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America's Bitter Pill: Fighting to Fix Broken Healthcare System, An Excerpt

By    |   Wednesday, 07 January 2015 06:57 AM

An excerpt from the book America's Bitter Pill: Money, Politics, Back-Room Deals, and the Fight to Fix Our Broken Healthcare System by Steven Brill


At 10:51 a.m. on Thursday, September 26, 2013, Henry Chao sent a memo to colleagues around CMS reporting that “it looks like the bar” for traffic—the maximum traffic the exchange could handle—“is set at 10k concurrent users.” That was the amount that another unit of CMS had found that Kentucky could handle.

Worse, it was not clear why Chao thought the bar was set even that high. About an hour earlier he had received an email from one of his deputies stating that the only testing done so far had been for five hundred concurrent users.

On the morning of Sunday, September 29, a worried Todd Park emailed Chao, with a copy to CMS operations chief Michelle Snyder, asking if “the team” had run various kinds of performance and capacity tests. He got no answer before the launch.

Meanwhile, President Obama and his White House aides had begun to lower expectations. However, they were still focused on how many people would enroll, not whether they would be able to. So in background briefings they emphasized that October 1 was simply the beginning of a six-month enrollment window and that in Massachusetts most people had waited until near the end of that state’s sign-up period before enrolling.

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October 1 was not Election Day; it was the beginning of a campaign, they explained, without dwelling on whether the voting machines were going to work.

On Monday, September 30, Obama told NPR, “I would suspect that there will be glitches. . . . When Massachusetts, just one state, set this up, it took quite a long time. It took several months before everything was smoothed out.”

The president was not trying to underplay what he suspected would be a disaster. He was clueless, not deceptive. He really thought there might be glitches, but that they would be minor. That is what his senior staff told him. There would be some hiccups, but this was really going to work. People would come to the site, sign up, and all the bitter politics would be in the past. Just like Social Security and Medicare.

White House chief of staff Denis McDonough had a friend who had been pestering him with calls in September. The friend warned the chief of staff that his insurance industry contacts thought the exchange wasn’t even close to being ready. One had even told McDonough’s friend that his company was thinking of pulling out to avoid being involved in what was going to be a fiasco. “My people say he’s overreacting to some last-minute problems,” McDonough had assured his friend.

Now, on the evening of September 30, just hours before the launch, McDonough called the same friend. “Based on the reports I’m getting I think we’re gonna knock your socks off tomorrow,” he promised.

October 1–3, 2013

A few minutes after midnight on the morning of October 1, 2013, CMS administrator Marilyn Tavenner was sitting by the phone in her apartment watching television. She was nervous. She had told her staff to call her as soon as the website was up so she could check it out.

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Now she called into the office to find out what the problem was. Why hadn’t anyone called her?

“No problems,” one of her deputies said. “We just wanted to watch it for a while before we called you. It’s fine.” Tavenner smiled, then went to sleep.


The first challenge at the Department of Health and Human Services and its CMS unit later that morning had to do only indirectly with Obamacare. True to Ted Cruz’s promise, Republicans had refused to pass a budget unless Obamacare was defunded. They were also threatening not to pass an increase in the debt ceiling.

Opposition to Obamacare had shut down the government, and seemed on its way to causing a more calamitous default on the national debt.

More immediately, this meant that the first job for the senior staff at HHS and CMS wasn’t to worry about traffic or enrollment at their new website, but to figure out which “nonessential” employees they had to send home because they could not be paid.

Beyond the most senior people, the definition of who was “essential” depended largely on what budget bucket they were in. That meant hundreds of people who had worked on Obamacare had to leave the building as it was launched.

“It was so bittersweet,” recalled Chiquita Brooks-LaSure, a veteran healthcare reform advocate who was one of Gary Cohen’s deputies at CCIIO. “We were finally giving people coverage in this country. But now we were sending our colleagues home who had helped make it happen.” Even Mandy Cohen, a highly regarded physician who was overseeing policy and communications with the non-insurance healthcare community, had to be furloughed.

At about 8 a.m., Tavenner met with senior staffers, including Brooks-LaSure and Julie Bataille, who ran the CMS press relations shop. Bataille reported that there was no news of any import yet from Gary Cohen’s CCIIO command center in Bethesda, Maryland, the command center run by CMS Office of Operations head Michelle Snyder in Baltimore, or the tech command center overseen by Henry Chao and housed at an office rented by contractor CGI in Herndon, Virginia. Everything seemed to be working, but they had no enrollment numbers.

As for actual traffic online, the CMS people had access only to the same data point that any website operator has—how many visitors had come. They had never installed a dashboard that would give them up-to-the-minute traffic numbers for individual pages, let alone the number of people who had actually enrolled. All that would have to be tabulated at the end of each day. But they did know that visits to the home page were high. Amazingly high: over a million visits by 7 a.m.

There were smiles all around. “Chiquita [Brooks-LaSure] had tears in her eyes,” Bataille would later recall. “We were finally doing this. We were all just so proud.”

At about 8:15, Bataille began hearing from some of the CMS people who had offices in the HHS building and had not been furloughed that they were seeing Twitter chatter about the website not working. Soon, the Twitter messages were multiplying, almost by the second.


By now Bataille was picking up reports from call center supervisors that people were complaining about something having to do with the identity verification process for registering an account. Either it was broken or the instructions about how to use it were unclear.
I already knew that. At 8 a.m. I had gone online pretending to be from Indiana (one of the thirty-six states on the federal exchange) and was told, first, that, unlike in Kentucky, I had to establish an account before I could browse around. To establish an account I had to provide my name and Social Security number. Then I had to answer some “security” questions in order to prove I was who I said I was.

The process is used by many security-conscious websites. A big data company—in this case Experian, the giant credit rating and background checking service—would assemble questions that presumably only I, and Experian, would know how to answer. What brand was the first car I owned? Where was the first house I had ever bought using a mortgage? If I answered the questions correctly, I was me.

The instructions about how to proceed to the quiz were, indeed, unclear. And when I figured them out, it did seem that something was broken. None of the questions appeared, yet I was told I had failed.

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It looked like one of the risks of having multiple contractors with no one in charge of the whole package was playing out. Experian routinely connected this software into hundreds of website deployments. Either lead contractor CGI or Experian, or both, seemed to have failed to complete the link for HealthCare.gov.

I tried again. This time I got three questions, but before I could check the multiple-choice boxes, the screen went blank. On the third try, I got no questions. Instead, I was taken back to the home page Bryan Sivak had built, and to “Sonya,” the smiling young woman whose face dominating the screen was about to become the ubiquitous image accompanying every news story about the website. By now Sonya seemed like she was laughing at me.

I tried one more time. Same result, except that this time I couldn’t even get back to Sonya. Instead, I got a message that would become the staple of the news coverage of the launch: “We have a lot of visitors to our site right now and we’re working to make the experience here better. Please wait here until we send you to the login page.”

While I kept that screen opened hoping to get back to the log-in page, I tried the handy option allowing me to do a live chat with one of the customer service people whose scripts Mandy Cohen and Julie Bataille had slaved over. This service had been put up live in the weeks prior to the launch, and when I had tested it then with various questions, the answers I got were so quick and so smart that I had begun to think maybe they really were going to pull this off.

Now, I typed in my question about the identity verification glitch. This answer repeated itself eight times over fifteen minutes:

“Please be patient while we’re helping other people.”

Then I got a ninth message: “Your chat session is over. Thanks for contacting us, and we hope we’ve answered your questions. Have a great day.”

I emailed a press spokesman—the first one who had talked to me about his colleagues’ post-traumatic stress disorder ten days before—to ask about the glitch, and about the fact that by now I had been waiting nearly forty-five minutes to get back to the log-in page.

Here’s what I got back:

This is what we’re telling reporters right now:

“We have built a dynamic system and are prepared to make adjustments as needed and improve the consumer experience. This new system will allow millions of Americans to access quality, affordable health care coverage. . . . Consumers who need help can also contact the call center, use the live chat function, or go to localhelp.healthcare.gov to find an in-person assistor in their community.”

It was a parodylike attempt to glide over reality with the kind of happy talk—“dynamic”!—that Washington reporters roll their eyes at. My own reaction to that statement and to the “Have a great day” live chat sign-off was more jaundiced. I remembered all the speeches Barack Obama had made about the arrogance, lack of accountability, and overall incompetence and consumer unfriendliness of insurance companies.
Then again, the press statement was the product of honest ignorance. No one at HHS and CMS, including the press office, had any idea of what the problems really were. Even if the staff at any of the command centers had been inclined to level with their bosses or the press flacks, they, themselves, didn’t know much, either. They had no idea of how many people were getting through and enrolling. By now, 8:45, they had heard something from Bataille about the identity verification problem, but throughout the day they would not know what the rates of error were for the identity check, or even what the wait times were for the home page.


By midmorning, everyone in the outside world who cared was aware of the identity verification problem. It was all over social media. Twitter had become the dashboard for real-time monitoring of the government’s most expensive, ambitious website ever.

As word about the identity problem came in to the command center run by Chao and hosted at CGI, the CGI people were already grousing that they had warned that the system needed to be tested end to end and that Experian had done a lousy job.

At CCIIO’s command post, the toldya-so’s were all about CGI and Chao.

At the White House, there was also frenzied activity amid charges and countercharges. But it was all about the government shutdown, not the Obamacare website. What functions and people had to be suspended? How should the president’s schedule be changed? What was the exact deadline, based on available Treasury funds, for getting the debt ceiling raised before the government would be in default? And what would be today’s plan of attack to force the House Republicans to relent?

As for Obamacare, they knew there were some problems, but Sebelius had assured chief of staff Denis McDonough that it was all about the traffic, which was so huge that it had busted one of the pipes—the identity verification process—that would soon be fixed. The system worked.

True, the site was now not even allowing people onto the home page to encounter the identity verification hurdle. But that, too, was all about traffic, the White House team was told. Despite the worried internal emails at CMS just days before about insufficient capacity, the White House staff were all told that they could fix that quickly, too.

In a noon Rose Garden statement, with a dozen citizens whom the White House press office said were about to benefit from buying insurance on the new exchanges standing behind him, President Obama lashed out at the Republicans: “One faction of one party in one house of Congress in one branch of government shut down major parts of the government. All because they didn’t like one law. This Republican shutdown did not have to happen.”

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Obama then turned to the program the Republicans were holding hostage, explaining how the rollout of the exchanges that morning would help the people standing behind him.

“Sky-high premiums once forced Nancy Beigel to choose between paying her rent or paying for health insurance,” Obama said. “She’s been uninsured ever since. So she pays all of her medical bills out of pocket, puts some on her credit card, making them even harder to pay. . . . Well, starting today, Nancy can get covered just like everybody else.

“So if these stories of hardworking Americans sound familiar to you,” the president continued, “well, starting today, you and your friends and your family and your coworkers can get covered, too. Just visit HealthCare.gov, and there you can compare insurance plans, side by side, the same way you’d shop for a plane ticket on Kayak or a TV on Amazon.”

However, Obama warned, the website wasn’t going to be like Amazon on day one. “Now, like every new law, every new product rollout, there are going to be some glitches in the sign-up process along the way that we will fix,” he said. “I’ve been saying this from the start. For example, we found out that there have been times this morning where the site has been running more slowly than it normally will. The reason is because more than one million people visited HealthCare.gov before seven o’clock in the morning. To put that in context, there were five times more users in the marketplace this morning than have ever been on Medicare.gov at one time.”

Obama didn’t point out that it was CMS—whose experience with websites only extended to the little-used Medicare site he had just mentioned—that was running HealthCare.gov.


At 8 a.m., there had been a gathering of the people from CCIIO who would be participating twice a day in meetings of the CCIIO “war room”—which should not be confused with the CCIIO “command center,” which was where designated CCIIO operations people would spend the day.

This first war room meeting at 8 a.m. had been convened to spell out how the subsequent meetings would work. It seemed like they had their act together, according to minutes of the meeting compiled by a staff person. A “CIRT Team” would “report cross-cutting issues to raise to Michelle [Snyder, the CMS chief of operations] and Marilyn [Tavenner].” Not mentioned was Henry Chao, who was supposed to be in charge of the website’s technology.

“CIRT is a Tiger Team; it stands for Critical Incident Response Team,” the minutes explained.

By the time of the war room’s second meeting, on the afternoon of October 1, 2013, there had been a lot of “critical incidents,” and things seemed considerably less buttoned up.

Everything seemed to be going wrong, not just the identity proofing.

Some of the problems that had surfaced were near comic: A majority of people who managed to get far into the application process were answering “yes” to a routine question about whether they were currently in prison and, therefore, ineligible for federal help in paying their premiums. Apparently, the website had worded the question with some kind of double negative and “most people would answer it in a way that mistakenly indicates they are incarcerated when they are not,” the minutes of the meeting reported. Testing would have caught that.

A report that an offering of a dental insurer in South Carolina had been “suppressed” was discussed in the same conversation in which someone else reported, “We heard that the capacity was 100,000 people, and there are 150,000 people on.” Capacity, of course, was nowhere near 100,000, or even 10,000.

As for the headline news, one member of the Tiger Team reported to the others in the war room that there were “5,800 applications in the world right now—unsure if they are completed at this point.”


By the next morning, the war room would be told that as of 8 a.m. October 2, 2013, “6 enrollments have occurred so far.” No one knew where that 5,800 number had come from.

From the book AMERICA’S BITTER PILL: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System by Steven Brill. Copyright © 2015 by Brill Journalism Enterprises, LLC. Reprinted by arrangement with Random House, an imprint of Random House, a division of Penguin Random House LLC. All rights reserved.

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America’s Bitter Pill is Steven Brill’s much-anticipated, sweeping narrative of how the Affordable Care Act, or Obamacare, was written, how it is being implemented, and, most important, how it is changing—and failing to change—the rampant abuses in the healthcare industry.
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Wednesday, 07 January 2015 06:57 AM
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