Lessons Learned Over a Decade with Health Care Marketplace

HealthCare.gov has a storied history — from a successful initial launch, to its infamous challenges in 2013, to its record-breaking numbers this past enrollment cycle. While the site has seen its ups and downs, its transformations have prompted the Centers for Medicare and Medicaid Services (CMS) to create lasting cultural change and promoted valuable lessons across government.

Although the Marketplace’s failed launch in 2013 has become the stuff of civic tech legend, HealthCare.gov saw a successful premiere on July 1, 2010. The website’s first version offered a lightweight screener tool that, for the first time ever, allowed visitors to see all the public and private health insurance options available to them. This was the beginning of cost transparency in the marketplace — previously, consumers weren’t able to access all of the price points available to them.

“We were parsing through billions of options for people and presenting a clear menu of things that they could look into,” said Edward Mullen, who worked on early versions of HealthCare.gov and currently serves as technical program director at Nava.

Following this successful debut, CMS set out to launch the Health Insurance Marketplace in 2013. This was a major expansion of digital services, intended to give consumers the ability to apply for Medicaid and CHIP coverage or to purchase a private health insurance plans.

But on Oct. 1, 2013, HealthCare.gov crashed within two hours of its launch, and only six people nationwide were able to select health plans on the website’s first day. It took about two months for the emergency “tech surge” team to get the website operational.

An Office of Inspector General report found that CMS and the Department of Health and Human Services (HHS) made various missteps throughout the development and implementation process. A lack of leadership, the report said, “caused delays in decision-making, lack of clarity in project tasks and the inability of CMS to recognize the magnitude of problems as the project deteriorated.”

Following the launch, CMS implemented an abrupt culture shift to tackle these problems, adopting a “badgeless” culture for the project. Staff, contractors and the new tech surge recruits were encouraged to collaborate across the silos that plagued them previously. CMS also implemented a process of “ruthless prioritization” to deliver the most important and achievable goals. Within two months, the website was operational for consumer use — as were more effective organizational practices within the agency.

“CMS didn’t need a technical surge, they needed an organizational surge,” an agency employee told the investigators.

Overall, the experience led CMS to take a hard look at its core management principles and improve upon them.

“That sort of situation can serve as a catalyst,” said Rohan Bhobe, tech surge team member and Nava CEO. “It makes the soil more fertile for that kind of change. Change can be difficult, change is expensive, change is hard. So there has to be a reason. And although nobody would have wished for a failure just to justify the change, once the failure did occur, CMS took a pretty hard look at, ‘How can we be better?’”

Bhobe pointed to CMS’s next major launch of a digital service as proof of its growth. The Quality Payment Program instituted major changes to the ways that providers were compensated.

“It was a success because there was no fanfare about it,” he said. “It just worked — people were clear about what they had to do. The system was available, it was reliable, it scaled, it was easy to use — all of these things that you would want out of a modern service. And that was just about two and a half years after HealthCare.gov.”

HealthCare.gov itself is leaps and bounds from the issues that riddled it in 2013. During the last open enrollment period, the site supported a record-breaking 14.5 million people who signed up for 2022 health care coverage through the marketplace.

CMS was able to reach consumers through expanded outreach efforts, and it also refreshed its web design and the features that help consumers navigate the process.

“We are proud to have completed the Biden-Harris Administration’s inaugural open enrollment with a record-breaking 14.5 million Americans who now have high-quality, low-cost health coverage, thanks to President Biden’s American Rescue Plan and our unprecedented outreach efforts,” said CMS Administrator Chiquita Brooks-LaSure in a press release. “We will continue to deliver for the American people and work to ensure no one is left behind in getting access to the care they deserve.”

And even through today, the agency continues to invest support in those connecting Americans with needed health care through the platform. Last week, HHS awarded a record $98.9 million in grant funding to 59 navigator organizations helping consumers navigate the health care enrollment process.

For Bhobe, the HealthCare.gov story is one with important lessons learned for government at large — lessons that public-facing federal services need more than ever as the pandemic accelerates digital processes.

“We have to be good at this,” he said. “There’s a sort of an arc between HealthCare.gov as a catalyzing moment, the pandemic as a current catalyzing moment. We’re building that deeper capability together that we’re going to need as the country goes into the future.”