivity/time off for recreation.
  • Increased monitoring of our vitals – alerting us to health issues in days instead of weeks or months.
  • Reduced exposure to environments with significant amounts of communicable health issues.
  • Advanced analysis of our health vitals to determine patterns of health that are disconcerting and need review.

Let me give a few examples of how a device like this might function:

  • Jane is fairly healthy. She uses her multi-function device once a week. It gives her peace of mind that her main vitals continue to operate within normal bounds. She doesn’t spend as much time worrying about whether this or that minor issue might be part of a bigger dilemma.
  • John uses his device daily. The device notes over a months time that John has significant blood sugar spikes around noon every Friday and this is accompanied by extreme bouts with sleepiness throughout the day. The device alerts John and John is able to change his dieting habits to reduce the sugar intake reducing his sleepiness.
  • Mary has chronic heart problems. While family bought her one of those devices that calls 911 if pressed they still worry about her constantly…until she received a multi-function device. She keeps a wireless patch on her all the time – which covers her vitals. It lets her know when she is working too hard and in danger of bringing on a heart incident and will even call 911 if she keels over – without her interaction.

Analysis:

I know some people are afraid of having their records kept electronically. I could explain why I don’t think this is a major concern but perhaps another time[4]. The keeping of electronic records instead of traditional paper records would offer several significant benefits:

  • Medical offices could (with permission) share information instantaneously. No more waiting days or weeks to get paperwork transferred from one office to another.
  • Medical offices could communicate with one another electronically and share results to coordinate better treatment plans.
  • A significant reduction in the amount of paperwork could be made. Individuals could give HIPAA consent via an e-sign form rather than through the useless bundles one receives at each doctor.
  • The data could be analyzed anonymously to garner important health information and to look for patterns invisible to the naked human eye. Think about it – we could find that individuals who now live in every state in the union and are suffering from stomach cancer all originally lived in the small town of sometown. While this might not solve their health problems it could launch an investigation to discover that (name toxin) is present in (name location – e.g. elementary school).
  • Further, the efficiency of treatments, the possibility of causes, the analysis of diseases could all be significantly expedited by such a process. The data could be anonymized and then made available for legitimate researchers to utilize in performing research (e.g. such as World Community Grid projects).

Pre-Treatment:

A lot of expense and time is caused by the inability to discover issues before they occur. What if we could monitor our health? What if we could be alerted (and allow our medical professionals to be alerted) before a major issue arises? If our spiking cholesterol levels were managed before they became a crisis? If our hearts failing functionality was noted before it resulted in a heart attack? If our liver and kidney function could be monitored?

Severity Monitoring:

I get sick somewhat often with minor bugs – a stomach bug, a cold, a virus. Annoying but not life threatening. In my line of work (IT) sometimes its really important to get a project done and while I personally am of the opinion that it is better to stay home and heal before returning to work many others in my field (and the American culture in general) are not. Sometimes even I succumb to the pressure to be present when feeling under the weather. What if I could cough into a small device attached to my multi-function and receive feedback on what sort of cold or virus I have? If its just the common cold I take some dayquil and am good to go – but if its strep, bronchitis, or the flu – well I stay home and see a doctor. How many epidemics could be prevented or reduced?

Conclusion:

I am not arguing for or against nationalized healthcare. I do wonder why there is not more effort in the areas I have outlined above – by governmental and private agencies – to utilize technology to solve these issues. I recognize that these solutions will have minimal effect on what some are especially concerned about (I am concerned as well) – the masses who are unable to receive affordable healthcare coverage. I suppose my thought is that if we can reduce the burden on the overall system, reduce our costs overall, this would provide more time and finances to direct towards those who have a need (whether that is on a governmental, religious, local, or personal level) while creating a sustainable system for future generations.

I eagerly await your thoughts and feedback. Thanks for your time and consideration of my ramblings!

  1. [1]In this instance my qualifications consist in their entirety of (a) reading Newsweek weekly, (b) keeping current on major headlines [including healthcare] via Yahoo, and (c) reading/skimming a wide variety of rss feeds covering a gamut of tech/health topics.
  2. [2]I disagree with those who utilize (Christian) Scripture as a argument against socialized medicine. I see no such impetus in Scripture. On the other hand, I find myself less optimistic about the effectiveness of governmental organizations than many more liberal minds (in Christian circles, Jim Wallis comes to mind).
  3. [3]Since defunct.
  4. [4]In brief, (a) privacy is an illusion – our information is already available, perhaps just not centralized and (b) I have nothing to hide – so why hide it? You want to know I struggle with Obsessive-Compulsive Disorder? Now you know. Finally, as outlined above I think the benefits are huge (and outweigh the negatives).