The Midterm Grade for HealthCare.gov

Mark Wilson/Getty Images President Obama delivering remarks about the problematic debut of HealthCare.gov in the White House Rose Garden on Monday.

Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.

I was challenged by people who commented on my last post to opine on the troubled rollout of the federal health insurance exchange HealthCare.gov, and I will oblige.

The best place to start is President Obama’s remarks in the Rose Garden of the White House on Monday.

Shortly before the president’s appearance, White House officials let it be known that the “president will directly address the technical problems with HealthCare.gov - troubles he and his team find unacceptable.” But in that Rose Garden appearance, the president did not explain what the technical problems with HealthCare.gov were, though he did acknowledge their existence and stated “there is no excuse” for them.

He then promised that in a techno-surge he would recruit the best information technology talent in the country to come to the rescue and fix the problems. It made me wonder why the A-team, as the White House now calls it, was not enlisted in the first place.

President Obama taught constitutional law at the University of Chicago Law School. How would he have graded a student’s performance on, say, a term paper or test that the professor viewed as “unacceptable,” especially when there was “no excuse” for the paper’s deficiencies?

One would hope that the grade would have been F, even under modern grade inflation. I certainly would affix that grade to such inexcusably deficient work.

But who exactly should be assigned the F for the troubled rollout of HealthCare.gov?

At the Rose Garden ceremony, President Obama noted, “There’s no sugar coating it, the Web site has been too slow, people are getting stuck during the application process, and I think it’s fair to say that nobody is more frustrated by that than I am.”

That makes it sound as if the president was surprised and then angered by the poor performance of HealthCare.gov. Indeed, in a television interview Tuesday with Dr. Sanjay Gupta on CNN, the secretary of health and human services, Kathleen Sebelius, appears to suggest as much, even though HealthCare.gov is reported to have crashed days before the start on Oct. 1 when only 100 people tried to register simultaneously.

As someone who has lectured on corporate governance and served on corporate boards, I find Secretary Sebelius’s statement astounding. Is this how the project was managed? They knew the Web site was not working and yet decided to go ahead with it anyway, without the president’s personal O.K. for so strategic and risky a decision?

Once elected, a president becomes chief executive of a giant federal enterprise. Anyone familiar with corporate management would have thought that for as ambitious and technically a complex project as the initial rollout of HealthCare.gov - so important to many uninsured Americans and so politically important to the White House - the chief executive would have remained in very close touch with the management team overseeing the project and thus would have been briefed daily or at least weekly on the progress of the project and especially on any problems with it.

Woe to the members of the management team in a corporation if problems with a project are hidden from the chief executive when they become known, exposing the chief executive to embarrassing public relations surprises. Heads would roll. The board, however, would assign the blame for such problems not primarily to the management team and instead to the chief executive himself or herself. He hired and supervised the team.

From that perspective, the blame for the disastrous rollout of HealthCare.gov goes to its entire management team, to be sure, but primarily to the chief executive on top of that project. In my view, not only the proverbial buck stops on the chief executive’s desk, but, for the management of this particular project, the grade of F goes there as well.

It is worth reminding readers, however, that grades on midterm papers or tests do not constitute the overall grade in a course. Students receiving an F on a midterm paper or test often end up with a respectable overall course grade, spurred on in part by that very failure.

Similarly, with enormous effort and, one hopes, constant future supervision by the chief executive, there is hope that the technical problems encountered so far can be fixed in time, with the celebrated A-team of software experts now on the scene.

Finally, it bears emphasizing that the ill-fated rollout of HealthCare.gov should not be taken as a commentary on the concept of health insurance exchanges in general, nor on the Affordable Care Act.

The idea to use means-tested public subsidies to assist low-income Americans to purchase competitively offered private health insurance sold through health-insurance exchanges has been popular among policy analysts and policy makers of both political parties since the 1970s. Any such exchange will have to have roughly the same kind of architecture and tasks as those required for HealthCare.gov, as is shown in the sketch below.

Particular versions of this general construct were built into the Clinton health plan in the 1990s and the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (Part D of Medicare). It was also part of the health reform plan proposed by Senator John McCain, Republican of Arizona, during the presidential campaign of 2008 and of the Patients’ Choice Act proposed by Senator Tom Coburn, Republican of Oklahoma, in 2009.

Indeed, it has been the foundation of every health reform proposal in the United States other than the single-payer Medicare for All idea since the 1970s. And it would be the core of the defined contribution plan now being proposed by Representative Paul Ryan, Republican of Wisconsin, for the Medicare program.

Now, it may be argued that private electronic health insurance exchanges - for example, eHealthInsurance.com - have long been available to Americans in the market for individually purchased private health insurance, obviating the need for a new HealthCare.gov. That would imply an unfair comparison.

EHealthInsurance.com is a purely passive exchange that merely lists the policies and estimates of their premiums for sundry health insurers listing on the exchange. It does not grant subsidies toward the purchase of health insurance and establish eligibility for those subsidies, nor does it guarantee prices. It simply refers interested individuals to insurers to purchase policies, which are not community rated but actuarially priced. Such an exchange can be quite simple.

If one wants to couple means-tested federal or state government contributions toward private coverage - as the health-reform plans proposed by both parties do - then by necessity the insurance exchange must ping and interact with numerous other Web sites, each with its own software language of various vintages.

The sketch below illustrates that construct, but only for the most important linkages that must be pinged. HealthCare.gov probably has to ping still other sites. Such an exchange is incomparably more difficult to establish and prone to computer glitches than is, say, eHealthInsurance.com.

But several states did manage to establish on time such complex health insurance exchanges under the Affordable Care Act, with only minor rollout glitches of the sort one would expect. Somehow they managed.

With proper management and more energetic work earlier on, and untainted by the political desiderata reported to have affected the architecture of HealthCare.gov, that Web site’s management team should have been able to achieve the same success. It did not, hence the midterm grade F.