While Obamacare has been a political firestorm in many parts of the country, in Washington state one of the biggest challenge of what’s formally known as the Affordable Care Act has been technological.
Building a website for consumers to use to shop for and purchase health insurance, then connecting that website to the state’s eligibility databases, and then tying everything to a federal data hub is a daunting challenge even with ample time for planning.
But the ACA, passed in 2010, set an Oct. 1 deadline for the site, which will house the state’s new health-insurance exchange, called the Washington Healthplanfinder, to be fully operating. As the date approaches, the site’s developers can look back at a process akin to building the technology that powers a hefty startup.
“When you think about the flight path for having something of this size and impact completed in the time frame that is being asked, it’s a pretty heavy lift,” says Michael Marchand, director of communications at the Washington Health Benefit Exchange. “We feel fortunate that we got out ahead of this earlier than some other states.”
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Richard Onizuka, CEO of the benefit exchange, agrees. As assistant director for health policy for the Washington State Health Care Authority, Onizuka was in on the planning for the exchange after the Affordable Care Act was signed into law in 2010.
And when the Washington Health Benefit Exchange, was created by state statute in 2011, Onizuka was named CEO. Immediately, he says, he knew that “the major hurdle is the amount of time that we’re trying to squeeze to get everything done.”
And it wasn’t just the task of creating an easy-to-use website for consumers. His agency also had the even greater challenge of integrating state eligibility data with federal databases.
“My first objective was to bring on a CIO,” Onizuka says. “Then we had to figure out where to start.”
Should the benefit exchange try to build on top of the existing state eligibility databases? Or should it start from scratch?
“Coming in from the outside, I was wondering whether there were any templates,” says Curt Kwak, who was hired as chief information officer in August 2012. “Has anybody done this? Can we learn from their experiences? I quickly found out that no one has ever done this.”
Ultimately, the team decided to follow a third strategy. “The eligibility system has all sorts of pieces to it — food stamps, housing, medical, other things like that,” explains Onizuka. “The process was to pull the medical piece out of that system, build a new rules engine, then put the rest back together.”
The key challenge in that process, says Kwak, is getting the state medical eligibility data to interface with other databases, especially the federal hub.
While formatting data so that it interacts with other databases can be time-consuming, Kwak says that has not been his team’s biggest challenge. Rather, he says, it’s the challenge of putting it all together without being able to really test the system.
“Our challenges have not been with data formats but rather full availability of the test environments to fully test our functionality,” he says.
What limited testing the team can do is currently under way. Kwak says the portal is now being used on a limited basis by agency staff. “So far it’s going really well. We’ve had a pretty high pass rate and we’ve discovered a lot of defects that we’re fixing.”
“We’re still one of the first states to be where we are,” adds Kwak.
While integrating the relevant state and federal databases has been a huge task, developing a Web interface for consumers has been equally important.
“We didn’t use a cookie-cutter approach,” says Marchand. “We collected a lot of feedback just to make sure that we were getting the necessary comments through the lenses of the stakeholders who would be using it from a consumer standpoint or from a provider standpoint.”
According to Kwak, the starting point for Web development were sets of requirements provided by the Centers for Medicare and Medicaid Services (CMS), the agency within the federal Department of Health and Human Services that manages the state exchanges.
“We’re working off a blueprint that was agreed upon between us and CMS,” says Kwak. “It was a step-by-step process that we followed, covering everything from security policies and protocols, to the actual functionality of the application itself.”
At the same time, the feedback the team is getting from consumer groups is to keep the site and its navigation clean and simple. “People really want to see something that is fresh and clean,” Marchand says.
While the work isn’t finished yet, Kwak is confident everything will be ready to go on Oct. 1.
“I think one of the main challenges was management of the defects that came and are still coming through integrated testing and user-acceptance testing,” he says. “So the challenges were around how we prioritize and fix all of these issues prior to ‘cold freeze,’ which is going to occur in the next few weeks.”
According to Kwak, most of the things they’ve had to fix have been cosmetic. “The wording here and there, the look,” he says. “And some things around the navigation of the tool. There are some concerns about some of the buttons and drop-down menus.”
One of the major tools the team has been working on is a health-plan rate calculator that estimates users’ monthly costs based on household income, number in the family, ages and, if appropriate, subsidy payments for those with household incomes below 400 percent of the federal poverty line. That calculator, of course, is being adjusted to reflect the insurance plans and rates certified for the exchange.
And the team is considering working in additional features. The calculator, for example, doesn’t factor in county of residence, and plan costs can vary significantly by county.
There are some other capabilities Kwak says may have to wait for a Version 2 to meet the Oct. 1 deadline, including an online chat capability. “We’d like for customers to be able to access customer support through this service on Washington Healthplanfinder,” says Kwak. “We also want to build out our mobile experience, which would ease access, data look up, and status checking for mobile users.”
What the team is working on most now is getting all the different pieces to work well together. The state eligibility system is still running on a mainframe computer, for example, while the Web interface is an Oracle-based application. Getting those two pieces to interact well takes some tweaking.
And since the Healthplanfinder has an Oracle-based back end, while the Web application is Java-based, they also need to be aligned and synchronized.
Finally, coordinating efforts among all the staff at all the different agencies and departments at the state and federal level is an continuing challenge. “When you deal with organizations that are not your own, you’re going to have different jargon, different acronyms, different understanding of level of expertise,” says Kwak. “That’s been the hardest part — maintaining proper and continual communication to make sure we’re all on the same page.”
Patrick Marshall is a freelance writer in Seattle. This story was produced through a partnership with Kaiser Health News, an editorially independent part of the Kaiser Family Foundation, a health-policy research and communication organization that is not affiliated with Kaiser Permanente.