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MNsure technology barriers are barriers to coverage

MNsure.org screenshots

Tuesday was the start of open enrollment under the Patient Protection and Affordable Care Act, using new state health insurance marketplaces. In Minnesota — and across the country — technology issues impeded enrollees from learning about plan options, and from signing up for coverage.

In Minnesota, the MNsure website was slow and nonfunctional for many users, displaying obscure error messages. Some enrollees were told their identity couldn't be verified, and they could click a link to learn more — but the link didn't work. The opening of MNsure was the leading story on the 10 p.m. news, yet anyone visiting MNsure at that time would have seen that the website was closed for the day. The website has "open hours" of 6 a.m. to 10 p.m.

Some would say that it's only day one, week one; the real test of the effectiveness of MNsure will be the long-term increase in coverage. But it's also important to realize the fragility of public opinion, especially amid a federal government shutdown and charged political rhetoric. Certainly, any perceived failures in technology infrastructure for state health insurance exchanges will play into right-wing messaging.

The public's ever-changing opinions and low tolerance for technology frustrations are precisely the reasons we must get this right.

The smallest glitch on an enrollee's computer screen creates false uncertainty in the whole system. This isn't just about a few bugs on day one, however, it's about a fundamental problem with MNsure's choices in software project management, technology, user experience, and accessibility.

Technology should remove obstacles, not create them

The Minnesota Department of Health reported that in 2011, 9.1 percent of Minnesotans were uninsured. Of that group, approximately 60 percent were eligible for public health insurance programs but chose not to apply. Although cost or lack of interest was a factor, many cited logistical reasons for not applying: lack of awareness, complexity, paperwork, or confusion.

MNsure and the Affordable Care Act seem like the perfect vehicle to address logistical and access obstacles to obtaining coverage.

Minnesota participated in an 11-state collaborative design process called Enroll UX to create a standardized design prototype for an enrollee application and an account portal. The goals were: simplicity in use and understanding, readability for seniors, multiple language support, support for visually impaired enrollees using screen readers, and at least some support for mobile devices.

You won't see all of that hard work implemented on MNsure. If you make an error in a form, you'll lose all of your work. If you don't understand a question, no help options are available. If you get stuck along the way, you can't always save your progress. A number of features haven't been implemented yet across the site, and there's no support for mobile devices. Visually impaired users are told to call or email; the site might not work for them.

Fifty-six percent of U.S. adults are smartphone users, but you can't easily shop for plans on MNsure using your mobile device. Young, relatively healthy enrollees are heavy smartphone users, and their health insurance premiums are needed to balance the insurance pool against health care costs for older enrollees.

Adding to the confusion, MNsure's plan finder asks when you would like the coverage to start, yet not everyone is aware that coverage cannot begin until January 1, 2014. Entering tomorrow's date will result in an error message stating that "no plans are available," potentially leading an enrollee to erroneously believe that they aren't eligible for coverage.

MNsure also asks automated identity verification questions, a process that has failed for many users. When the site cannot verify your identity, it suggests you visit a county office in person, or print and mail a form with a copy of your state ID. Not everyone has access to a copier and printer, a stash of envelopes and postage at home, or transportation to a post office. Reasonable alternatives like a fax number or secure upload form weren't implemented.

A call to Hennepin County's Public Health Department with questions about where to go for MNsure identity verification was met with confusion, and a suggestion to call MNsure. Upon calling MNsure, the phone system estimated a wait time of 15 minutes, but presented an option to enter a phone number for a call back within 15 minutes. MNsure never called back.

User-unfriendly design

Everyone is a user of health care. The legislative intent of the Affordable Care Act was to ensure coverage for everyone, which means MNsure's technology and processes must be usable and accessible by everyone — regardless of user needs, values, culture, abilities, or limitations.

That's the definition of user experience design, something MNsure and its vendors ignored.

Websites should create multiple paths to success in order to ensure users don't fail at completing a task. In the Enroll UX prototype that Minnesota helped create, but didn't use, attention to detail and visual organization added clarity and comfort to users.

The cost of MNsure's poor technology implementation? Payments to vendors could be as high as $41.2 million. To their credit, that does include some pretty heavy requirements for security, and complex interactions with multiple data sources.

But does any of that matter if potential enrollees are turned away by a system that doesn't work or make sense to them?

MNsure could have built on top of the collaborative work that was done with 10 other states, and kept some money local by working with any of Minnesota's top design and development firms to co-design with actual Minnesotans from all walks of life, instead of using a pre-built, lightly customized vendor “solution.”

For the money that was spent, Minnesota consumers deserve better.

Tony Webster is a designer and software engineer, and alum of digital health startup accelerator Rock Health. You can follow him on Twitter @webster.

WANT TO ADD YOUR VOICE?

If you're interested in joining the discussion, add your voice to the comment section below — or consider writing a letter or a longer-form Community Voices commentary. (For more information about Community Voices, email Susan Albright at salbright@minnpost.com.)

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Comments (5)

Weak Praise

Bad as it is, we're doing better than Wisconsin, where my girlfriend is trying to get signed up. The system times out "due to user inactivity" and has locked her out of her account for a week. Except the inactivity is on the server end, which is trying to handle too many queries from too many users. The federal site wasn't designed to handle this much activity any more than MNSure's site was.

I'm sorry that the state of

I'm sorry that the state of Minnesota didn't see fit to use this guy's program for MNSure's web site. Everything then would have gone swimmingly, without a hitch (despite there being hitches all over the U. S.)?

Everyone does see, right, that he has a specific business reason to be as critical of the whole shebang as this article is?

Still...

He has some VERY valid points - no online help and no way to save your work until fully-completed are inexcusable.

Of course, we can't afford proper system designers because we have a sports facility to pay for. ;-)

Re: MNsure technology barriers are barriers to coverage

I agree that the MNSure system is very badly designed but also the inability to get real help dealing with it is very frustrating! I've made 24 attempts so far to create an account. I'm currently in my daily 24 hour waiting period. I know all the identity questions that will be asked including the one about buying medical insurance for my non-existent pet! Anyone could have gleaned the answers to my identity questions after that many repetitions by looking for the common response choices - how effective or secure is that! I sent 4 e-mails to gethelp@mnsure.org since Wednesday and I have yet to receive a response. I e-mailed my county office as suggested on a MNSure web page (actually, the suggestion was to visit the county office) - they wrote back that counties are unable to help with any MNSure issues at this time. I called the MNSure help line twice; their response is to just keep trying up to 6 times each day, then wait 24 hours and try again - you'll eventually get in - beyond that, they are unable to provide any further help to get the account created. I was looking forward to getting affordable health insurance since I have not had coverage for the last year but I have this uneasy feeling that I will never accomplish creating a MNSure account. Paul or Babe, can you help me?

Ameateur Hour, at it's best

I'm glad for the law, and for the promise of the exchange. But as someone who is very aware of technical challenges and the difficulty of delivering good software .... this has been a clown show. No one wanted amateur hour. Web sites are not suppose to have "business hours" where they cease to work. The number of places I've seen the website break down is ridiculous. Who ever is building the site, and whatever techniques they are using ... well, they are not from this decade. It's time to hand the reigns over to the professionals and let them fix the mess that's been created.