State Health Insurance Exchanges Still Sick

over the site or help rehabilitate it. Connecticut's Access Health CT is actively marketing software and services, based on its implementation, to other states whose exchanges have been struggling or have yet to build their own exchanges.

In January, Minnesota governor Mark Dayton sent a five-page letter of complaint to IBM, pinning much of the blame for the underperforming MNsure site on shortcomings of IBM's Curam software, one of the website's foundational components.

In Nevada, Xerox is taking heat for problems with that state's exchange, and Deloitte has picked up a $1.5 million contract to study how the site could be fixed by the time the next open enrollment period begins in November.

Vermont experienced problems with its CGI-built Vermont Health Connect website, but said this week it still hit its goal of signing up 100,000 citizens. Vermont plans to stick with CGI as it continues to improve the system.

One of my favorite theories about what went wrong from the beginning of this process is that government leaders, from President Obama to the governors in these states and their subordinates, thought of building a health insurance exchange as a "just another website" project and couldn't imagine it would fail. Distracted by partisan political battles over the law, they failed to concentrate on making sure they could deliver the technology to enable what they envisioned: a slick online shopping experience for millions of grateful voters.

I also have to wonder whether dividing the responsibility for building these exchanges to the states was ever a good idea. Originally, the idea was that every state was supposed to build its own exchange -- something I suspect was built into the law to attract the votes of Republicans who disliked the idea of a big, centralized government program. So we got an even bigger, messier program.

Creating many versions of the required health information exchange software was also a way of spreading money around to more IT vendors and contractors, rather than picking a single winner. Politicians like to spread money around, and this division of labor gave more leaders an opportunity to dole it out. Yet many states passed on the opportunity to assert local control over a scary-hairy IT project, at least in the first year, directing their citizens to HealthCare.gov instead.

You could also argue that allowing a diversity of approaches to building a health insurance exchange would produce more innovation in the long run. In theory, I get that, but it strikes me as a hard argument to make, given what we've seen over the last six months.

Suppose that, instead, citizens from every state in the country had been directed to sign up on HealthCare.gov, period. Suppose that it had failed to work as designed when it launched on Oct. 1, just like what really happened. At least, the drama would be over now.

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