Originally written for MinnPost Community Voices
October 4, 2013

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.