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 It marks the final deadline for most Americans to sign up for
health insurance under President Barack Obama's 2010 Affordable Care
Act, popularly known as Obamacare, if they want coverage starting on
January 1.
If enough people — and the right mix of young and old — do not
enroll, the ambitious program designed to provide health benefits to
millions of uninsured and under-insured Americans risks eventually
unraveling.
The deadline caps a turbulent roll-out this year for Obamacare and
the HealthCare.gov website that is key to enrolling millions of
people in the initiative. The website crashed upon its launch on
October 1, frustrating users trying to shop for insurance plans. It
now is functioning much better, but is still not at 100 percent.
Despite the continuing problems, the administration is expressing
confidence that Obamacare is getting back on track after enrollment
accelerated in December, with more than 1 million people signing up
for private insurance.
Here is a look at some notable moments in the months leading up to
Obamacare's troubled launch.
EYES WIDE SHUT
In June 2012, Margaret Tavenner was worried.
As acting director of the Centers for Medicare and Medicaid Services
(CMS), she was responsible for orchestrating the launch of the most
sweeping U.S. domestic legislation in more than four decades.
With uncertainty surrounding how the new law would work, most states
were undecided whether to establish their own insurance marketplaces
or rely instead on a federally run exchange.
"What keeps me up at night is knowing around December, there are
going to be like 30 states who want to come in and be state-based
exchanges," Tavenner told a Washington healthcare conference,
according to the Modern Healthcare newsletter.
Tavenner's anxiety — more than a year ahead of the planned launch of
the exchanges — spurred concerns among industry and advocacy groups,
which publicly questioned whether the multiple government agencies
involved in the effort would be able to pull it off.
The White House was closely briefed on the issues. Tavenner was
cleared to visit White House officials involved in the project 425
times from December 2009 to June 2013, including several meetings
with Obama, visitor logs show. The White House said later that Obama
knew only the broad picture, not details of the effort.
The administration also sought industry feedback, but some groups
complained their warnings fell on deaf ears.
On a video of a February 2013 conference of health insurance brokers
and agents in Washington, attendees could be heard grumbling when
CMS official Chiquita Brooks-Lasure asked for feedback by the next
day on a "streamlined" insurance application form.
The 21-page packet was jammed with questions on income and insurance
status. For insurance brokers who had learned to keep it simple for
customers, it was a harbinger of trouble.
"It was ridiculous," said Tom Harte, president of the National
Association of Health Underwriters, which sponsored the conference.
He said the group had been making suggestions to the administration
on Obamacare enrollment for months.
"The image I always had (of the administration's efforts) was of a
horse with blinders on, just plowing ahead and ignoring everything
else," he said.
DANGER SIGNS
Added to technical and administrative issues, CMS had run into
political problems on Capitol Hill with Tavenner's permanent
appointment as director.
A former head of Virginia's state health system, Tavenner had been
acting director of CMS since December 2011 while her confirmation
was delayed by partisan clashes in the Senate over Obamacare.
Finally, a Senate hearing was set for April 9, 2013, and she and
others on the CMS staff had to prepare her for tough questions about
the healthcare program's roll out.
Tavenner assured the panel that software development and testing for
HealthCare.gov would be done by September 2013.
A week later, on April 18, Tavenner's boss, Katherine Sebelius,
secretary of Health and Human Services, delivered a similar message
to a House budget panel. She said work on the insurance exchanges
was "up and running, and we are on track."
These confident public displays masked a different reality.
Earlier that month, Tavenner and Sebelius had been briefed by an
outside consultant about a broad array of risks threatening the
October 1 launch of HealthCare.gov.
The report by the consulting firm McKinsey & Co depicted a tangled,
leaderless bureaucracy managing the effort and warned of possible
system failures that materialized barely six months later. It blamed
tight deadlines, insufficient testing and the absence of a "single,
empowered decision-making authority."
The report sounded the alarm. Attendees at high-level briefings that
followed included Todd Park, the White House chief technology
officer, and Brian Sivak, the HHS technology whiz brought in to
jumpstart health technology systems.
The consultants met with Tavenner and Jeanne Lambrew, Obama's
healthcare adviser who, two decades earlier, had worked on a failed
healthcare overhaul spearheaded by then-first lady Hillary Clinton.
Obama also was briefed on McKinsey's findings, White House press
secretary Jay Carney later acknowledged. White House logs show two
McKinsey consultants arriving for a meeting on April 8, but the
company would not comment on the visit.
The first public hints of official concern about possible problem's
with Obamacare's technology actually came on March 22 — before
Tavenner and Sebelius had expressed their confidence to Congress and
just as McKinsey's findings began to make their way through the
administration.
At a forum sponsored by America's Health Insurance Plans, the
national trade association representing the health insurance
industry, CMS chief technology officer Henry Chao noted that the
launch of HealthCare.gov was about 200 days away.
"I'm pretty nervous — I don't know about you," Chao told the group,
according to Congressional Quarterly.
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"The time for debating about the size of the text on the screen, or
the color, or is it a world-class user experience, that's what we
used to talk about two years ago," Chao said. "Let's just make sure
it's not a third-world experience."
THINGS FALL APART
By July, Chao's concerns had escalated.
A former Navy avionics technician once billed as a rising federal
tech star, his reputation was tied up in the success of a website
that was partially built and not yet fully tested.
His agency already had paid the website's prime contractor, CGI
Federal Inc, nearly $88 million by March 2013. And costs were
climbing.
Chao wrote to colleagues on July 16 to say that he feared CGI could
"crash the plane at takeoff," according to e-mails released by
Republican congressional investigators. CGI has declined to comment.
Alarming assessments streamed in from CMS technical advisers.
"We believe that our entire build is in jeopardy," wrote one,
referring to the elaborate website construction.
E-mails flew back and forth between Chao and the contractors until a
CGI vice president assured Chao, "I am on top of this."
For Chao, meeting the October 1 deadline to have the website
functioning well had become a matter of personal honor. Along with
Tavenner, he had given sworn testimony to a congressional committee
and assured skeptical members that the agency was on track.
On July 20, Chao urged his staff to redouble its effort and sent a
link to his testimony.
"I wanted to share this with you so you can see and hear that both
Marilyn and I, under oath, stated we are going to make October 1,"
Chao wrote. He urged them to "put yourself in my shoes" and help him
make those words the truth.
A MAD SCRAMBLE
As October 1 approached, bleak assessments about the website
surfaced everywhere — except from the Obama administration.
Brett Graham, a partner at the healthcare consultant Leavitt
Partners, predicted a rocky enrollment period.
"The lack of testing and short timelines increases the probability
of exchanges experiencing unexpected problems," he told a House
subcommittee on September 10.
At CMS, system tests during the third week of September were "not
good and not consistent at all," one employee told Chao in an
e-mail. At a time when the website should have been able to
accommodate 10,000 simultaneous users, it was crashing with 500
simulated users on it — about a week before the site's scheduled
launch. Contractor CGI called the glitches "part of the tuning
exercise."
Chao shot off an all-caps message to his staff, ordering that tests
continue, just five days before the deadline.
At the White House, technology officer Park questioned Chao about
the website's progress. If Park sensed disaster, he gave no hint.
"Massive kudos again for the incredible progress the team is
making!" Park wrote in an e-mail.
THE RUSH TO FIX IT
HealthCare.gov went live on October 1 amid a sea of error messages,
blank pages and crashed applications.
"We are making improvements as we speak," Tavenner told reporters on
a conference call that afternoon.
The site's meltdown continued, however. A frustrating month of
up-and-down performance prevented many Americans from purchasing
insurance. The administration brought in technical advisers to help
with an upgrade.
After a few weeks of stumbling explanations from top officials,
Sebelius took responsibility during an October 30 congressional
hearing.
"No one indicated it could possibly go this wrong," she said. "Hold
me accountable for the debacle."
Obama apologized on November 14. Compounding the technical problems,
Obama's repeated promise that Americans could keep their existing
insurance if they wished proved to be inaccurate. Millions of people
with bare-bones policies that did not meet the minimum standards set
in the Affordable Care Act lost them.
Republican critics of Obamacare accused the administration of a lack
of transparency.
"The administration was on track — on track for disaster," Rep. Fred
Upton, the Republican chairman of the House Energy and Commerce
Committee said on November 19. "But stubbornly, they stayed the
course."
The political damage flowing from the website's troubles is likely
to continue through the 2014 elections. Control of Congress will be
at stake, and Republicans have vowed to make Obamacare's troubled
roll out, as symbolized by the botched debut of Healthcare.gov, part
of an assault on the healthcare program that they say is too costly
and robs Americans of coverage choices.
The website eventually found its footing.
As of late Sunday, more than 1 million people had signed up for
private coverage through HealthCare.gov, and hundreds of thousands
more were expected to do so Monday and Tuesday, just before a
deadline to get coverage that starts January 1.
Even so, the administration's initial goal of signing up 3.3 million
people by the end of December seems out of reach.
(Additional reporting Gabriel Debenedetti and David Morgan;
editing
by Marilyn W. Thompson and Maureen Bavdek)
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