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5 lessons all CEOs can learn about execution from healthcare.gov’s epic failures

Thought Leadership on Execution Strategies presented by Simple Solutions.

One of the most visible and epic examples of execution failures in recent times is the launch of access to the Nation’s first universal health care enrollment system, Healthcare.gov – the website for the Affordable Care Act.

Independent of the policies, politics and technology of Healthcare.gov, the faltering debut of the initiative provides examples of execution mistakes that are commonly made by many CEOs of every type of business operation.

Five of these mistakes are offered below. The list is compiled from existing research on Healthcare.gov(1) and is neither an exhaustive nor a definitive analysis of the program itself. Instead, its purpose is to help demonstrate that all execution missteps, especially the most egregious, appear to be painfully obvious with hindsight, and like healthcare.gov “are both predictable and greatly preventable.”(2)

  1. Formulate your initiative from reality, not the vision. It’s not clear that the vision for healthcare.gov was ever grounded in reality before it was initiated. On September 26, 2013 President Obama compared healthcare.gov to popular e-commerce sites. “Now, this is real simple,” he said. “It’s a website where you can compare and purchase affordable health insurance plans side by side the same way you shop for a plane ticket on Kayak, same way you shop for a TV on Amazon. You just go on, and you start looking, and here are all the options.”

This vision may sound good. But the features described were traditionally accomplished through insurance agents who help individuals review options over a period of several days (if not longer). When translated into an automated system, a typical user might have to navigate 75 screens to obtain insurance, and the whole system could contain over a thousand screens. It may not have been realistic to expect that so many functions could be accomplished in a couple of hours by users who potentially lacked advanced computer skills or high-speed internet service at the system’s initial public launch.

  1. Recognize and respect your limitations. The initiative was the first time anybody had ever tried to develop a single web-site where diverse users could 1) establish an on-line identity, 2) review hundreds of health-insurance options, 3) enroll in a specific plan, and 4) determine eligibility for federal subsidies — all in real time.   Despite advice to appoint an outside health reform “czar” with expertise in business, insurance and technology, the President selected the director of the White House Office of Health Reform to be in charge of the law’s difficult implementation. She along with others had guided the legislation through Capitol Hill and knew its every detail. Said Harvard Professor David Cutler on the subject, “They were running the biggest start-up in the world, and they didn’t have anyone who had run a start-up, or even run a business,” and “It’s very hard to think of a situation where the people best at getting legislation passed are best at implementing it. They are a different set of skills.”
  1. Learn how to successfully bridge fragmented authority. There was no single person whose sole responsibility was to ensure the unified implementation of the Affordable Care Act. A total of 55 contractors were hired to produce the various pieces of the program, and in order for all the steps to work, five federal agencies, 36 states, and 300 private-sector insurers offering well over 4,000 plans needed to be involved. Representatives of disparate agencies such as the Internal Revenue Service, the Centers for Disease Control and Prevention and OMB’s regulatory office all had a role in putting the law into practice. Meetings to work through tough regulatory questions convened the HHS Secretary, the Treasury Secretary, the Chief of Staff and the Domestic Policy Council Director until meetings petered out after some of the participants stopped attending.

Responsibility to convene and oversee these and many other meetings were assigned to busy administrators for whom, “implementing the exchange was one of 39 things (they) did.” Due to different parts of the bureaucracy contending for control, key decisions were often delayed, guidance to contractors was inconsistent, and nobody was truly in charge.

  1. Insist on organizational honesty even (and especially) in the face of tough politics. Due to the fragmented authority and the tough political environment, government employees are said to have concealed critical information from each other, and on occasion mandated that certain features be implemented or suppliers be used despite contractor warnings that problems would result. Outside consultants and contractors on the project were said to have repeatedly warned government officials about functional difficulties. But the internal environment enabled denial about how defective the site was to survive unchallenged until eventually the truth was lost. As a result, the White House was never adequately informed about potential problems and HealthCare.gov was never subjected to systematic review until after the site went live and nearly collapsed.
  1. Always set and utilize relevant and useful performance metrics. The absence of reliable metrics during the implementation of healthcare.gov helps explain why federal officials didn’t realize until it was too late that the site might not be ready for its public launch on time. A leader’s most important tool to help ensure execution success is the imposition and use of rigorous and unambiguous performance metrics in measuring progress. After the healthcare.gov launch, the government was reported to have made “improvements in the site’s key operating metrics” which implied a lack of adequate ways to measure the site’s performance at the outset.

(1) Computing News, Diagnosis for Healthcare.gov: Unrealistic Technology Expectations, David Talbot December 2, 2013

HealthCare.gov: How political fear was pitted against technical needs – The Washington Post, Amy Goldstein and Juliet Eilperin, November 2, 2013

HealthCare.gov Diagnosis: The Government Broke Every Rule Of Project Management – Forbes.com 2015

Behind the Curtain of the HealthCare.gov Rollout, Majority Staff Report, U.S. House Of Representatives, 113th Congress, September 17, 2014

(2) Matthew Heusser, 6 Software Development Lessons From Healthcare.gov’s Failed Launch, CIO, Nov 18, 2013

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