Obama's Trauma Team: Inside the Nightmare Launch of HealthCare.Gov(content.time.com) |
Obama's Trauma Team: Inside the Nightmare Launch of HealthCare.Gov(content.time.com) |
https://news.ycombinator.com/item?id=4605904 https://news.ycombinator.com/item?id=3763907
I don't even want to imagine HIPAA compliance for something of this magnitude.
How? With another 14 million dollars... that is how. You can do a lot of things with 14 million dollars, this is not especially true when you are talking about the govt spending this kind of money, but still - it is not pocket change to the average company.
http://www.nextgov.com/cloud-computing/2014/02/cost-obamacar...
Using Obama for link bait means your article gets no reads from me.
..and slightly ignorant regarding this HIPAA kerfuffle that popped up. I did some quick [hilarious] research that resulted in an issue where commented copy was being used as an indicator that there was to be no sense of privacy on the website.
source: http://www.politifact.com/truth-o-meter/statements/2013/oct/...
I'm not entirely sure that's what you're referencing or whether you're just bein' a smart aleck, but I had some fun reading up on the story. I also learned that the website healthcare.gov doesn't necessarily need as much HIPAA compliance as I had initially anticipated. To enroll, the only 'medical' type data you need to include is whether you are a smoker or not - I thought there would be much more sensitive information right off the bat.
I'll always remember what Mikey told us in December, after the site was back up, could handle a non-trivial amount of traffic, and people who wanted health insurance could finally get it:
"1 in 1000 uninsured people die each year. It's not an exaggeration to say that due to the work we're doing here, 5,000-10,000 people will live to see the end of 2014. You should be proud of what you've done, but we should also all be grateful to have this opportunity."
We're all grateful to be here, but there's a hell of a lot more work to be done.
If any of you out there are an amazing software engineer or SRE, and want to help make our government work better, please shoot me an email: brandon@hcgov.us!
This probably a significant exaggeration. It is based on a 2009 study[1] which examined correlation, not causation. It did not control for many factors that may be relevant (e.g. smoking). The study expressed this in much more careful words: "Lack of health insurance is associated with as many as 44,789 deaths..." (This number was then divided into 45M uninsured in 2009 to get 1 in 1000). Politifact did not rate this claim due to lack of information[2], but they previously rated "Half-true" a number half as big[3]. The latter essay cites work that did control for relevant indicators and found: "the risk of subsequent mortality is no different for uninsured respondents than for those covered by employer-sponsored group insurance."
I'm not sure where to place blame:
- On the authors of the correlation study, who should never have studied this question without looking at extensive control variables or without more specifically studying causation?
- On Alan Grayson and similar folks, who are smart enough to understand the difference but are happy to assert causation?
- On Abbott, who implies causation, pointedly rejecting caveats ("it's not an exaggeration") in order to motivate developers?
I don't want to blame brandonb, particularly. I very much support his recruiting effort. In fact, I would say that the government probably has a disproportionate number of people who can resist unwarranted self-justifications. But I don't think a statistic like this should be left unchallenged on HN.
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[1] http://www.pnhp.org/excessdeaths/health-insurance-and-mortal...
[2] http://www.politifact.com/truth-o-meter/article/2013/sep/06/...
[3] http://www.politifact.com/truth-o-meter/statements/2009/aug/...
From the abstract: "After additional adjustment for race/ethnicity, income, education, self- and physician-rated health status, body mass index, leisure exercise, smoking, and regular alcohol use"
> On the authors of the correlation study, who should never have studied this question without looking at extensive control variables or without more specifically studying causation?
How do you suggest studying causation in this setting? A randomized controlled trial where we deprive people of health insurance? Even that will likely not yield a true causal estimate, because randomization only helps for pre-randomization differences in the population, and behavior change from lacking health insurance will occur post randomization. The authors do extensively discuss their control variables, and important to remember is the fact that most papers only control for variables which ended up doing something, a subset of all variables that were tried. The NHANES data the study was pulled from includes a staggering number of covariates.
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While not an ironclad study, I found the paper itself vastly more compelling than the politifact analysis of it, which boils down to "Well, observational studies might be wrong because reasons".
I'm also skeptical of Politifact's competence to adjudicate public health scholarship.
Yeah, thanks for fighting for the cause! #sarcasm
Is HN supposed to be a place where we try to find a flaw on every statement and make sure it doesn't go unnoticed?
What you pointed out doesn't even diminish an ounce of what Brandon and his teammates are doing.
Unless I'm misreading the polifact article you linked to in [2], it says that the 2009 study did control for smoking, and that they did a better job of controlling for such factors than previous studies.
> Still, their work stands out from previous efforts because it used more recent survey data and presented a more apples-to-apples analysis between the uninsured and insured populations. For example, it compared deaths rates for uninsured smokers with insured smokers, as well as other factors such as drinking, obesity, income and education.
My assumption when things melted down so drastically, was that the key problem was integration with the various vendors. Yes we all could look at the Html itself and make assumptions about poor practices but given that you are on the inside - what was the biggest issue?
That's what Mikey and the other Site Reliability Engineers fixed. They set up a war room with an engineer from each and every subcontractor, and the war room had three rules:
Rule 1: "The war room and the meetings are for solving problems. There are plenty of other venues where people devote their creative energies to shifting blame."
Rule 2: "The ones who should be doing the talking are the people who know the most about an issue, not the ones with the highest rank. If anyone finds themselves sitting passively while managers and executives talk over them with less accurate information, we have gone off the rails, and I would like to know about it."
Rule 3: "We need to stay focused on the most urgent issues, like things that will hurt us in the next 24-48 hours."
Once you have that process working, it's the same as optimizing software: you find the current bottleneck, fix it, find the next, etc. The Time article mentions two -- the lack of DB caching and the bad ID generator. There were dozens of things like that. And still are!
Hospitals don't let uninsured people die and insuring people doesn't magically save their lives.
Not sure where you're getting this. A quick Google Scholar or PubMed search shows a consensus that mortality rate is significantly higher for uninsured than for insured. [1, 2, 3]
[1] e.g. http://jpubhealth.oxfordjournals.org/content/32/2/236.short -- On multivariate analysis, uninsured compared with insured patients had an increased mortality risk (odds ratio: 1.60, 95% CI: 1.45–1.76). The excess mortality in uninsured children in the US was 37.8%, or 16 787, of the 38 649 deaths over the 18 period of the study. Children who were hospitalized without insurance have significantly increased all-cause in-hospital mortality as compared with children who present with insurance.
[2] e.g. http://journals.lww.com/jtrauma/Abstract/2012/11000/Undiagno... -- Undiagnosed preexisting comorbidities play a crucial role in determining outcomes following trauma. Diagnosis of medical comorbidities may be a marker of access to health care and may be associated with treatment, which may explain the gap in mortality rates between insured and uninsured trauma patients.
[3] e.g. https://www.sciencedirect.com/science/article/pii/S000296101... -- A total of 1,203,243 patients were analyzed, with a mortality rate of 3.7%. The death rate was significantly higher in penetrating trauma patients versus blunt trauma patients (7.9% vs 3.0%; P < .001), and higher in the uninsured (5.3% vs 3.2%; P < .001). On multivariate analysis, uninsured patients had an increased odds of death than insured patients, in both penetrating and blunt trauma patients.
This said, it is still a shoddy use of statistics. "1 in 1000 uninsured people die each year" by itself tells us pretty much nothing. What is the rate of death for insured people?
Wikipedia tells me that 8.39 in 1000 people die in America every year, so if uninsured people are only dying at a rate of 1 in 1000 every year, it seems to me that either it is beneficial to be uninsured, or uninsured people are not representative of the population (perhaps because many of them are young and healthy?).
I suspect that what is going on is this person actually meant to say something along the lines of "1 in 1000 people die every year in ways that could have been prevented if they had insurance" A subtle but important difference. The actual mortality rate of uninsured people is most likely much higher than 1 in 1000, but the deaths of uninsured people in motorcycle accidents would not be counted in that "1 in 1000" figure.
Either way, it is shoddy.
However, due to lack of regular care, by the time you show up at the ER it might be too late.
They don't do as much to stop them from dying. (Other than public hospitals -- of which there are a limited number with limited capacity -- they are only obligated to stabilize them in the ER and then, if they have further medically-necessary care but are stable, they can discharge them and/or transfer them to a public hospital if one is available, whereas those that have resources, insurance or otherwise, to pay would be admitted.)
> insuring people doesn't magically save their lives.
Strictly true -- it doesn't do so magically. It does so, instead, but the relatively mundane mechanism of providing them the ability to pay for care other than emergency stabilization, which reduces the probability of them having such care denied or delayed.
http://www.reuters.com/article/2012/06/20/us-usa-healthcare-...
The patient with metastatic cancer who needs chemoradiation on an outpatient basis must pay for his/her care.
Irrelevant, even if true. Uninsured people often don't go to the hospital until it's too late, because they know the expense will ruin them and they're hoping it will get better on its own.
I'm trying to reply to each person, but it may take a couple of days. :)
If, for whatever reason, you haven't heard back from me by Monday, please email again!
(The discussion on the 1 in 1000 fact has also been interesting, and I've personally learned a few new facts about the original study and what is controlled for. I'd rather have rigorous analysis of impact for everything, including and especially "good causes," than to give us a free pass.)
I emailed you on Thursday, haven't received a reply back. Is the Monday expect-a-reply-back time frame still good, or are you just buried under all of the replies? :-)
I don't want to spam you with inquiries if you're busy, just wanted to check in on this. Thanks.
To clarify, you don't need to be able to commit long term-- if you can take leave from what you're otherwise doing for a few months, that's enough.
If you want to work on something with real impact and help change the culture of government technology, email Brandon above! We're actively looking for a few good people.
What about your co-workers. What's everyone motivation to help fix this site?
How about sending to prison those that paid nearly 1BILLION for this site as well as the bankers and defense industry gluttons who stole trillions from us in the last ten years?
If I want to make my government modern - I'd put in place a system of accountability.
http://online.wsj.com/news/articles/SB1000142405270230381970...
I'm wondering - how is this perceived within the current team? Are you relieved that you will be getting reinforcements, worried that another big contractor could contribute to the complexity, or even disturbed that they could get the credit for fixing the site after all the hard work you put in?
I used to work at Accenture, so I'm curious as to how this will turn out.
Maybe I don't understand Obamacare well enough but I don't understand this statement (which I hear all the time on the commercials). Who couldn't get insurance before this website? I know the health care law did add guarantees around pre-existing conditions. So other than that, who couldn't call an insurance company directly (or use esurance or other portal) and sign up for insurance? This website is just a marketplace hooking you up with normal private insurance companies correct?
There are millions like me who can take risks for the first time, whether that's working for a small company or starting one. And I don't have to worry about the next 40K hospital bill burying me.
Who couldn't get insurance before this website?
You can only get the Federal subsidies through the insurance exchanges which was supposed to primarily be online, but had small phone support staff too. The phone support staff was completely overwhelmed due to the website problems, which left thousands with no method to get insurance.
I'd say the two most urgent roles we're looking for now are: * Site reliability engineers * Software engineers, including backend and frontend
If you do something else, like design, product management, or data science, feel free to send me an email anyway — I'm certainly happy to check around and see what's needed!
Basically, if you're a citizen and don't lie on applications and resumes and in interviews then there's really not any significant barrier to entry.
Haven't worked at Google, Facebook, whatever, but would love to help.
(I'm not in a federal marketplace state, though, and I ended up having my insurance canceled under ObamaCare and got a 364 day short term $750k policy instead. Still no idea what I'm doing in 2015.)
It's such a high-intensity project that I think the we'll want to keep it to full-time for the time being. Otherwise, it's hard to even keep up, let alone make progress.
(As a technical point, though, even though everybody is working on this for well over 40 hrs/week, we're technically hourly subcontractors. That's just how the government works.)
Is this in addition to the background rate? If true that would be quite astounding. Or is it just rounding?
Using that logic, how many have died due to the botched rollout of the website?
"Rule 1: "The war room and the meetings are for solving problems. There are plenty of other venues where people devote their creative energies to shifting blame."
Rule 2: "The ones who should be doing the talking are the people who know the most about an issue, not the ones with the highest rank. If anyone finds themselves sitting passively while managers and executives talk over them with less accurate information, we have gone off the rails, and I would like to know about it." (Explained Dickerson later: "If you can get the managers out of the way, the engineers will want to solve things.")
Rule 3: "We need to stay focused on the most urgent issues, like things that will hurt us in the next 24--48 hours." "
(long pause ...)
I sit in meetings weekly with mangers discussing issues that I know about the most but I can never get them to hear me out.
Good engineers are able to finish work even if you do not babysit them.
Not really an issue for them since healthcare.gov sort of became the dictionary definition of "crisis mode," but worth keeping in mind if you're on a project with a more normal trajectory.
I used to be this guy. The guy with the lofty ideas, but who thought the implementation was "beneath me". The guy who would sit around, waxing poetic about various features, user acquisition, header alignment, etc. Don't get me wrong I had serious technical chops, but fixing that annoying localization bug? Blegh. Form encoding off? Don't wanna get my hands dirty. I had "big ideas"! I was going to change the world! People who change the world don't do the dirty work! So I'm very empathetic to the Obama Administration.
Like them, I needed a real wake up call. In my case, a friend who had implemented an idea I had sold the software for a lot of money. When I confronted him about sharing the profits he started running git blame on files across the project. My name came up maybe once or twice, across a multi-k LOC project, and even then on nearly inconsequential lines. It hit me then that while ideas may have value, the implementation usurps all of it. An idea alone is powerful, but once it's implemented the idea becomes worthless. At that point it's all about rolling up your sleeves and getting shit done. When you focus on that problems like an "ID generator" becoming a bottleneck (I had to read that bit several times over... apparently I need to start raising my rates to the hundreds of millions) disappear. It's a hard lesson I had to learn, and it's one the Obama administration has hopefully learned as well. Of course, I had just turned 17 when I learned my lesson, and Obama is now a lame duck with less than 2 years left on his final term. I guess this exemplifies my greatest struggle with the Obama legacy, in that it has become one defined by squandered potential.
I also see you're a YC alum! If you're interested in helping out, or just to provide an error report on the problem you encountered, email me at brandon@hcgov.us.
HealthCare.gov had been constructed so that every time a user had to get information from the website's vast database, the website had to make what's called a query into that database. Well-constructed, high-volume sites, especially e-commerce sites, will instead store or assemble the most frequently accessed information in a layer above the entire database, called a cache.
It also struck me as a little funny that Time had to define the term 'cache'. Even my mom (74 years old) has some idea what a cache is (browser cache).
https://www.gsaadvantage.gov/ref_text/GS35F5457H/0LUS2P.2NVK...
Page 25. Top developer rate for 2014 is $99/hr which requires 10 years of experience.
If this happens the entire contracting landscape of DC would change dramatically.
Someone needs to disrupt the government contracts business pronto.
I know people who are involved in this. Just being able to bid takes decades and a network you either can't buy or need to be very rich to buy into. It takes either already being there or finding excellent bonuses (e.g. the kind of benefits that come with setting up your business in Detroit). And then you have to compete with the entrenched interests.
This is, or at least can be, far down the ladder from Lockheed-Martin. But it's the same kind of environment: If you're already there, it's easy money. If you're not, it almost certainly out of your league. If you know how to play the game, you still need to know the right people. If you do know the right people, you need to grease their palms. And once you've done that, you're part of the problem.
"Someone needs to disrupt x" is a magically simplistic and meaningless point of view.
It's an incredibly difficult thing to do, though. Procurement practices that are enshrined in law are much harder to disrupt than those that are just bad habits that ossified over time.
Awarding work in this way isn't necessarily a mistake. But when the selection process itself is broken, you end up giving a lot of work over time to a contractor that can't do the work.
Even then, a lot of the problems with Healthcare.gov were caused by incompetence on the government side of things.
A clinically-dead patient can be revived, but the condition they're in is far from OK.
It's definitely a form of mental dissonance.
The government needs a lot of help. I wish there were more crisis opportunities like this to use as an excuse to hire the right team to build good systems for citizens. Tough to get systems integration above the fold regularly to call attention to the issue.
how in the heavens would he know that you can deliver? you'll choose the one you'll know at least. and since he has documents to back him up(mcse, mcsa, he might have worked for microsoft for a while). he's the obvious choice.
i worked for the government in healthcare for a while. these are not intentionally malicious people. hell, they even want to make it better, but it's a combination of regulation(bidding system that favors friends), lack of knowledge, and a little bit of ignorance.
but if you want more details feel free to ask. it was kind of fun to see a corruption case close up.
This information troubles me, because QSSI was just hired to fix Maryland's broken Health Exchange site. It sounds like the company is cashing in on the donation of brandonb and others experts' time?
brandonb, is your team involved with the Maryland efforts, or is that a completely separate team?
To be clear, it's not like QSSI or anybody else is ripping us off. We're all getting paid the standard contracting rate. But many of us probably would've worked for free if they had let us.
I wonder if they meant that the default caching was turned off, or that all the queries had "no cache" clauses, or that an additional caching layer (Redis, Memcached) was not implemented?
Just for the record, contractor did not wanted to use it and argued the team have no experience with it. Someone in government decided it must be done that way (in spring or summer).
#1: Understand the customer!
In this case it's http://en.wikipedia.org/wiki/Karen_Ignagni (They lobbied a congressman from Chicago w/ donations to elect, and Republican side is pissed their side did not get more.) In EU, it tends to be written for the people, but in USA, it's the lobbyists as customers.
#2: You can't fix political problems with software!
For example we can make the problem 10 times less by allowing each state to manager Healthcare and compete for residents. Like Massachusetts. It's a fools errand. But you can milk the feds if you bribe the right official.
#3. You won't find good and un-employed engineers!
Not in SV anyway. A - type engineers are ~ $240K and up. Y-combinator is mostly n00b growth hackers, not expereinced coders. Plus the rumor is that you have to be loyal to the party of New Democrats as the main req, not software systems.
#4. I heard it's written in .NET and Oracle Access Manager.
A requirement? That's not what google plus, facebook or iTunes use or such use. I don't want to code w/ those people that use that stack ( but I would have a great time w/ them after 5pm, they tend to be nice people ).
Kalvin and Brandon: The most patriotic thing to do is to not try and catch a falling knife so that each state can have a system they own - and we can move to a state that has a good one. Party greetings to you.
It would not have been "micromanaging" for him to have done what was necessary to be sure that what he was saying matched up with reality. Yes, it was a giant IT project of the sort governments usually suck at. But that was the bill he got passed and signed. If his administration wasn't capable of leading that project to successful, timely completion, he has to shoulder much of the blame.
Cultural problems like this are often caused by leadership. Whether you will be told bad news depends a lot on your management style and on people you decide to work with. You do not have to micromanage, but if they are scared to tell you the truth, then it is often your own fault.
I'm not a regular time magazine reader, am I missing something here?
Just a fragment of old media leaking onto the internet.
http://infiniteundo.com/post/25509354022/more-falsehoods-pro...
You need both. Implementation people aren't all that useful without a vision. A vision isn't all that useful without implementation. It's a symbiotic relationship.
Steve Jobs without a Steve Wozniak probably wouldn't have been as successful. Steve Wozniak, without Steve Jobs, probably wouldn't have been as successful. But the two put together made some great things happen.
Same with the moon landing. As much as it took a tremendous engineering effort to put a man on the moon, it took someone with the vision and power to make it all work. JFK didn't get involved in the details, I'm sure, but he really helped to set the tone of the whole effort.
There's a fine line between looking at implementation as "beneath" your position and knowing when you're being more of a hindrance than a help. In my experience, nothing has driven me more crazy than a person above me who, while being a great project manager or whatever, tries to get involved with things that end up hindering the effort. If you take a weekend course on programming in Java, that's great! But don't start giving out "helpful" tips in something that is not your domain.
37signals' take on this was the best one I've seen (paraphrased):
Ideas are a multiplier. If your execution is good, a good idea will multiply that. If your execution is minimal, a good idea will scrape by. If your execution is abyssal, a good idea will make it worse.
I'd link the actual page in the book, but I have always had trouble finding it.
That said, obviously they should have brought in the campaign website team to oversee this instead of doing the standard federal government contracting route, which leads to a late, over-budget project literally every single time.
That's called cronyism, and, for the most part, it's either against the law, or will get you destroyed in the media. One of the biggest challenges in government is that, for those of us in startup-land, the process goes something like: "I need to hire someone, I'll call my friend who I know does good work". You can't really do that in the government, or everyone who isn't your friend won't be happy.
The standard federal contracting route is certainly a mess as well. The underlying belief that everything can be reduced to a series of checkboxes, and whoever can check the boxes the cheapest wins leads to a disaster.
Hopefully, one of the outcomes of all of this is we rethink how the government software (and other sorts of procurement) process is done.
Can you suggest some effective mechanisms by which "political opponents" have been able to "sabotage" their efforts? Do these people get depressed when they hear an eeeevil Republican saying what they're doing is wrong, or even evil?
And by my calculations, since we're several months out from the mid-terms, Obama has well over two years left. Not that I'm expecting much from them.
Especially in areas where I have expert knowledge, a definition like that gives me reference on what the general knowledge is, and teaches me to articulate my knowledge better.
Kudos to your Mom, who I'm guessing knows what a browser cache is from talking with you, but this detail is technical enough that a quick explanation is in order.
This definition is concise and descriptive and isn't long enough to derail the gist of what the article is talking about.
Depends on what industry you work in. A Cache may look more like a giant pile of weapons as opposed to some memory in a computer.
http://en.wikipedia.org/wiki/Cache
http://www.etymonline.com/index.php?term=cache&allowed_in_fr...
[1] "make what's called a query into" instead of just "query"
b. The explanation of cache seemed a bit too plain and didn't give enough context in the article. I was thinking an analogy might have work better, such as:
Caching is way of reducing the amount of work that needs to be done by a system. Suppose you had a system that was hooked up to a thermometer and reading the temperature from this thermometer takes 1 second.
Without caching, every time you asked the system what the temperature was, it would do a new reading from the thermometer. If 1000 people asked the system what the temperature was, it would do 1000 readings, which would take 1000 seconds collectively.
With caching, the first time the system was asked, it would do a reading and it would save the reading somewhere it could get it much faster than 1 second, let's say 0.01 seconds. For all subsequent readings, it would use the saved reading, until enough time had pasted to do warrant doing a new reading.
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Obviously, my version is 3 paragraphs long so it's not ideal either :D
More importantly, as it only requires emergency stabilization and not further care to be provided without regard to ability to pay, once they are stabilized they can be discharged instead of being admitted.
It can be adapted to what can we actually decide now rather than to discuss possible future paths (the more speculative discursive stuff can happen in other meetings).
Some people have theorized that Accenture's new role is to quietly replace much of the current code base with their not quite so horrible California exchange code.
To give some background, 36 states use the federal marketplace, and 14 built their own. Covered California is run by the state of California, with an independent contracting company, codebase, set of servers, etc.
We do have some ideas about how to improve that situation over the long term, but those will take time to bear fruit.
That said, I also think that the current procurement methods are broken and that a less rigorous procurement process would eliminate contractors that specialise in government procurement.
One way would be to implement a randomised audit where the deal would be re-examined and the procurement officer would have to defend every choice he made. if 5% of the deals were audited then bad actors would be caught very rapidly.
An other approach would be to adapt the jury-trial approach to government procurement and have them review every procurement contract.
Third approach would be to combine this to reduce the workload.
Ah, yes, the classic American healthcare problem. The poor person just gets to go to hospice and keel over. The rich person gets to limp along, endure 3 rounds of chemo, and spend the few remaining months of her life hooked up to machines in what is arguably a Pyrrhic victory and even lower quality of life.
Many others don’t survive, obviously, but the chance of survival of many cancers really isn’t so bad.
Given this, I would argue the "poor person" in this argument could easily get similar levels of necessary care as the insured individual through Medicare. The insured (preferably rich) person could however travel to all the best clinics, participate in many medical trials and experimental operations, and quite likely simply spend their final months of life as a guinea pig with a similar outcome as the "poor person." The only upside is the insured individual gets to bankrupt themselves and family in the process as insurance doesn't cover most of these non-standard therapies. I've seen it happen to too many people.
This is also one of rare times where we have a non-zero chance of pushing the government towards solving technological problems in better ways than hundred million dollar contracts with broken specifications for projects that are doomed for failure.
Kalvin is a friend of mine, and when he called me up I saw it also as a chance to work with a good friend and a great group of people, so it is exciting as well. It has been a great experience working with Brandon and everyone else on the team.
Damn it. Thanks. :P
That said, it's not a bad living wage. I suspect below industry standard though, is what these folks are saying.
Of course, I guess I should have assumed that, there aren't many direct government jobs for this type of thing anymore, it seems.
Speaking from experience as capture manager.
http://www.forbes.com/sites/theapothecary/2014/01/18/coverag...
"Instead of expanding coverage to those without it, Obamacare is replacing the pre-existing market for private insurance. Surveys from insurers and other industry players indicate that as few as 11 percent of those on Obamacare’s exchanges were previously uninsured"
But wait a minute! Obamacare was supposed to cut my rates my $2,500 A YEAR right? WRONG. Apparently, it still costs too much for the people who really need it:
"Of those that didn’t sign up for Obamacare-based coverage, 52 percent stated that “affordability” was their biggest complaint with the exchanges’ plan offerings. Only 30 percent cited “technical challenges in buying the plans.”
"Joan Budden, chief marketing officer at Priority Health, told Wilde and Mathews that Michigan’s health insurers had expected 400,000 uninsured Michiganders to enroll in exchange based plans during the initial enrollment year. According to the latest data from the Obama administration, as of December 28, only 75,511 had “selected a marketplace plan.” Of those, only an unknown fraction had paid their first month’s premium, and therefore were actually enrolled in new health coverage."
So if this is such a success, why isn't the White House trumpeting the real numbers of people who've signed up then??
http://www.washingtontimes.com/news/2013/oct/4/white-house-s...
"For the fourth day in a row, the Obama administration on Friday declined to release figures on how many Americans have purchased health insurance through the just-opened online markets tied to the new health care law.
White House spokesman Jay Carney told reporters that millions of people have visited the federal HealthCare.gov site, which directs people to coverage options, but he did not have “specific data” at this early stage in the enrollment period."
There are better ways to do this than handing over 1/3 of our economy over to the Federal Government. You want competition? You can start by letting insurance companies deal across state lines. More competition, increased quality of care, lower costs and better care for everyone.
And that's really saying something, because the first link is an OpEd by Mitt Romney's former health care advisor who is a senior fellow at a conservative think-tank.
Some of the downsides of allowing health insurance to be sold across state lines are addressed at http://www.kaiserhealthnews.org/stories/2010/september/30/se... - and they include an AEI fellow's views for balance. The auto insurance market is a hybrid, though, and doesn't show a large cost savings for states that effectively allow cross-state lines operations via identical regulations.
I think it's also fair to ask also why health insurers that operate in all/most states (UnitedHealth, Aetna, Cigna, Athena, etc) are not substantially cheaper that BC/BS peers that don't.
You don't know what you are talking about. My mother-in-law makes shit money, and yet she has a plan that is extremely affordable for her.
Your a partisan hack, and your facts are regurgitated from professional partisan hacks. Your absurd "handing a 1/3 of our economy over to the Federal Govt" comment points out your biased sources of knowledge. How is a website which matches consumers with private insurance companies equate to "handing over" to the Federal Government? What planet do you live on? Alabama?
We also make API calls into the existing system, which is written in Java, so it helps to be able to grasp a complex Java codebase with way too many layers and enterprise systems. :)
But mostly, we're just looking for great software engineers who want to make a difference, not any particular set of acronyms.
And I recall that one of the trickier requirements is correctly sending and acking enrollment info (EDI?) to and from the many (dozens?) of insurance companies involved. Is that piece looking ok?
Like many films, it hasn't aged very well. It relies on the atmosphere that existed at the height of the Cold War, and a certain atmosphere of darkness and paranoia that's less popular as a plot device in modern times. Also, for a modern audience it would have required better special effects, using methods that didn't exist at the time.
A recurring and important (to me, anyway) question here is how technical skill may be leveraged to provide real value to the world. This is a hard and unanswered problem. This [brandonb's] statement is so strong that, if it were true, it would eliminate a vast territory of alternate [possibly correct] paths to answers ("oh, you did X? My code saved 50 lives this year."). So it [brandonb's statement] is worth challenging (or correcting) more so than any random statement here. And yes, I do view promoting accuracy (even disillusion) as fighting for the cause.
I hope Brandon will accept my sincere thanks for working on something that is important. Irrespective of health impact, the financial risk borne by the uninsured is an important issue and not controversial.
edit: clarifications in []
"This is a hard and unanswered problem. This statement is so strong that, if it were true, it would eliminate a vast territory of alternate paths to answers ("oh, you did X? My code saved 50 lives this year.")."
It seems like you are more of the problem rather than Brandon's statement. No matter what Brandon says, accurate or not, people will still find a flaw in it. People will see what they want to see.
If you want to eliminate alternate paths to answers, the sure way to do that is not say anything at all.
I believe the following are potentially bad consequences of Grayson's/Mikey's claim spreading:
- People work on insuring others, at the expense of other activities that they would otherwise believe to be more valuable.
- Insuring people (or the ACA) is deemed a failure because mortality rates do not come down as "expected", plausibly leading to the ACA's repeal.
- A developer expends time working on the project expecting mortality rates to improve; when it doesn't, the uncritical idealist becomes an uncritical cynic, rejecting any future promise of saving lives/improving things.
Right. It sounds like you're implying that was his intent, and he failed. I really think it was an noble effort to get to the heart of what might be a misleading soundbite. Very much in the spirit of HN.
Is the spirit of HN nitpicking the smallest things?
I'm actually not sure the study authors should be blamed.
But: given how politicized this question is, they could have reasonably anticipated the misuse of their results, and thus could have written their results in such a way as to avoid this. Or they could have publicly corrected non-experts who cited them for causation. Or: they could have controlled for factors that would make mortality and insurance-status independent. This last option is difficult & requires complex judgement calls (see [1] for a reasonable attempt), but even if you feel the other two aren't required of academics, this last one very much may be.
(Separately, I agree that Politifact should not be trusted automatically, but these seem like reasonable analyses, and I did not quickly find anything better.)
This is an appeal to authority. And unfortunately, the evidence is accumulating that there are problems with that authority. The success of peer-review depends on the quality of the peers and of the review. If those reviewing don't understand how to evaluate a correlation study, or do understand but don't take the time to properly evaluate it, then garbage will slip through.
It turns out, lots of garbage is produced and sent to the reviewers, as was noted in a recent Nature feature:
http://www.nature.com/news/scientific-method-statistical-err...
see also:
http://www.nature.com/news/weak-statistical-standards-implic...
http://www.nature.com/nature/focus/reproducibility/index.htm...
---------
tl,dr; lots of crappy correlation studies are published in peer-reviewed journals. These studies later turn out to be irreproducible.
Also, while "Correlation is not causation" is, as you mentioned, a tired canard on the internet, people often seem to forget that all things that do have a causal relationship with have some form of association. Association doesn't prove causation, but it's a damned fine first step, and miles above "guessing", which is what happens without evidence.
Probably taking away insurance from people who have it as an experiment is too extreme, and not implementable anyway. But is it really that unethical to take a subset of population without insurance, give it to a random subset for some time, and observe the differences? Why? No one from the control group is prevented from getting insurance on their own (compare with the candidate drug trials, where the control group can't just buy the drug on their own).
No, it's not set in stone, but if you're talking about implementing studies now, you're not going to get major medical ethics reform first. You go with the system you have, and the system you have is probably going to push back pretty hard.
> No one from the control group is prevented from getting insurance on their own
This alone is a difference between the control and treatment groups that takes place post randomization, and knocks said experiment back into the realm of "correlational"
So, no, you never prove anything nor imply anything at all with correlation. You're still guessing.
There are all kinds of things that we cannot prove, because it is either impossible or wildly unethical to conduct a randomized study. For those things, you can make a determined effort to control for as many "third factors" - the technical term for them is confounders - and that gives you a level of evidence which is well above guessing.
Since I can't reply to your comment, my responses here:
> "You didn't say proof but you said it's better than guessing, and I don't agree with you at all."
It is better than guessing. You're welcome to disagree, but a well conducted observational study is considerably firmer evidence than pulling it from your posterior.
> "What if there is a correlation between Vegetarian-lifestyle and Serial-killers ? Does it tell you that it's better than guessing ? Do you even question if the association/correlation makes remote sense ? Is there any underlying mechanism of action that would remotely explain rationally why this correlation could be linked to any real causation phenomenon ?"
All you've done is describe a really bad study. You can have really bad RCTs as well, by the way.
Of course you question whether or not an observed association has a clear biological or social mechanism. And you attempt to control for other variables that might influence the link between your exposure and your outcome. You run followup studies in different populations to try to understand if the result is a widespread phenomena, or a fleeting bit of statistical noise.
Basically, you do your job well. Which is why I used phrases like "a good first step".
Your example is about as useful as "Programming is useless because once I coded something poorly and corrupted my data".
This is a totally unreasonable stance to take. You can't even imply anything at all with correlation? Really, nothing at all? It's no better than a random guess? Try actually doing some actual science with this attitude, and keep to it consistently, and let me know how far you make it. In fact, try the same thing with ordinary life, any kind of reality where your decisions have consequences in reality.
FTFY
Blood pressure medication will almost certainly add many years to my life - decades, maybe. Without insurance, I couldn't have afforded the half-dozen trips to the doctor or the meds. And I'd wind up getting lifesaving treatment for an early heart attack or stroke in the ER.
I'll take the insurance, thanks.
(I'm assuming that your doctor charges $250 or less per visit. Six visits would cost $1,500. I'm assuming those visits were spread over at least a number of months, so you could see whether each medication was effective. I'll also assume your health insurance is at least $400/month, though that number is likely higher if you're over 30 or female. This means your six visits cost roughly four months worth of insurance premiums.)
I have a friend a few months younger than me. She makes less than $15k/year, and has two children living at home. Under those financial circumstances, she has totally paid off her home, which should tell you how frugal and responsible she is. She has also experienced extensive hospitalization due to illness. If she had to pay for that (it was paid for by state-subsidized health care), she'd have lost her house.
edit: Medical costs are the leading cause of bankruptcy in the US.
Well, that just a visit. What about lab tests? Doctor offices can do some basic stuff in-house, but for anything interesting, it has to be sent to an external lab. Depending on the tests, that could be $500 USD a pop, easy.
And the medication is expensive too. That drug may be costing the patient $15 per refill, but it definitely costs more than that in total.
This is actually the problem for a large group of insured. It would be cheaper to pay out of a health saving account and have catastrophic insurance than pay the continuing insurance premium. This is especially true for young workers who we are now forcing into an additional cost to support older workers. For the price you were paying for insurance, the health saving account and paying out of pocket for those exams would have been cheaper. People unable to pay that should have been the ones helped by a health care law, not the typical consumer.
If we would get rid of this "one size" crap and deal with the groups we actually have (e.g. "ongoing expensive care", "typical person", "catastrophic"), we would have had a much better system. Grand visions suck for normal people.
What, you think nobody plays hardball in DC?
"What, you think nobody plays hardball in DC?"
National level Republicans as of late have been playing badminton at best.
That you cannot cite "some effective mechanisms" after making such a broad claim suggests to me that you're approaching this discussion as a political, not a technological, one.
Yes.
Before instituting Obamacare/Romneycare/$POLICY, we should have run a pilot program based on random assignment with clear predefined success metrics. But that's politically dangerous - after all, what if the experiment shows that $POLICY doesn't work?
We did that, by accident, in Oregon (google Oregon Health Experiment). There were no statistically significant results beyond the placebo effect [1]. Strangely, none of our fact based politicians have proposed scrapping the medicaid expansion based on that.
[1] People with insurance perceived themselves to be healthier before actually consuming any medical care and became less depressed. But no statistically significant difference was observed in any of the objective metrics chosen before the study started.
As for the Oregon study, the results of that study are still relatively new (the idea that any measure focused on preventative health will show results after two years is pretty suspect). The authors of the study discuss this for diabetes:
"Medicaid significantly increased the probability of being diagnosed with diabetes after the lottery (by 3.8 percentage points, relative to a base rate of 1.1) and use of diabetes medication (by 5.4 percentage points, relative to a base rate of 6.4). As discussed in the paper, based on clinical trial evidence on diabetes medication, we would expect this increase in the use of medication for diabetes to decrease the average glycated hemoglobin level in the study population by 0.05 percentage points, which is well within our 95% confidence interval for the impact of Medicaid on the level of glycated hemoglobin."
As for the number you are cherrypicking, it is true that health insurance increased medical consumption (including ER visits, in spite of what ACA supports claimed) among people who received it. However, no measurable effect on health (besides depression) was observed.
A lot of uninsured people can get medical care in emergency rooms which are not allowed to turn them away, but then the cost adds one more huge burden on top of an already-difficult struggle to get out of poverty.
Which might be the case. You argue that Oregon showed that. Doesn't that paint medicine as a huge fraud, regardless who is paying for it?
So that's part of what happened - if you look at the data, both the control and treatment group did consume medicine. You don't need insurance to get treated. But medical consumption increased in the treatment group - it just didn't improve health. That suggests medicine has a point of diminishing returns, and people without insurance already consume enough to reach that point.
(Also, a caveat: the Oregon Experiment was too short to measure an effect on life expectancy. They measured several other proxy health measures instead.)
Someone who works for 'Bayesianwitch' should know better than to rely on p = 0.05 as the sole basis on which to evaluate something.
correlation doesn't mean causation.
>to help make our government work better
i somehow doubt that throwing a team of "rockstars" to clean up the mess is making the government to work better. If anything, it enables the typical government behavior we saw in the case of healthcare.gov.
As a statistician, I guess I should be happy that more people are aware of this. But I also think too many people are taking "correlation != causation" superficially. I mean, almost all of science is based on significant correlational findings, especially when the traditional way to prove causation (i.e. via randomized trial) is unethical (i.e. we can't randomly assign people to be insured vs. uninsured).
Along these lines, I often find people who say "correlation != causation" don't stop and wonder "so how _can_ we prove causation (in a non-randomized study)?" I guess many of them can be partially excused since the answer is non-trivial. But generally, here's a few rules of thumb for making a stronger case for causality from correlation:
* the effect size is relatively large (e.g. uninsured children die at 60% higher odds than insured children)
* the cause comes before the effect (e.g. people are uninsured before they go to the hospital and/or die)
* reversible association (e.g. risk of dying at a hospital changes when people get insurance)
* consistency / consensus across multiple studies (e.g. many studies showing that a difference in insurance status is associated with a significant difference in hospital mortality )
* dose-response relationship (e.g. I didn't link examples previously -- but there were a few studies showing that different levels of insurance, from none to Medicaid to private, is associated with different rates of hospital mortality)
* plausibility (e.g. even from a qualitative point of view, it's quite believable that people who unable to pay a hospital bill might get worse service)
Once you control for this, and other potential common causes, your case for causality becomes much stronger (or non-existent).
there's no such thing as a monolithic 'government' being that can either work better or be enabled to act a certain way. there are people, and groups of people that do certain things. some of those things are worthless, some of those things are worthwhile. i'd argue the mess the 'rock stars' cleaned up is a generally positive activity.
i'm just saying that being from a poor or damaged family, uneducated, having mental illness or substance abuse problem, etc... usually leads to higher mortality and also to not having health insurance. Giving them a health insurance [i'm all for it, i think modern civilized society should provide basic level of free health insurance to everybody] would be inconsequential in many cases as not having the insurance isn't the cause, just a manifestation.
>there's no such thing as a monolithic 'government' being that can either work better or be enabled to act a certain way.
http://en.wikipedia.org/wiki/Systems_theory
and if we specifically consider a closed loop system of "government + society" then this may be of interest too:
So, the same problem every vendor encounters when doing a software project. I cannot tell you how many "lay people" can't simply grok this.
They don't finish the last coat of paint, load an air wing, and send it out on deployment.
The other big problem is operations — many steps are done manually which should be done with tools like chef or puppet. When you have a lot of manual steps in your deploy process, it makes the whole system harder to scale, test, modify, and keep running. "Devops" has become a buzzword but it's definitely needed here.
Especially the latest one, where the Park Service went to great efforts, employing a lot more armed Rangers to keep people out of anything they could claim as their turf, including things open 24x7 without corresponding 24x7 coverage, like the WWII Memorial. But not, curiously, a rally for immigration "reform".
Look, I spent a dozen years "inside the Beltway", I know political theater when I see it. It's just that, not "hardball". Heck, they even made the furloughed employees whole, as they have in times past.
I would have said that looking at chronic health outcomes after just a few years was probably a losing proposition, and asked to see some power calculations, or a longer term analysis plan.
I've done so for other studies. Was actually grousing about one in a meeting...two weeks ago?
I believe the ACA should be understood to promise increased insurance rates leading to (a) less medical bankruptcy and (b) moderate improvement in certain healthcare measures (not mortality). I don't think it should be deemed a failure in any sense if it fails to reduce mortality amongst the newly insured.
Correlation is useless, and there's a ton of observational studies out there finding correlations every single day for which we have no rational explanation at all. Observational studies are full of variations in the way they are designed, the way they are reported and the subjects of the studies, it's rather a miracle if you actually detect a hint of causation based on the garbage noise that you get.
How can you tell if you missed one?
> [...] gives you a level of evidence which is well above guessing
> It is better than guessing
Why? Without any support, this seems to be an appeal to probability.
> a well conducted observational study
> a really bad study
The fallacy of moving the goalposts; also the no true Scotsman fallacy.
Similar studies, using as many variables as you can find. Residual confounding is always and ever a problem, but the odds that something is both a strong residual confounder and has never been observed to have an association with the outcome or the exposure is pretty rare?
> Why? Without any support, this seems to be an appeal to probability.
It's really not - if for no other reason than it's forced you to think about your system more than a simple guess would. It's not an appeal to probability, its using data to update whatever prior you came in with. Guesswork is just using your prior.
> The fallacy of moving the goalposts; also the no true Scotsman fallacy.
Not really, no. Some observational studies are crap - this is just true. But that doesn't say anything about the potential quality of observational evidence, and many of the commonly raised objections to observational studies are actually objections to poorly run studies. The example used was a study that examined no potential confounding variables, looked at a correlation with no prior evidence suggesting any linkage between the two or biological plausibility, and then asserts that they've found a causal link.
That's a bad study. It's not 'No True Scotsman Fallacy' to say that the problems with a bad study don't generalize to all studies. If it is, then we're all screwed, because you can run a bad RCT too.
Appeal to probability; appeal to common sense.
> Some observational studies are crap - this is just true.
Special pleading.
> But that doesn't say anything about the potential quality of observational evidence
Straw man.
> many of the commonly raised objections to observational studies are actually objections to poorly run studies
> That's a bad study.
Moving the goalposts. No true Scotsman.
> It's not 'No True Scotsman Fallacy' to say that the problems with a bad study don't generalize to all studies.
Straw man.
In a study by Elizabeth Warren that scored any bankruptcy which included medical bills in the discharged debts as their "being the cause" of it, no matter what the fraction they were.
http://www.businessweek.com/bwdaily/dnflash/content/jun2009/...
> Honest, non-snarky answer... to be pedantic, for me it's not a question of affordability.
This is a pretty good representation of the quality of health care discussion on HN.
The original study that showed aspirin's effect on heart attack prevention comes to mind for the former circumstance, and a number of HIV prevention studies for the latter.
Either way, no point in continuing this.
Beyond that, in an intentional randomized trial, rather than the 'happy accident' like the Oregon study, the actual control is not 'Nothing' but the medically indicated standard of care. Studies are often required to provide medical care, education, etc. to their participants. I cannot imagine a study managing to get "We deny a bunch of folks health insurance" by an IRB unless it was an externally forced process, like the Oregon study.
Your insult about not understanding statistics, in addition to being off-base, is rather spurious. This isn't a statistical question, it's a public health ethics question. Statistics doesn't really come into whether or not "Keep a bunch of people from accessing healthcare" will get nailed by an approval board.
Also, the FDA often does take observational evidence into account, especially when expanding things like what age range a drug is medically indicated for.
"Your new homepage goes viral, but you aren't sure what copy is converting. Hook that copy up to BayesianWitch and only converting copy will be showing. No waiting days for the answers from an A/B test."
Seems to imply a reliance on "correlational" data. Is there some hidden randomization in there? Or are you giving your clients a lower standard of evidence?
Underemployed (part time, whatever) or sort-of-poor and not disabled people in their 50s are a major segment who can't pay the real cost of their medical care, though. Or, people with lifelong expensive illnesses in the 0-64 age range (who are often making a lot less money than median, too, due to their medical conditions.)
Those in their 50's should have had some cash built up from earlier savings, but they spent it all on premiums instead of building up a hedge. Lifelong illnesses are something that we should just acknowledge as bad for insurance and deal with otherwise. Insurance should be for events and not continuous medical conditions.
We have not dealt with the price of medical care in a sane manner. I don't think the political will exists to break the current insurance scheme while at the same time not overreaching with government.
Being old is just a series of increasingly severe health events till one of them kills you.
Even people with dementia don't typically last longer then 10 years (which is the sort of time frame you're looking at for people who recover from cancer to stop racking up bills).
The concept of insurance we use for healthcare is broken.
You act as if an expansion of Medicare to cover prescription drugs was an alternative to the more recent reforms, rather something that already happened prior to them and did not, as you suggest, address the problem that the more recent reforms were aimed at.
Similarly, if you have 10,000 seo-optimized microsites, each with traffic too low for a per-site A/B test, we'll improve your conversion rate across the 10,000 microsites.
If you want to make a long term change (e.g., logo, button color, feature) for a high traffic site (your one and only landing page) you are better off using a traditional A/B test.