Healthcare.gov Is Not Amazon.com. Should We Care?

by Jonathan Cohn | December 4, 2013

Everybody agrees that healthcare.gov is working much better than before. Everybody also agrees that it’s not working as well as it should. So what’s a fair way to evaluate its progress? One way is to compare its performance to commercial websites. Two smart writers on the right, Philip Klein and Megan McArdle, have made that case in the last few days. Here’s Klein: 

… an HHS chart … shows system uptime now at 95.1 percent (excluding scheduled maintenance), which compares to 42.9 percent a month ago. But, the industry standard is for websites to be available for users 99.9 percent of the time. Anything below that is considered a failure and 95.1 percent is a disaster.

A 2012 study by web monitoring firm Panopta that looked at the performance of 130 major retailers' websites from January to August 2012 found that the lowest uptime rate was 99.34 percent. …

A 95.1 percent uptime means that over the course of a year, a website would be down for about 18 days. Alternatively, imagine what a disaster it would be for sales if, during the holiday shopping season, Amazon’s website were down for about a day and a half, excluding scheduled maintenance.

The comparison to commercial websites is perfectly valid, particularly since President Obama used it all the time when promoting the Affordable Care Act’s virtues. (And, for what it's worth, the site's performance seems to be getting closer to that mark. On Tuesday, the administration says, healthcare.gov handled 950,000 visitors without much queing, although it's still early for making definitive judgments.)

But the comparison to commercial websites should come with two very important caveats. One is an acknolwedgment of the huge, fundamental difference between what the two types of systems must do. Innovative companies like Amazon are constantly developing new, more efficient ways to sell books, clothing, and other goods. (Just check out those stories about the Amazon drones.) But they are still engaging consumers, producers and retailers in a series of relatively straightforward transactions. And they are using technology that, for the most part, has been around for a long time. 

Healthcare.gov, by contrast, must perform a whole series of complex transactions—taking and verifying identity and income, determining eligibility for government programs or private insurance subsidies, calculating individualized insurance prices based on that data, presenting options for consumers to buy, notifying and paying insurers, and following up with consumers after the process is done. To do that, the system must communicate with multiple government agencies, at both the federal and state levels, as well as private insurers. Each one has its own information systems and, particularly when it comes to those state agencies, the technology is relatively antiquated. 

Of course, consumers accustomed to quick and easy online purchasing may not care that Amazon's job is easier. But that brings me to the second caveat. If we’re going to compare the process of buying health insurance at healthcare.gov to the process of buying books at Amazon, we should also compare it to the process of buying health insurance before Obamacare came along. That wasn’t always so much fun, either. Websites like eHealthInsurance offered a convenient clearinghouse for browsing and selecting plans. But plan details were frequently opaque. Without the law’s requirements on essential health benefits and simple use of metal tiers to describe plan generosity, there was always the risk of buying plans with major gaps in coverage—the kind that only relatively sophisticated consumers understood to check.

More important, if you shopped for insurance through an online broker—or through an insurance company directly—the prices you saw were quite possibly not available to you. All policies were subject to medical underwriting, which meant that insurers could charge higher rates, withhold benefits, or deny coverage altogether based on preexisting conditions. That was obviously also true for policies purchased off-line, whether through brokers or insurance companies directly. Medical underwriting process also took time—days or, frequently, weeks. Healthcare.gov eliminates that process entirely, because medical underwriting is no longer legal.

Again, holding healthcare.gov (and the state exchanges) to the standard of commercial websites is fair. The public sector should perform as well as the private sector. And there are still all those back-end issues (like communciation with insurers) that deseprately need attention. But if healthcare.gov's consumer interface isn't yet living up to the standards of Amazon, it's already surpassed the standards of buying insurance before the Obamacare came along. That's progress.

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