What Went Wrong at healthcare.gov

By Brian Lucas

This one is dedicated to Sally, “Di politica nunquam nos!”

“Truth never damages a cause that is just.” ― Mahatma Gandhi

By now most of America knows that the healthcare.gov website one of the main delivery portals of the Affordable Care Act was a disaster except.  Even back on November 13^th only 13% in a Slate poll[1] thought it was successful and a week is a long time in a political “hot potato” such as this.  There are so many political sharks circling the water smelling blood on this issue that the last thing we need is another political commentary[2].   What can we ALL learn from this unfortunate debacle?  How can it be prevented in the future?

I am not going to engage in calling for U.S. Health and Human Services Secretary Kathleen Sebelius’s resignation even though she continues to demonstrate that she either does not understand the true state of affairs or is deliberately reporting an unrealistic optimistic view of when the numerous issues are going to be resolved.  Nor will I levy blame at the White House’s chief technology officer, Todd Park.  Blaming is nonproductive at this point.  I am not even going to rip my shirt open to reveal my superman outfit and tell everyone how to solve the problem.  Instead let’s look for root causes and learn what can be done to prevent such a disaster in the future.

So let’s ask the question how can a “project” not a natural occurrence like a flood or a hurricane become such a manmade disaster?  One answer, that is undeniable, is an obvious failure of management.  Just look at the variable figures of cost for the overall implementation and the website separately.  Is it $600 million, $350 million, $125 million or $70 million[3]?  Everyone from the GAO on has a different figure. If this was managed successfully there would be no doubt as to the up to the minute cost.  Before you jump to conclusions, I will readily admit that far too few software projects are adequately managed.  Then there are the optimistic projected end dates that Kathleen Sebelius was providing.  Does anyone really believe they are going to be achieved?  Those are proof of a management system failure.

So the failure was an ineffective management system!  What caused the management system to fail?  Believe me; I am not calling for more government regulation.  Procurement is already a tedious and convoluted process.  At some point, the American people and the government have to realize that it cannot legislate its way out of every crisis.  To understand this failure, we need to come to a fundamental understanding of a similarity in the nature of the underlying forces of management systems and agile methods.  Both run on two critical principles:

1. Being able to tell truth to power.

2. Being incented to accomplish the strategic vision.

Surprised?  You should not be!  These are problems that have plagued business management for centuries and software project management for decades.  Let’s look and the second factor first.  The best management system in the world will never run smoothly if people are not incented to achieve and understand the big picture.  In a large project, that uses many private vendors and has a distributed development structure, it is easy for things to slip through the cracks.  Contractors are only concerned with completing their statement of work so they are not liable for legal action and can get reimbursed for their efforts.  This puts the entire onus on the overall management team.  They have to first create a phenomenally detailed and accurate requirements definition.  Second they must possess a superior knowledge of all the individual efforts so that they can provide oversight.

Is there any surprise that this fails as often as it does?  Instead, if the overall vision is a part of the requirement for each development team and the onus for technical coordination (not administrative management) is pushed down to the working level, everybody wins.  Teams know they must work effectively with the other teams or they won’t get paid.  If I develop my part to what I thought was the specification and you develop yours to your understanding and they don’t work together, we both fail.  That is often missing in government thinking.

Second, the most critical aspect of any operation – business, government, whatever – is being able to effectively tell truth to power without blame or retribution.  This is a documented problem as old as Sophocles’ fourth century B.C. play, “Antigone.”  The play is the actual source of the modern cliché, “shooting the messenger.”   The hierarchic management structure imbeds the chain of command and that is its greatest and often lethal weakness.   If you are down on the chain and actually doing the work and seeing the problems you have no way of escalating the issue past your direct manager.  If that manager chooses to cover up the problem because they feel it reflects poorly on them or they think that the executive management will not be receptive to criticism, failure is assured.

This is the greatest lesson that every executive should learn.  Have a real “open door” policy and don’t shoot the messenger.  Furthermore, it doesn’t pay to treat these kinds of issues as finger pointing exercises.  You should instead understand them as process failures.  Then managers, who previously blocked bad news from coming up the chain, will have no motivation for repressing the truth even when the news is bad.  That is the biggest failure here and the reason that something can go live and be in as bad a shape as the healthcare.gov website was.

I must point out that this is not a failure of the current administration.  It has plagued almost every administration in my memory including the previous one.  From Watergate to Bob Woodward’s book “State of Denial” those who tell the truth are often crucified. It is not easy to implement successfully or more administrations would have done so.  Implementing a telling truth to power mechanism is not the same as a whistleblower one.  The former is positive; the latter, though necessary, is negative.  Both must begin at the top and that means the president.

Implementing truth to power and uniting former antagonists can be accomplished even in a large organization.  Just look at Alan Mulally’s success at Ford.   When Mulally arrived at Ford, it had one of the most caustic corporate cultures ever seen.  Executives put the advancement of their careers ahead of the company’s success – even its survival.  Mulally openly applauded executives in meetings who reported problems and showed each person they had a vested interest in seeing Ford succeed by tying their compensation to the success of the whole company[4].

It will be a slow process to repair the damage that was done to the Affordable Healthcare Act by this botched implementation.   The president himself will need to set the tone for change.  The question is did the administration learn a strategic lesson and will they change the underlying motivations of the government’s workforce and vendors to correct the situation and prevent future failure.  Did you?