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Monday, December 2, 2013

ACA, IT and Dismantlng the New Deal

I've been a requirements person on complex medical IT systems. I did apply to the folks running the ACA program, but they didn't hire me. I'm kind of glad because if they had I'd be the designated "firee". The hurdles that ACA faced were so many and large that what is happening to the workers trying to make it work is both familiar, and painful, to me to watch. It has all the issues I'm so familiar with on Joint projects involving multiple developers and unclear/unrealistic requirements. I don't doubt that someone needs to be fired, but I suspect they won't fire him or her, but instead will fire the designated "firee". It's the sort of job I regularly get hired for, and I've learned how to manage. Had I worked on the ACA implementation it either would have succeeded or I'd have specific notes on why it doesn't work.

Integration

The Front End suffered from what is known as "changing requirements". The Republicans refused to cooperate with the creation of ACA. The Republicans tried to destroy it. The Supreme Court allowed the States to opt out of cooperating with it's creation, and the same states that opted out of cooperation also opted out of the Medicaid extensions that would have made it work better for the customers, us. And this all was in flux and still is in flux. It's difficult to deliver the right software if one doesn't have the requirements for what that software is supposed to deliver until just before the delivery deadline. In fact, impossible.

Unfortunately, while I've worked as a requirements manager requirements are written by politicians, bureaucrats and officials, and if the requirements are contradictory, the software created will be sketchy. Infighting, changing rules and requirements, insufficient funds, etc... all contribute to problems with schedule, delivery and cost. Those are a triangle that no amount of hope and will can change. It takes money, time, and breaking down a problem into it's pieces and tackling the pieces. That they got what they did up on the first day was about exactly what I expected. One can ask or a Cadillac but if one only has resources for a toy wagon, won't get one.

The backend of the ACA requires cooperation between private insurance companies and the Federal Government. It had to be rebuilt because originally the Federal Government was going to refer people from a national website to State Websites. Where the State websites are healthy, the system is working well. The Federal government did something right. The Federal Government created a standardized form, called the 834, which is supposed to be filled out online and sent to the insurers. This was a good way to standardize the requirements across the board.

But to ensure that piece works they needed to do integration testing. They had virtually no time for integration testing so the integration testing they are doing is with live data, online, and that is a mess. It is a predictable mess, and the engineers are right to point that out. But not having "enough time" or resources is never an excuse when problems arise, so someone's head will roll. A scapegoat is needed. I volunteered but didn't get the job. As a Requirements manager that was always my role or that of the project manager. In this case the requirements were unstable and always changing, the project managers were dealing with shortages of time and resources, and that always adds to the cost and dysfunction of the result. But probably some Project managers will lose their jobs. The iron triangle of program management is time, resources and scope. And the faster you slap something together the lower the quality.

I'm sure all this will eventually come together. Government IT projects take a lot of time because they are complex, require sustainment, and most business project management types are only concerned with delivering the minimum possible on the contract, getting the biggest return from government disbursements, and so all the risks are always with the program office, unless a private company under-bid on it's deliverables and can't deliver -- and even then the contractor seems to manage to get paid for the shoddy things it delivers.

Here one solution would be to require the insurance companies to electronically verify the 834 form and if there are problems request corrections either from the Government or the insured. [For more see: Glitches, but as with all private contractors I've ever met, there are some bean counters who are only concerned with what they can get away with. They are perfectly capable to ask for extra money to fix a problem they were originally required to deliver differently on. Any excuse will do. The Republicans are such privateers they prefer to sink programs that they can't loot. Kind of like some of the contractor managers I've met.

Every identified problem can be fixed. It will add to the costs over what would have happened had the plan been realistically costed, funded, scheduled and executed, but that is what always happens with governing efforts. They are messy because people don't cooperate, because with new things, stuff gets missed, and because folks listen to marketeers more than engineers. It was going to take as long as it is taking to roll out ACA. Some of the problems they are facing are inevitable. When I worked on the Theater Medical Information Program (TMIP) we had many features where doctors and other stakeholders told us what they wanted (or we had to guess) and we delivered different from what they wanted and had to fix it. Good requirements requires a lot of up front work, and hurry up and get it done projects rarely budget money or time to that, and so FUBAR is built in.

When I first worked on the TMIP program, the users were so unhappy, I drew a tank shooting at us in my notebook based on comments from one stakeholder who was making such withering comments that I was wondering if I was working on a shelfware project and she was going to bring in a tank and blow us up. By the last few months I was there the Program was working so well she was praising it and my Manager was considering finally staffing my job with enough personnel to keep up with all the work. I did my job by relying on the engineers and project managers. If you can get the requirements right up front you can get any job done right. ACA has requirements that depend on the States, and when the States decide to cooperate the people will get what they want. In Government the people are the stakeholders, and as people see what they are getting they'll tell program management what they want. Sometimes managers forget that. Certainly at that project we had our share of folks who didn't get the message that it wasn't about what we wanted or padding profit margins, but delivering medicine to injured and hurting people.

In one project there were some things we couldn't get done on time despite having gotten the requirements, because we couldn't get the requirements approved in time for them to be built when they needed to be built. That is how obstruction works. It threatened whether the software could be used. I left before I found out the denouement, but I believe fortunately the contractor got away with the late delivery and I've heard the problem got fixed after I left. Obstruction is sneaky and can undermine anyone's efforts. I can only imagine what it's like having an entire faction of people obstructing one's efforts.

But that doesn't excuse the Republicans.

ACA was a heritage foundation idea. Most of us Democrats wanted a single payer system to extend what we've already done with medicare and medicaid to everyone. As we can see from the sabotage of the Republicans, they've been actively dismantling things done for rural and city places, such as rural hospitals! That their own base depends on. They refused the "medicaid expansion" that would have brought medical coverage to the poor and restored medicaid coverage that the Republicans had been cutting all along. But this represents a wholesale attack on the poor and middle class, including 47% of their own base in rural areas. It is time for us Progressives to step up to the plate and get our Democratic Politicians to support a New Deal for folks, or to back real progressives and get them out of office. We need to point out that their own supporters are being betrayed with bait and switch arguments that gin up racism and fear in order to get folks to vote against their own interest.

Further reading:
http://www.npr.org/2013/11/30/247898470/glitches-in-digital-insurance-forms-threaten-aca-rollout

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