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10/1/2013
10:39 AM
Chris Murphy
Chris Murphy
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Obamacare Health Exchanges: How Oregon Got It Done

Oregon's experience building a health insurance exchange shows what's involved for IT operations.

As certain members of Congress tried to stop or delay Obamacare, members of Oregon's IT team spent last Saturday and Sunday doing what IT teams do ahead of a big tech launch: testing, bug fixing, conference calling, retesting.

Across the U.S., insurance-buying exchanges go live on Oct. 1 as part of the Affordable Care Act healthcare reform law, meant to let people shop for health insurance using exchanges that factor in their eligibility for tax credits and other assistance. Reports already have trickled in about technical glitches. Expect more this week.

Oregon's plan was to launch its exchange on Tuesday but give access only to insurance agents and other community partners, who can guide their customers through the buying process. Oregon won't open the online exchange to the general public until later in the month. It's a play-it-safe, soft-launch approach that recognizes glitches are likely, so better to work those bugs out with a limited number of agents and lessen the general public's confusion.

[ What's the role for private HIEs? Read Obamacare: The Rise Of Private Health Insurance Exchanges. ]

Oregon's approach left me wondering: What's so hard about creating an online insurance buying exchange, this technology that's so pivotal to making healthcare reform work? Progressive already can give me a handful of car insurance quotes in a few minutes online. Amazon.com sells thousands upon thousands of different products. Ecommerce feels like pretty mature technology.

To understand the challenge, I spoke with Aaron Karjala, CIO of Cover Oregon, which runs Oregon's health insurance marketplace, and Carolyn Lawson, CIO of Oregon Health Authority and Department of Human Services, which started the exchange project before state lawmakers created Cover Oregon. Here's a look inside some of the challenges facing Oregon's more than two-year effort.

Established Technology, Complex Rules Engine

Presenting a product -- an insurance policy -- isn't the hard part. The hard part is figuring out which federal and state programs and tax credits a person or family is eligible for. Getting that part right takes creating an extremely complex rules engine.

About 1,700 individual rules affect eligibility for health insurance subsidies in Oregon. Children might qualify under different rules from their parents, or half-siblings might have different eligibility based on their parents' income. In Oregon, writing the eligibility rules engine took 12 people nine months. Confirming eligibility requires integration with multiple outside data sources, such as confirming income and citizenship with federal sources, and that process is what separates it from ecommerce sites.

"When you go to Amazon you're not applying to get a product for free if I say what my income was last year and what I think it is going to be next year and who I'm related to and all those type of things," says Karjala.

Cover Oregon's insurance exchange is built on an Oracle technology stack and hosted by Oracle in two U.S. data centers. Siebel CRM provides the core software for managing customer information. It uses Oracle's database, rules engine software, SOA integration and Web front end. Call center reps (who are Cover Oregon employees) can view CRM data that people enter into the Web-based exchange, so they can guide people through enrollment.

Hard Deadline, Shifting Requirements

Oregon began its project in 2011. It was among the first states to start building a health insurance exchange, landing $48 million as one of seven federal "early innovator" grant recipients.

But the question was what to build. Oregon needed a highly iterative development strategy because the federal government was itself just figuring out how it would implement the Affordable Care Act and deliver the needed data.

"The policies and rules came to us a little at a time," Karjala says. "It was constantly emerging requirements." For example, the Federal hub that state exchanges connect to for verifying income and citizenship was completed this summer. That timing helps explain why exchanges are doing so much testing down to the deadline.

The solution, says Lawson, was "ruthless incrementalism. We had to build in an agile fashion and build what we know, and then put the pieces together like Legos."

Cover Oregon also had to build new ties with private insurers -- creating real-time, bidirectional interfaces with them to offer the 16 different medical plans that are set to be available on its exchange. From spring 2012 through mid-July of this year, 80 to 100 people from Cover Oregon and insurers held twice-weekly joint development sessions -- some in a room in Oregon and others online.

How do you herd that many cats? "We did it well sometimes and learned lessons other times," Karjala says. It helped to come into those meetings with interface prototypes and specific plans to discuss, rather than starting wide open discussions, he says.

Politics?

In parallel to all this work ran an impassioned national political debate about the merits of the Affordable Care Act, along with an ongoing effort to roll it back. "We just focused on getting people covered in Oregon," Karjala says.

More complicated were the practical, Oregon state-level dynamics for how the insurance exchange would run. Oregon started the exchange project under the Health Authority, where Karjala was deputy CIO, before the state legislature created the Cover Oregon organization to run the exchange. The Health Authority was the system integrator, a job that it didn't completely hand over to Karjala's Cover Oregon team until June.

Karjala's team started with a few people in a rented house north of the state capital building and has grown to about 200 tech pros, most of them contractors. Karjala needed to create an IT shop that could ramp up to build the exchange but then shrink to a self-sustaining run-the-exchange operation after 2014.

The work doesn't end with the Oct. 1 launch. To make that deadline, the IT team focused its energy on the consumer-facing elements. Work started this week on version 1.1 of the exchange, which includes building a lot of the behind-the-scenes processing and automation. Since insurance coverage doesn't begin until Jan. 1, the IT team pushed work around payments and other back-end systems down the priority list. "Oct. 1 is just a point in time," Karjala says.

Perhaps. But it's a point that a state, and a country, is watching with intense interest to see if this new technology backbone is up to the formidable task it's been given.

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EarlWer
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EarlWer,
User Rank: Apprentice
4/25/2014 | 9:59:54 AM
Re: 6 month follow-up
Some automative magazines run long-term tests.  They report back every year (or so) on repair costs, etc.

It would be interesting to have a 'One Year Later' follow-up on the various IT projects that are announced and then disappear.  If this project was not part of the ACA it would have disappeared, along with millions of dollars of our hard-earned tax money.  
David F. Carr
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David F. Carr,
User Rank: Author
4/25/2014 | 9:46:09 AM
Re: 6 month follow-up
EarlWer
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EarlWer,
User Rank: Apprentice
4/25/2014 | 12:58:30 AM
6 month follow-up
This is a typical government IT project.

How Oregon Got It Done?  They didn't.


$300 million later, everyone is fired and the project never worked.

http://www.washingtonpost.com/national/health-science/obama-administration-prepares-to-take-over-oregons-broken-health-insurance-exchange/2014/04/24/ff9aa220-cbc4-11e3-95f7-7ecdde72d2ea_story.html

What. A. Joke.

Here's an idea, if you have the intestinal fortitude.

Instead of puff pieces on taxpayer projects that are almost guaranteed to fail, what about a yearly follow-up on what actually happened to the projects you reported on in the past?

You may be unpleasantly surprised by the billions of dollars spend on government IT projects that never worked or needed additional funds or were simply shutdown.

 
Mordock
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Mordock,
User Rank: Apprentice
10/4/2013 | 8:16:53 PM
re: Obamacare Health Exchanges: How Oregon Got It Done
1700 rules? Those can't all be from Obamacare. If the Obamacare people created that many options for subsidies, then they are idiots.

The bottom line is that nobody is capable of managing 1700 rules manually, not even someone with serious insurance training let alone Sally Jones, recently laid off single mother who never finished high school and needs health insurance now. I have been self-employed many times over my life and health insurance has always been a major hassle even when not eligible for any kind of subsidies. Who knows, with that many options, maybe I was and didn't have any way of knowing.

This is just another example of how Health Insurance is broken in America and how these exchanges should have been set up years ago before Obama even became President. The Insurance Commissioners of all 50 states should be ashamed of themselves for not doing this 10 years ago. Once they get these done, they should start work on exchanges for Auto Insurance, Home Owners Insurance, Life Insurance and every other kind of Insurance that the Insurance commissioners regulate.
ChrisMurphy
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ChrisMurphy,
User Rank: Author
10/2/2013 | 12:38:23 PM
re: Obamacare Health Exchanges: How Oregon Got It Done
Right, though there's no hard-and-fast public launch date. I think MedicalQuack makes a great point that all these sites would've been wise to just call the first month a beta launch, admit the reality they all knew that these sites would have problems.
David F. Carr
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David F. Carr,
User Rank: Author
10/1/2013 | 9:01:03 PM
re: Obamacare Health Exchanges: How Oregon Got It Done
Except if I understand right, he's only giving himself a few weeks of "beta" breathing room
ChrisMurphy
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ChrisMurphy,
User Rank: Author
10/1/2013 | 8:44:08 PM
re: Obamacare Health Exchanges: How Oregon Got It Done
I exchanged messages with Karjala about results from the launch: the site had 1,400 to 5,000 users on the public site at a time; had more than 100 agents successfully get on the system by mid-day; and had collected applications for enrollment. He said there were "a couple minor glitches which we resolved within minutes."

I was browsing the site around mid-day and got a "whoops looks like something went wrong" message when trying to look at medical plans, but that was fixed soon thereafter.
ChrisMurphy
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ChrisMurphy,
User Rank: Author
10/1/2013 | 8:39:10 PM
re: Obamacare Health Exchanges: How Oregon Got It Done
Karjala made a similar comparison in our conversation -- that opening it up just to the agents and community partners was very much like the way Apple or Google would open up news systems only to a select group of developers or beta testers.
Thomas Claburn
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Thomas Claburn,
User Rank: Author
10/1/2013 | 8:05:11 PM
re: Obamacare Health Exchanges: How Oregon Got It Done
The fact that the government isn't mailing out brochures scanned into PDFs and burned onto CD-ROMs should be considered a major IT victory, regardless of glitches.
Ken Terry
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Ken Terry,
User Rank: Apprentice
10/1/2013 | 7:38:30 PM
re: Obamacare Health Exchanges: How Oregon Got It Done
Great story, Chris. I'm afraid that Oregon's experience points to even greater problems in other states that aren't as committed to making this work. Also, the feds are running the exchanges in many states, and I wonder what problems they're encountering in dealing with local conditions. One size doesn't fit all.
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