$90 million in maintenance per year for healthcare.gov
blogs.law.harvard.edu
blogs.law.harvard.edu
A SQL server, probably Oracle, should almost always be the answer for a large bureaucratic product like this.
However, there's absolutely no doubt the contractors weren't familiar with it and its paradigm. A SQL RDBMS, which pretty much everyone is familiar with, would have been a much less risky bet. But the CMS had had success with the XML database, and since they arrogated to themselves the roles of general contractor and system integrator (and in fact were "fired" about the time that article was written), the consulting companies had no choice but to use it.
See my other comment where people are suspecting Accenture might just throw away a lot of the current system and replace it with what they did for California.
EDITED: to make more clear the distinction between the unit of the Federal government CMS and CGI Federal, the fired contractor.
...and also attempted to arrogate to themselves those future roles. Would that there were taxpayer protections against that kind of anti-competitive (on face, at least) strategy.
Ditto Oregon, when they hired a new IT person who though they could save something like $32 million by being the prime contractor (as I recall; don't remember what happened with systems integration, except of course it's still totally failing).
We could only wish that government contractors had locked themselves into the prime contractor and systems integrator roles for CMS or HHS; who knows, maybe they would even have had the stones to tell the politicians NO! when the latter continued making requirements changes too late for implementation. Compare to Kentucky, which won by hiring a prime (Deloitte) who maintained a ruthless focus on what we call the MVP.
Heh. That's a good one.
MDD: Mortgage Driven Development
http://skillsmatter.com/podcast/agile-testing/refuctoring-yo...
“This is real simple,” Mr. Obama said, during a speech in Maryland on Sept. 26. “It’s a website where you can compare and purchase affordable health insurance plans side by side the same way you shop for a plane ticket on Kayak, same way you shop for a TV on Amazon. You just go on, and you start looking, and here are all the options.”
In August, less than 2 months before launch, orders came down from on high that all interactions would have to be proceeded by account creation and login. (Why? Well, given that you could only give it your current set of numbers under penalty of perjury....) 1 week before launch, the 2nd week into testing, the system failed with something like 200 simultaneous simulated logins).
And while Silicon Valley and the startup community has largely moved away from this methodology, large bureaucracies, ever afraid of risk, seem drawn to them. But as far as I can tell, this idea that "nobody ever got fired for choosing IBM" is a function of marketing, not of a track record of success (IBM's latest for the feds: http://sam.gov. $171 Million).
What we can do to solve this problem isn't to scoff and laugh at government. While some want larger or smaller government, we all should want it to do what it is doing affordably.
The opportunity for smart technologists to take on the idea of working with government commercially is the next step in the Civic Hacking movement. I hope those invited to go to their next hackathon for the city or invited to give their free advice and labor to the city out of a sense of civic duty, begin to ask the question: why are you asking me for stuff for free with one hand, whilst handing out million dollar contracts with the other. How can you fix procurement in a way that allows me to compete for the serious work, so that I can save you from this mess?
Yes, government projects of this sort are inevitably going to cost far more than a startup company, and mistakes will be made. But $90 million out of the federal budget isn't even worth blinking at. The Defense Department spends that much in about an hour and a half.
But if you really want to save money in this area, you should argue for eliminating the exchanges and healthcare.gov altogether. Just sign everyone up for Medicare. Save a few hundred billion over the next few years give or take.
It seems a fair percentage of HN'ers have not experienced the sheer Khafkaesque deadlock that is a large corp or govt department.
The cost is not in the dev effort, quite often there is actually a very small team of devs doing the "real" work. Outsourcing the dev work is not going to help because it is the massive bureaucratic pyramid which is crushing the devs, and that pyramid can't be outsourced.
This is not a technology problem. It's an enterprise management problem.
Frankly, tech contracts aren't the only thing that goes wrong. Civil engineering contracts are just as awful with people underbidding and then having massive cost overruns because there was no expert there to say, hey... this isn't reasonable.
so one more consulting participant and review layer to dig teeth into government money without actually delivering on the project? And with the best intentions like everybody else :)
One example would be training for people who have been out of work for more than 6 months. The training os how to dress and wrote a resume and apply for jobs.
These are put out to tender.
There are companies that are very good at making a bid and giving the presentation and winning the contract. But then their expertise drops away and they are hopeless and actually providing the scheme they just got awarded.
You comment made me think that a decent spreadsheet could optimise a companies ability to make the perfect bid. You then either sell that software or win lots of bids.
Given how bad the system still is (e.g. 5% error rate in sending info to insurers http://www.washingtonpost.com/blogs/wonkblog/wp/2014/01/09/a... and also see his very high signal to noise ratio blog: http://healthpolicyandmarket.blogspot.com/), and how much of it is left to be done (paying insurers, change in status updates, etc. etc. etc.) this is not just cheap, but some are suspecting that when Accenture fully takes over, right at the end of the spring enrollment period, they'll just throw much or most of the existing system away and start with what they did for California, which isn't hardly as bad.
I'm pretty sure for 85 million, I could assemble a crack team of devs to knock this out as a more competitive price.
Of course. Anyone could, but you see, this is not about using your money or getting the job done well. The $90 million is going to companies that have bribed politicians appropriately, and are now reaping the returns on their investments.
this is highly sensitive data, you can't treat it like a private business does, say like Target.
this needs to survive countless audits, from code, to docs, to various accessiblity and other norms.
a large number of data interfaces in the background to byzantine and opaque systems.
etc etc etc.
COMPLIANCE is the cost driver. and not necessarily for a bad reason.
You're joking, right? Because the lack of care that was put into security is WIDELY documented. They couldn't even get internal signoffs on security and decided to launch anyway.
It's simple, really: the government doesn't care if they break their own laws. The laws are for everyone else.
some new business site/app does not fall under the same public and governmental scrutiny. the ones that do with the same scope as this site - cost as much.
http://www.computerweekly.com/blogs/public-sector/2013/05/pu...
Connecting for health cost £11bn - billion - and is in various states of abandoned.
Time to join the 21st century and push for universal healthcare.
No it's not. Source: I'm a Finn.
Compare two scenarios:
A) Healthcare is run with money that's just taken from people.
B) Healthcare is run as a business, with people paying for it voluntarily.
The obvious answers are: No, No, and No, and that's exactly what happens with everything that's run by any government, because it's always with someone else's money and the "customers" aren't actually customers - they have no choice.
It's rather unsurprising, then, that Finland's public healthcare system is of poor quality, and that we have to wait for weeks or months for an appointment.
Given that companies loved playing games to expand what gaming meant, I am not surprised they decided to do something.
Well why would you not "allow" it, and what's the alternative? Credit card companies are "self-selecting" away from people who game the system, right? It works the same for any business that needs to worry about people gaming their system.
If they were good about their self selection process we wouldn't have mandatory health coverage right now.
Hell the entire problem could potentially be put on their decision to go away from properly underwriting and just checking when something came up.
I didn't say it's a bad idea because ours sucks. I said it's a bad idea because if you're using money that's just taken from other people, you're not motivated to provide them with good service, and so on.
The factors I listed cannot be escaped. You can rest assured that your system is slowly turning to shit too.
Your model is flawed.
What if you're not actually the people who run the system? Your question about some random, individual good doctors is not related to how the whole healthcare system is run and what can be expected based on it.
If a slave takes a meal from his master, it doesn't mean he must condone slavery.
First, taxation is not "stealing", it's literally extortion. A mafia makes it clear that if you don't pay them "protection money", they will hurt you, and governments make it clear that if we don't pay taxes, we will be forcibly hauled to jail etc. In both cases, you're making payments under the threat of violence. Taxation is extortion.
Second, your argument is that I shouldn't complain about taxation because I'm using the services funded by it. This makes no sense for at least two reasons: 1) I can't not use the services, and 2) extortion is still extortion, and immoral to begin with.
If McDonald's decides to extort money from you, and then rams a Big Mac down your throat "in return", does the Big Mac entering your stomach make extortion moral?
> I think you'd be a lot worse off if you decided not to pay tax and go without everything being a taxpayer entitles you to.
Here it's worth pointing out that I can do neither. I can't not pay taxes, and I can't not use the services provided with tax money.
Also, thinking that being a taxpayer "entitles" you to something is wrong. First, you have no choice. Again, you don't choose to "be a taxpayer", and being extorted doesn't "entitle" you to anything - you're just extorted and lose money. It's not like your extorters are interested in giving you anything, they're only interested in taking from you.
``...pricing systems in socialist economies were necessarily deficient because if government owned or controlled the means of production, then no rational prices could be obtained for capital goods as they were merely internal transfers of goods in a socialist system and not "objects of exchange," unlike final goods. Therefore, they were unpriced and hence the system would be necessarily inefficient since the central planners would not know how to allocate the available resources efficiently. This led him to declare "...that rational economic activity is impossible in a socialist commonwealth."''
The UK system has competition. For example: an NHS trust might provide drug and alcohol services. When the contract is renewed a charity might win that contract.
Your post also makes the weird assumption that supplies (medication, medical devices, dressings etc, beds and sheets and food and everything) is all also owned and provided by the government. They are not, they are made and sold by private companies to other companies - some of those are private companies, some of them are foundation trusts.
Modern health provision is much much more complex than "the government does it".
You should investigate the NHS because it's fascinating,even for people ideologically opposed to this model of health care provision.
No it doesn't.
> The UK system has competition. For example: an NHS trust might provide drug and alcohol services. When the contract is renewed a charity might win that contract.
The competition is a sham. The contract goes to whoever is the chummiest with the right people in power.
> Your post also makes the weird assumption that supplies (medication, medical devices, dressings etc, beds and sheets and food and everything) is all also owned and provided by the government.
His post did contain the word "socialist", but that doesn't mean he's assuming what you described there. I believe he just wanted to make a point about "socialist" policies, like public healthcare. Sure, the word can be defined in various ways, but healthcare is what we were talking about. The lesson here is that it's just inevitably going to be worse run than a business would be. The Mises quote wasn't directly related, but it's a good idea to read whatever Mises had to say. You might learn something about how economies really work.
There is a matter of degree involved. The more the healthcare market is socialized, the more prices will be distorted. The goods you listed may still have rational prices, still being provided by the market, but the prices of services will be distorted since there's no actual trade involved (hence no price signals) so it has to be centrally planned.
And yes of course health provision is complex, which is exactly why the prices cannot be rationally decided by central planners. They simply don't have the necessary information to make rational decisions that depend on the millions upon millions of price signals that are disseminated on a daily basis in a distributed fashion in real markets.
A good illustration of this is that communist planners in the Soviet Union had to rely on world prices (i.e. capitalist world prices) as guidelines for the pricing and allocation of resources.
Some services are really struggling: drug and alcohol rehab; a&e; mental health services; especially mental health services for young people. But on the whole it it pretty good.
A) Healthcare is negotiated by individuals, fearful for their lives, and with no other options. B) Healthcare is negotiated by bulk, by experts with the authority to set minimum standards of care.
Which one will be better quality? Suppose you're running a car repair shop, but your "customers" will starve to death if they can't drive to the closest grocery store 100 miles away. Are you motivated to: 1) provide permanent service that won't break down again, 2) avoid gouging customers, 3) maintain high standards?
The obvious answers are: No, No, and No, and that's exactly what happens with everything that's run by any corporation, because it's always a contract between an amoral company and an individual responsibilities.
It's rather unsurprising, then, that the USA's healthcare system is of poor quality, and that people can easily be driven into bankruptcy by medical costs.
Option B was running healthcare as a business, with voluntary customers. You seem to be talking about something else.
This is the third time I've heard this comparison on HN, and it still confuses me. It is probably true that people in poor health are very interested in receiving health care, but that does not equate to being forced to use a particular provider, or to accepting service under onerous terms. The point of running health care like a normal business is that if one physician is overcharging or underdelivering you can just go to a different one. Maybe whatevsbro's experience doesn't match your own, but you can't dismiss it so glibly, and in that experience, patients in a "universal" system don't have the option of choosing.
http://www.pbs.org/newshour/rundown/2012/10/health-costs-how...
The "choice" argument is also suspect, on a deep level. Americans are often trapped in jobs they hate, for fear of losing their health insurance if they quit or take another job. Worse, it hampers small businesses, that find it nearly impossible to provide insurance for their employees. Meanwhile, employees have little or no choice about the insurance plans they get.
The current American system is an expensive, incompetent failure. The ACA was designed to try to fix some of the gross problems (lack of coverage for 15% of the population, mostly), but protect the core design of employer-provided private insurance. That's why the software failed. It's incredibly complex, and that complexity drives costs.
It's not. It's that any service that's run with money that's just confiscated from other people will be poor quality, because there's no motivation to provide good quality, because you don't actually have customers.
You get to choose between an Android phone or an iPhone, for example. Imagine you were forced to only buy Android phones. Do you think they'd be good quality?
The observed data is that the American system is over twice as expensive as the average of comparable countries, and half again as expensive as its nearest competitors, while the results are little better and often worse.
If your ideology of confiscation and motivation does not explain the observed facts, then your ideology is wrong, not the facts. That's what makes them facts.
Nope, I was talking about the way people work.
> The observed data is that the American system is over twice as expensive as the average of comparable countries
I didn't claim that the US healthcare system represents anything even remotely close to a free market. I was making a point about "public" vs "private" in general.
If socialized models provide more expensive and poorer quality healthcare than systems with market forces involved, then it should be directly reflected in the American system being at least marginally better than the socialist systems. It is not. It is demonstrably far, far worse. Therefore, your argument continues to be flawed, despite your attempt to dodge the reality of facts. (I suppose you could argue that the American system of private insurers and private providers is somehow more socialist than any of the European systems. Good luck with that.)
As an aside, I reject your implicit assumption that "customer service" is the only thing that motivates good work. Pride, decency, and enjoyment all motivate better work than money. That's why most people are better at and care more about their hobbies than their careers, and why people are willing to take low-paying jobs that are emotionally rewarding.
Seriously, you're buying a lot of ideology about money and motivation that simply makes no sense in the real world.
I'm not dodging anything, and you saying so doesn't make my argument flawed.
To make it more clear, it's about more government involvement vs less government involvement. The only way the government affects an economy is through coercion: taxes, laws, regulations, licences and so on. Without government involvement, people would just do business however they wanted, and the corporations bribing politicians would actually have to engage in honest competition.
The less government involvement there is in X, the better X will be. It's as simple as that. Obviously, the government is very much involved in the US healthcare system. There's Medicare, Medicaid, and yes, all those insurance companies between the health care providers and their customers. Providers can charge outrageous fees for procedures because their customer doesn't care - he's not the one paying, after all. Often the patients aren't even aware how much is being charged to their insurance companies, and if the patient himself is paying, the price is completely different. "Oh you're paying yourself?! Let me knock a zero off of that".
> As an aside, I reject your implicit assumption that "customer service" is the only thing that motivates good work.
You're free to reject an implicit assumption I didn't actually make, of course. The single biggest motivator for good work is self-interest, because your customer only pays you if he likes what he's getting in exchange.
The way business works is through benefiting its customers, because otherwise they wouldn't pay for its services. When exchanges are voluntary, both parties benefit. Your benefit is the profit you get from selling your services, and your customer's benefit is whatever you do for him. As long as you're doing business without any government involvement, you'll simply have to keep pleasing your customers, lowering your costs / improving your productivity, and just overall maintaining a good level of quality. But all of this is predicated on the existence of competitors, and buying your services being voluntary - otherwise these mechanics don't apply anymore, and then you get lower quality and higher costs. This was my argument, and it very much still stands. It's based on human nature, the way we actually work, here in the real world.
If the US is less socialist than the "socialized medicine" systems, and socialism leads to increased costs and reduced quality, then that should be reflected in the numbers. It is not. The American system is far more expensive than any other system in the world, for results that are generally no better and often far worse. This isn't despite the role of private insurance, this is because of the role of private insurance. Occam's Razor, man.
Your ideology is failing you because the results implied by your ideology are completely at odds with the observed facts.
I'm not.
> Are you saying the participation of private business (insurance and providers) is irrelevant to the equation?
I'm not.
> If the US is less socialist than the "socialized medicine" systems, and socialism leads to increased costs and reduced quality, then that should be reflected in the numbers
Yes, I get what you're saying, just like I got it before.
The US healthcare system is fucked in its own special ways which are different from the way Finland's system is fucked. Both systems involve heavy government involvement though, which is something you should consider.
Again, the point here is government involvement, because the more of that there is in something, the worse it will be for the general populace. This is why you don't want "universal healthcare". It's guaranteed to turn to shit sooner or later, and in the economic conditions the Western world finds itself in, it's bound to be sooner.
I'm not saying the US system is an example of "socialism", for whatever value of socialism we might want to use here. But it's most certainly not an example of little-to-no government involvement either. Your healthcare system's costs are outrageously high because of the way it's structured (through government involvement). It just happens to be a way to reach higher costs than what other countries have "achieved", but that doesn't mean I'm wrong about anything I've said.
Suppose this car repair shop is allowed to keep the true cost of your service a secret - what's an itemized receipt.
Suppose it's not the car's owner that's paying for it, it's an insurance company, but instead of there being a free market of insurance companies, there's only a couple of them, and they're the ones building car repair shops.
Suppose running a car repair shop is surrounded by untold layers of red tape, since if your car dies, you're not allowed to get another one, so few people are able start their own.
Suppose your car has non-standard parts, and you can't simply buy a replacement OEM part that will work.
Suppose your car came from the factory with several design problems it's simply impossible to permanently fix.
Suppose car repair shops had a history of gouging people so badly that the gut-wrenching stories of people dying penniless from cancer caused people to call their congressman such that they demanded a change to the existing car-repair system...
I could go on, but health care isn't car repair.
> I could go on, but health care isn't car repair.
That's why it was an analogy.
edit: I also went from dirt-poor (and I'm assuming really horrible) health insurance plans in the US to having ridiculously good private insurance in the UK, so I'm already aware I'm entering into a supremely Apples v. Oranges scenario as is.
I've lived in both the US and the UK (well, the Isle of Man; I've heard NHS is much more of a pain in the ass in the mainland UK), and I'm just shocked at how awful the customer service has always been in the US.
In the US, I have never arrived at a doctor's appointment without waiting far past the time the appointment was scheduled to start and then waiting for the GP to actually come to the appointment room once you're seated there. In the UK (so far), I've seen the estimated time left before my appointment on an LED screen, and then both been led to the room on time and had the GP come in almost immediately.
In every aspect of healthcare in the US, I've been shocked at how long you're just expected to wait for absolutely everything.
Even if you arrive early, you sign in, wait in a room full of sick people for (on average IME) 40+ minutes past your appointment time, and then you wait an additional 15+ minutes for the GP to actually come into the room to begin the appointment.
It actually makes me physically angry to think about how much time I've spent waiting in a doctor's room over the first 20-something years of my life.
In your scenario B), I'd expect to be able to book an appointment online, arrive two minutes before it's scheduled to start, and walk out fifteen minutes later with whatever result you were looking for 99% of the time.
To be fair, I've visited my general practitioner exactly twice since I've moved here, so I have no sample size; and as I previously stated, I live in an area that has a reputation for having much better healthcare than the mainland UK.
Sweet. Are you ready to take the next, and final step? They say that the difference between a Libertarian and an Anarchist is roughly six months (paraphrased).
> In every aspect of healthcare in the US, I've been shocked at how long you're just expected to wait for absolutely everything.
Yeah, it's completely fucked. Finland's system is similar in the waiting sense, at least.
> In your scenario B), I'd expect to be able to book an appointment online, arrive two minutes before it's scheduled to start, and walk out fifteen minutes later with whatever result you were looking for 99% of the time.
Exactly.
Finland has UHC don't they? My point is basically that the funding mechanism doesn't (at this moment) seem to have anything to do with what service you receive.
"Exactly."
I would pay ridiculous amounts of money for an Uber for healthcare. As long as I didn't have to be put on hold while I was trying to do so.
I don't take nearly advantage of what I should in the healthcare realm because I have to make a phone call, take time off work, make transportation arrangements, and then know I'm going to be subject to something annoying somewhere in the process. If I could press a button, see what appointments are available, and then know it would be annoyance-free once I arrived, I'd probably use my available healthcare a much more appropriate amount.
"They say that the difference between a Libertarian and an Anarchist is roughly six months (paraphrased)."
Yeah, I think that's about right. I think I passed that mark maybe four years ago?
> Yeah, I think that's about right. I think I passed that mark maybe four years ago?
"Libertarian" tends to refer to Minarchists, these days. But alright. You're there already, good :p
So you are saying the governments attempts to do this have failed for historical reasons.
> Time to join the 21st century and push for universal healthcare.
And now you are saying that the government should have a bigger part of the industry, by absorbing it completely.
This logic is faulty, you cannot use a failure to recommend an entity takes a bigger part in something.
Additionally how well the website for finding healthcare works is unrelated to whether or not we should have universal healthcare. Heck the $90 million maintenance is not unheard of for a $400 million+ product, nor is it a lot in the scheme of a government program.
Countries like Japan and Switzerland offer systems that rival the US system in every way and usually exceed it, for far less cost and bureaucracy.
You can't say "because they failed at X they should do Y" and then later make up a reason why doing Y makes sense, doing so does not change the validity of your original argument.
I'm sympathetic to arguments for universal healthcare but after the way the ACA was both designed and implemented I have little confidence our leaders wouldn't make things even worse. I'm sure many people share this view. The key lasting impact of the ACA may turn out to be delaying more meaningful reform of our broken healthcare system for decades.
It's a case of not seeing the forest for the trees. No matter the specific project, or what sort of healthcare system we're looking at, these sorts of problems affect them all. And they'll continue to do so long into the future unless something drastic changes in how federal IT contracting is handled.
http://news.cnet.com/8301-11386_3-57617153-76/google-to-buy-...