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Nine months before the country’s Obamacare insurance marketplaces were due to debut online, the agency responsible for building the District’s version made its first hire. No state began work on its marketplace later than the District.
“So that was the worst year ever,” says Mila Kofman, the D.C. Health Benefit Exchange Authority’s executive director and first staffer, as she thinks back to 2013. “I call it a high-risk pregnancy. Seriously, every day was quite challenging.”
When the nationwide due date arrived in October 2013, the federal government’s marketplace, HealthCare.gov, face-planted. The website’s persistent outages and malfunctioning software were an embarrassment.
Just a few state marketplaces—the District is treated like a state for the purposes of the insurance exchange—successfully opened on time, and one of them was the District’s miracle baby, DC Health Link. Today the site functions so well that Massachusetts is copying its code.
But at first, DC Health Link couldn’t do much more than crawl. Kofman says, “We had no bells and whistles at all,” just a basic system whose core functions worked. “Part of my job was essentially to say no to everyone—my board members, to staff, to other agencies.”
The software, from commercial vendors, was clunky. Even fixing a typo on the website required the agency to run a bunch of tests, bring the whole system offline, and then deploy it anew, as if from scratch.
One of its glitches caused the system to characterize every customer as a smoker, which non-smokers could see but do nothing about. This ultimately didn’t matter to the District, as it had opted not to surcharge health insurance for smokers. But the arduous update process meant the glitch took time to quash, and a lot of irritated non-smokers fumed, including Kofman.
“I was highly offended when I saw that they built that. And you can’t just change it like that,” she says.
The agency and its new contractor set about redoing the DC Health Link software in 2015, applying tools that are standard in Silicon Valley—Ruby on Rails, MongoDB, Amazon Web Services cloud servers—but still relatively exotic in government.
The revamped software is also open-source. Anyone with an Internet connection can view the code and suggest edits. It’s publicly visible on the agency’s account on GitHub, a service for developing and sharing software, chronicling code changes large and small pushed out multiple times each day. It’s a long way from the days of waiting to delete an errant comma from the website. The agency also no longer has to pay recurring licensing fees for proprietary software.
The grander promise of open-source software is that anyone can copy it, free of charge.
For DC Health Link, this isn’t theoretical: Massachusetts is cloning the District’s code. The ancestral home of Obamacare, a state whose healthcare overhaul preceded the landmark federal reform, is now adopting D.C.’s software for the part of its marketplace that handles insurance for small businesses.
“D.C. was able to offer: Take our platform, create an instance of it for you guys, and then customize it a little bit,” says Jason Hetherington, chief information officer of Massachusetts Health Connector.
Massachusetts is paying the DC Health Link software team to implement and maintain it. The D.C. Health Benefit Exchange Authority also earns a 6 percent administrative fee.
Massachusetts didn’t go looking to hire a government rather than a business, nor was it targeting open-source software. “No one ever gets fired for choosing IBM,” says Hetherington, citing an old business-world saying. “If you need a database and you propose Oracle, everybody thinks it’s a really good idea,” he says.
Massachusetts embarked on a routine procurement in 2014, going in search of a contractor to redo its small-business marketplace. None of the commercial proposals were fully adequate. Massachusetts tried another round a year later, unsuccessful once again. Then in 2016 it reached out to states whose marketplaces had strong reputations, looking for a partnership.
D.C. edged out Rhode Island as the winner.
“They were just the most modern, the most well-developed, the most resilient technology platform that we had seen in either of the prior commercial responses or in comparison to the other states we looked at,” Hetherington says.
He echoes Kofman’s emphasis on cost savings, noting they don’t have to pay software licensing fees or make a capital investment in servers to host the platform, instead renting only as much cloud computing power as they use.
Though a repeal of Obamacare could be devastating for people who receive subsidies to buy insurance, it would not necessarily doom state marketplaces. DC Health Link is funded by a 1 percent tax on the insurance companies doing business in D.C.
Once the August launch in Massachusetts is finished, sharing software will mean that D.C. and Massachusetts can split the cost of any new features they both want to see built.
Kofman has reached out to Minnesota about the possibility of adopting D.C.’s open-source software there.
“I would love to partner with other states as well, because it will make it less expensive for us and Massachusetts,” she says.