When the Affordable Care Act was passed by a Democratic Party-controlled House of Representatives and Senate and then signed into law by the president back in 2010, and then judged constitutional in a landmark Supreme Court ruling the following year, most people figured the hard bits would be the continuing Republican Party opposition in Congress and in those states with Republican governors and/or legislatures. Few people assumed the real stumbling block for the launch of this new system would be the website that people would use to shop, compare and purchase their new health insurance plans.

After all, it was reasoned, the two Obama presidential campaigns had set a very high bar with their use of the Internet, social media and computerisation in communicating with voters and the media. As a result, it was assumed the “techno geeks” in his administration – and its general familiarity and comfort level with this kind of thing – would mean it would be able to deliver the complex connections needed for this massive reworking of a major sector of the American economy.

Moreover, the public had all those examples of the thousands of e-commerce websites now blanketing the country, as well as the government’s own reliance on the Internet as the first point of contact for the millions of applicants for Social Security and Medicare payments, as well as complex veterans’ benefits applications. To get things rolling, developing the required computerisation and web interfaces were contracted to one of the many “beltway bandit” government contractors based near Washington. And that seems to be where problems really began. Among other things, no one seems to have truly grasped just how complex this task – in comparison with other more usual, single-purpose programmes – would be. There were interfaces with dozens of state-level health insurance exchanges, private insurance companies and other parts of the federal government – such as the Internal Revenue Service.

IRS interfaces were crucial to corroborate taxable income so as to confirm eligibility for federal subsidies towards the costs of premiums for new, individually purchased insurance plans. Moreover, because some states controlled by Republicans have refused to establish the anticipated state-level insurance exchanges, the federal task grew still more complex as it morphed into an even more complicated task.

By the time the website was first launched at the beginning of October, insiders were already predicting serious trouble ahead. And so it came, in waves. Thousands of people complained their initial attempts to complete their system registration, to plan comparison shopping and to make insurance purchases were being stymied by continuing screen freezes, extended website timeouts, and a miscellany of error messages. Inevitably, this vision of systemic failure was repeated in blogs and news stories, then amplified gleefully by the ACA’s persistent critics in Congress, as well as on media outlets like the Fox News Network.

By this time, it had also become apparent that some of the president’s over-exuberant rhetoric in selling the ACA in the first place was now coming back to haunt him as well. His frequently repeated credo that if somebody liked their current insurance, they could keep it under the new regimen did not, ultimately, pass The Washington Post’s so-called Pinocchio test for calling to account oversold, “under factual” political rhetoric.

But there was more to come. This was leading to a kind of public policy “perfect storm” – at least initially. Some people searching for their next health insurance policies were more than a little alarmed when they received announcements their then-current policies would be terminated by their current insurers by the end of the year. Moreover, the new policies that they would be able to purchase would cost rather more than their old policies had cost them. In particular, the complexity of the new system had been, up until that point, less than clear to most people. For one thing it was primarily individuals holding the so-called individual plans – plans not part of a large group such as a business or government division – whose insurance was now disappearing as they watched.

While they were not a majority of those currently insured, their howls of protest were, not surprisingly, loud and they were quickly becoming a particularly vociferous group whose cause was picked up by anti-ACA politicians. The law was intended to mould such individual health insurance policies into offering a minimum basket of health care provisions to all insured. One key element of that intention had been to chivvy insurance companies into dropping or changing these now-substandard policies and offer more comprehensive ones with better copayment and deductible regimens. While the obvious intent had not been to sandbag people insured under those older individual policies, the public message became even further muddied.

As a result of these flawed messages and missed opportunities to build support for the programme, the Obama administration found itself sliding into crisis mode, needing to implement an urgent plan to fix the website and sort out all the anomalies and confusions. After weeks of increasingly frenzied 24/7-style work, on Sunday, the Health and Human Services Department (the government department responsible for the overall management of the ACA) released a progress report on its efforts to heal the HealthCare.gov website.

At that time, administration officials said the worst is over. As Jeff Zients, the White House chief troubleshooter for the website, told the media, “The bottom line – HealthCare.gov on 1 December is night and day from where it was on 1 October.” (See Wall Street Journal chart.) Having said that, however, the Obama administration has also admitted that more work remains to be done, and that some users will possibly continue to encounter difficulties in using the full functionality intended for the website – i.e. they won’t be able to complete their purchase of a new health care plan.

The next deadline now looms on 23 December – one consumers and congressmen will be watching carefully – as health care plan purchasers rush to meet the deadline to ensure their new coverage can kick in at the beginning of 2014. However, Larry Levitt, a senior adviser at the Kaiser Family Foundation, a major private health care think tank and policy advocacy group, cautioned, “There’s not really any way to verify from the outside that the vast majority of people who want to enroll can now do so, but we’ll find out at least anecdotally over the coming days if the system can handle the traffic and provide a smooth experience for people trying to sign up.” Levitt did note that the HealthCare.gov website is now working better than it did when it debuted but its key task now is to convince those who were frustrated – or worse – during their first try with it to give it yet another shot.

In making their announcement about the revamped website, the Obama administration said they had fixed some 400 technical problems and that the site should now be able to cope with some 50,000 people simultaneously, at a high level of reliability. However, officials did not tell how many major issues remained to be solved or fixed. Moreover, the website’s companion sites for small businesses to log in and make small group purchases, as well as a Spanish version of the website, still remain unavailable. Another critical issue that remains unresolved is how reliably the data from an individual who believes he or she has completed the registration and purchasing process has actually been transmitted successfully to the requisite insurance company to complete the actual purchase of health insurance.

Describing the challenges that remain, The Washington Post observed, “New challenges lie ahead. Most Americans are required to have health insurance starting 1 January and the administration is racing to meet its now-tougher goal of enrolling 7 million uninsured people in health coverage by the end of March. When the Website launched, the uninsured, as well as people who were looking for better or cheaper coverage, were supposed to be able to go online to browse plans and rates, apply for subsidies and enroll in health plans. But many have encountered numerous technical difficulties on HealthCare.gov, the main portal for 36 states, as well as on a number of state-run Websites. Fixing the federal Website was a crucial first step for the administration to restore trust in the health program, which has suffered in the polls this fall. It was also critical from a practical standpoint; people buying insurance on the marketplaces have until Dec. 23 to sign up for health plans that take effect on Jan. 1.”

In commenting on the revamped website, meanwhile, the president tried to tamp down all those earlier expectations, saying he could not guarantee “100 percent of the people 100 percent of the time going on this website will have a perfectly seamless, smooth experience.” In fact, first reports say the system is now running properly around 95% of the time and that the site’s pages were crashing at less than once per 100 mouse clicks. As a result of this improved service, the administration is now giving itself a passing grade for having met its self-imposed goals of allowing some 50,000 people to log in simultaneously while permitting more than 800,000 people to shop for health insurance per day.

Commenting on this new version of things, however, the country’s biggest health insurer trade group said real problems remain and that they could well remain a serious impediment to consumers trying to sign up. Karen Ignagni, president and CEO of America’s Health Insurance Plans, commented, “HealthCare.gov and the overall enrollment process continue to improve, but there are significant issues that still need to be addressed.”

Even more than the initial consumer interface, the biggest problem may well be those back-end systems connecting to insurance companies. These processes are supposed to deliver the actual consumer information to insurers, and because they have still not been fixed reliably, Ignagni warned, “Until the enrollment process is working from end to end, many consumers will not be able to enrol in coverage.”

Commenting on all these problems, The New York Times noted, “The issues are vexing and complex. Some insurers say they have been deluged with phone calls from people who believe they have signed up for a particular health plan, only to find that the company has no record of the enrollment. Others say information they received about new enrollees was inaccurate or incomplete, so they had to track down additional data — a laborious task that would not be feasible if data is missing for tens of thousands of consumers. In still other cases, insurers said, they have not been told how much of a customer’s premium will be subsidized by the government, so they do not know how much to charge the policyholder.”

And The Wall Street Journal noted some states (36 states now operate their own state-level insurance exchanges) are trying to find a way around the federal site. The WSJ explained, “Insurers and some states are continuing to look for ways to bypass the balky technology underpinning the health-care law despite the Obama administration’s claim Sunday that it had made ‘dramatic progress’ in fixing the federal insurance website…. One of the leading states operating its own exchange is considering ways to decouple itself from the federal infrastructure it relies on to confirm residents’ eligibility for federal tax credits…. James Wadleigh, chief information officer of Connecticut’s exchange, said he was looking at having a new vendor support identity verification in addition to the federal vendor. He also said he wanted to be able to tap state databases, such as the labour department’s, to validate incomes and was seeking a way to prove people were legal residents without depending on U.S. data.”

But realistically, how else could all of this have turned out in the first days? Anybody who has memories of the early days of online shopping almost certainly remembers something of the same kind of thing whenever they tried to buy a book, a videotape, a CD, a bunch of flowers, some speciality foods, concert tickets – or even pet supplies. Back then, the computer screens often froze just as capriciously, the online systems sometimes made credit card data disappear, and orders would then go into a cyber black hole as well.

In fact, it is also easy to forget that the effective template for Obamacare, the state-wide system put into place in Massachusetts by a Republican, then-governor Mitt Romney back in 2006, and based on proposals made by a thoroughly conservative think tank, the Heritage Foundation, had a similar low take-up rate too. Although it works well now, by most estimates, there were just a relative handful of successful enrollees in its first month of operation.

What really matters now, however, is what happens going forward. Yes, the Obama administration has had to take some bitter medicine over the initial failures of the signature website that was to lead to the purchase of insurance under the ACA umbrella. It has had to backpedal from that ill-stated promise that if an individual liked their health insurance plan, they could just keep it. And it has had to deal with the irritation coming from the putative sticker shock of the new, more comprehensive plans on offer (although the federal subsidies will eventually ameliorate much of that anger).

Attempting to reach a preliminary assessment of the political fallout, The New York Times noted, “Whether Mr. Obama can fix his job approval ratings as well as the website is unclear. Public opinion polls suggest he may have done more political damage to himself in the last two months than Republican attacks on the health care law did in three years.”

But, six months from now, a year from now, if the vast majority of Americans come to find their health insurance, complete with more comprehensiveness of coverage, a certainty that pre-existing condition exclusions have become a thing of the past, and that an easier relationship with insurers will make their medical insurance easier to deal with, then the ACA will have achieved its promise as the Obama administration’s signal achievement. This might well become a springboard for some electoral success in the 2014 and 2016 elections. It may be useful to recall for a moment that some Republicans, after all, tried to use the socialism of Social Security as a scare tactic in the 1936 presidential election and to peddle the passage of Medicare in 1966 as a kind of wedge issue to punch up anti-Democratic feeling. These efforts had little traction with the vast majority of voters.

But, this time around, if problems persist with the ACA’s implementation, the Republican Party may just have found a lever to claw back some public favour in the 2014 mid-term congressional election – and then to set up their pitch for the presidential election that comes just two years later. Depending on how things work, the ACA can still be the political equivalent of a home run for either team. DM

Read more:

• Insurers Claim Health Website Is Still Flawed at the New York Times;
• Gov’t diagnosis: HealthCare.gov on the mend at the AP;
• A look at claimed improvement to health website at the AP;
• Operational Progress Report from the Department of Health and Human Services;
• HealthCare.gov meets deadline for fixes, Obama administration says from The Washington Post;
• Insurers Seek to Bypass Health Site – Administration Officials Acknowledged ‘More Work to Be Done’ in the Wall Street Journal;
• Romneycare: first 3 months – glitches plus two week downtime: Now – 96% insured, GOP nominee at Daily Kos;
• Obama agenda: Remember Romneycare? At NBC News;
• Report: 100,000 signed up through HealthCare.gov in November at Politico.com;
• Romneycare had super slow enrollment. The White House says Obamacare will be similar at the Washington Post;

Photo: President Barack Obama pauses while he talks about the Affordable Care Act in the Brady Press Briefing Room at the White House in Washington. (REUTERS/Larry Downing)