Just days before the launch of the new U.S. state health insurance exchanges that are the centerpiece of the Affordable Care Act, a nationwide push is still under way to test and patch the technology behind the online sites.
Officials working on the sites have acknowledged that information technology (IT) failures will prevent many of them from functioning fully for weeks, and perhaps longer. That will slow the government's drive to enroll millions of uninsured Americans under President Barack Obama's healthcare reform law starting Tuesday.
From a political standpoint, a successful opening day will shape perceptions of Obama's signature policy initiative. But the system's functioning is to a large extent beyond the control of politicians and policy experts, and instead sits in the hands of the battalions of coders working for IT sub-contractors.
Six months ago, people involved in setting up the exchanges were more hopeful that everything would be ready on time, said Cristine Vogel, an associate director at Navigant Consulting.
"I don't think there were enough hours in the day, or enough people with the skills," she said. "When we look back, I think we'll see that we missed an opportunity to share technology."
Opponents of the healthcare reform known as Obamacare say the computer problems bolster their view that the 2010 law is a "train wreck" and should be delayed or repealed. The Obama administration insists the exchanges will be open for business on October 1, even if some uninsured Americans may not be able to buy coverage right away. More importantly, they say, the new health plans will begin to provide health coverage on January 1, as planned.
"So long as the website is accessible and the plans and the plan information are displayed properly so a consumer can shop for coverage and compare the plans, they will claim victory," said Chris C1ondeluci, an employee benefits attorney at Venable LLP and a former staffer at the Senate Finance Committee who helped draft the Affordable Care Act.
This week, the Obama administration said its Spanish-language website would not be ready in time, and that it would be weeks before small businesses and their employees could sign up online for coverage on exchanges operated by the federal government.
The exchanges in Colorado and the District of Columbia, meanwhile, cannot calculate the amount of federal subsidies customers qualify for.
In New York, the exchange is not able to transfer data to some insurers instantaneously, as planned, one carrier told Reuters. Instead, the data will be sent in batches once a day or so. The glitch will not affect customers, but it raises questions that New York might have other IT problems.
Oregon had sufficient qualms about its online insurance marketplace that no one can enroll unless they use a trained, certified agent or other "community partner."
As late as this week, Oregon also had trouble correctly displaying information about insurance plans on a test site. The problem could mislead customers about deductibles, prices and other details if it occurs on the live site Tuesday.
In Ohio, Lieutenant Governor Mary Taylor, a fierce opponent of the healthcare law, said in a radio interview this week that her state's online exchange, which is being run by the federal government, could well crash on its first day.
In testing, she said, some plans filed by insurers "sat in a queue for the federal government for a week, so my concern is something similar is going to happen on October 1 because of the amount of (online) traffic."
WORKAROUNDS OFFERED, TAKE TIME
In most cases, exchanges will offer workarounds that will take time to execute. In Washington, D.C., off-line contractors will calculate federal subsidies and inform applicants what they qualify for in November, by which time the online calculator might be working.
In Colorado, until at least November, customers will have to call phone service centers, where representatives will manually take them through the calculations to determine what subsidies they qualify for.
Even before the exchanges open, the finger-pointing has begun, with states blaming contractors for glitches and contractors blaming states or other contractors.
The system to calculate federal subsidies for the D.C. exchange was built by Curam Software, which IBM acquired in 2011. In tests of complex family situations, the software was getting subsidies wrong 15 percent of the time, said exchange spokesman Richard Sorian.
In a statement, IBM spokesman Mitchell Derman said the city "decided that a phased-in approach best meets the needs of its citizens." He pointed out that Curam also built the eligibility software in Maryland and Minnesota, "two states that plan to have full functionality on October 1."
In other words, a company that achieved its goal on time in two states fell short in a third. The reasons, said outside experts, include relationships among contractors and the specifics of existing computer systems in a state.
In Washington, Infosys, the giant Bangalore, India,-based technology company, is the system integrator - the contractor that takes software from sub-contractors like Curam and puts it all together. The fact that Curam's calculation software is working on other exchanges suggests the glitch may not lie in its integration with the D.C. exchange's other IT.
"A software package like Curam's is put into the system by the system implementer, not the software provider," said an IT expert not involved in the D.C. exchange. A spokesman for Infosys was not able to comment on its D.C. work.
MEDICAID SYSTEMS POSE HUGE HURDLE
One of the most difficult IT jobs has been to integrate each health insurance exchange with its state Medicaid system. These legacy systems are typically decades old. In Massachusetts, for instance, the system runs on the COBOL programming language, which is to today's languages like a rotary phone is to an iPhone-5.
"These legacy systems are old and difficult to configure and re-configure," said Tom Dehner, managing principal at Health Management Associates, a healthcare consultant, in Boston and former director of Massachusetts Medicaid.
"To change how eligibility is calculated," as federal law now requires, he said, "you need to modify your Medicaid system, and that's not something you can do by buying software off the shelf."
The difficulty of interfacing with Medicaid will keep Colorado's exchange from calculating subsidies online.
To determine eligibility for federal subsidies, explained Nathan Wilkes, a member of the board of Connect for Health Colorado, the system "first goes through Medicaid determination. That means connecting to a legacy system," he said.
"Six or nine months ago we got an early warning that the way we wanted to integrate these systems wouldn't work, and then time got away from us."
Colorado's exchange tested 100,000 scenarios to see how its software calculated subsidies, and got error after error.
"It's an IT nightmare," Wilkes said.