Josh Marshall at TPM has been having a series of very interesting outside experts write in on what they see as Healthcare.gov problems. I think a few recent posts are hitting a highly probable failure point and an explanation as to why the state built and run exchanges are running better on average than the Federal exchange.
All the heavy lifting takes place on the back end, when the website passes your data to an extremely complex array of systems that span multiple agencies (like so many cooks in a kitchen). A central processing hub needs to get data from each of these systems to successfully serve a user and sign up for insurance. And if one of these systems — several of which are very old in IT terms– has a glitch and can’t complete the task, the entire operation fails for that user. Only if everything works perfectly, and the data gets passed back to the website, does the user have a good experience with Healthcare.gov.
Given that 25 states (or more) refused to create their own exchanges, the federal government became responsible for creating all of them, in one application. That’s 25 exchanges each with multiple insurance providers, all of which likely have their own unique interface requirements, meaning that they need to receive information from Healthcare.gov in a format they can use, or can at least re-format, to work in their own enterprise architecture.
The first set of problems involve making the IRS computers talk to HHS computers which then talk to CMS computers which then talk to however many other entities that all have kludged systems working. This is a common problem set no matter who built the Exchange front and intermediate layers.
The second comment has some useful insight. Almost all insurers who process claims electronically use common (federally mandated) file formats and record keeping systems (for the geeks these are the 5010s, 834, 835, 836m 837, 838 etc) but there is definate variation between firms as to exactly how they define discretionary elements.
State built exchanges have three significant advantages over the Federal Exchange. The first is that there was political will to make things work so active problem solving has been an ongoing process. Secondly,the number of unique data interfaces at the state level is far lower than the number of data interfaces that the Feds must manage. Finally, most states that are building their own Exchanges are working with insurers where there was a pre-exisiting working relationship. I know that we interface data daily with multiple state agencies. They know how we send data, we know what they expect to see and vice versa. Yes, there are new entrants to the market (co-ops etc) but most interfaces are building off of previous relationships.