[brandonb]

I've been working on healthcare.gov for the last few months alongside a bunch of other Google, Facebook, and Y Combinator alums.

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: [e-mail]!

[aamar]

> "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."

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.

---

[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/...

[Fomite]

> It did not control for many factors that may be relevant (e.g. smoking).

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.

---

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".

[yummyfajitas]

A randomized controlled trial where we deprive people of health insurance?

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.

[Fomite]

Medical and public health researchers are bound to ethical guidelines that would prevent something like this, because the preponderance of evidence is that having health insurance is a net positive for someone's health - the only reason it made sense in Oregon is the fact that they needed a lottery anyway.

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."

[yummyfajitas]

By this logic, it would be unethical for the FDA to demand a random trial for any drug that has some correlation studies showing it is effective.

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.

[Fomite]

You'll find that clinical trials are regularly halted when the treatment is found to be markedly superior or inferior to placebo or the control group.

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.

[streptomycin]

I mostly agree with you, but you seem to be ignoring this point: Medicaid decreased the probability of having an unpaid medical bill sent to a collection agency by 25 percent – which also benefits health care providers since the vast majority of such debts are never paid.

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.

[shubb]

Sorry, you seem to be suggesting that having insurance (access to non-emergency medical treatment) has no effect on life expectancy.

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?

[yummyfajitas]

No, it doesn't paint medicine as a huge fraud. For example, suppose people without insurance already do have access to non-emergency medical treatment. Then giving them insurance will not make them healthier - it will only make them wealthier.

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.)

[Fomite]

If you refer to Table 2 of the NEJM article 'The Oregon Experiment — Effects of Medicaid on Clinical Outcomes', while none of the results are statistically significant, most of the effect measures are headed in the right direction.

Someone who works for 'Bayesianwitch' should know better than to rely on p = 0.05 as the sole basis on which to evaluate something.

[yummyfajitas]

I also know better than to change the criteria after the study starts. A study was proposed. None of the critics of the study had anything negative to say about it until after the results were in - that's probably because they thought it would vindicate the 45,000 number.

[Fomite]

Actually looking at the results isn't "changing the criteria", it's looking at the results in a more nuanced way than null hypothesis testing.

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?

[slurry]

Why would you blame the study authors for doing a correlation study? I know "CORRELATION IS NOT CAUSATION!!!" is the go-to takedown on the internet, but correlation studies actually can have significant value - otherwise peer-reviewed journals wouldn't publish them.

I'm also skeptical of Politifact's competence to adjudicate public health scholarship.

[aamar]

I agree that correlation studies can be valuable, but I see many correlation studies as (intentionally or not) exploiting a propensity (arguably a bug) in human reasoning that conflates it with causation. In this situation, we have thorough documentation of multiple people clearly making the error.

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.)

[1] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2739025/

[mattfenwick]

> correlation studies actually can have significant value - otherwise peer-reviewed journals wouldn't publish them

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.

[Fomite]

Not only do they have significant value, but they're the only type of evidence you'll ever have for something like this - it's impossible, and almost certainly unethical - to run a randomized trial of keeping people from having health insurance.

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.

[anatoly]

You keep saying 'unethical' as if it's the end of the discussion. But what if our current standard of medical ethics prevent us from finding the better policies or the better treatments? Is this standard set in stone and never to be doubted?

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).

[Fomite]

> You keep saying 'unethical' as if it's the end of the discussion. But what if our current standard of medical ethics prevent us from finding the better policies or the better treatments? Is this standard set in stone and never to be doubted?

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"

[ekianjo]

Sorry, but no. 100 times no. Correlation is very often linked to a third factor or multiple factors which are not visible, nor measured in observational studies. Besides, let's not disregard the fact that correlation still has some good chance to be pure luck. Even correlation with 95% confidence statistical significance can be a random result in a non-nil number of times.

So, no, you never prove anything nor imply anything at all with correlation. You're still guessing.

[Fomite]

Find me where I said proof.

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".

[ekianjo]

You didn't say proof but you said it's better than guessing, and I don't agree with you at all. 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 ?

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.

[mattfenwick]

> make a determined effort to control for as many "third factors"

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.

[nzp]

> So, no, you never prove anything nor imply anything at all with correlation. You're still guessing.

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.

[aaronbrethorst]

I'm also skeptical of Politifact's competence.

FTFY

[dannyr]

"But I don't think a statistic like this should be left unchallenged on HN."

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.

[aamar]

> 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?

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 []

[dannyr]

I'm curious what do you think would have happened if you just let it go.

"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.

[aamar]

I hope my clarifications help explain what I meant in my parent comment.

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.

[yummyfajitas]

Why would your second point be a bad consequence? If the ACA doesn't work and we repeal it, isn't that a good thing?

[RickHull]

> What you pointed out doesn't even diminish an ounce of what Brandon and his teammates are doing.

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.

[dannyr]

But it's such a small part of Brandon's post.

Is the spirit of HN nitpicking the smallest things?

[thisisdave]

>It did not control for many factors that may be relevant (e.g. smoking).

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.

[aamar]

You are right, the 2009 Wilpers paper does bucket out current and former smokers, as well as look at BMI and other factors. The authors should be credited for that. But when those factors are considered, the null hypothesis is only barely rejected at 95% confidence. The Kronick paper uses a much larger dataset and discusses the issue of what is controlled for more extensively.

[Fomite]

So wait, now not only are we using hypothesis testing as your sole means of evaluating whether or not an effect exists, but you're moving the threshold around because...you want to?

[aamar]

No, I don't think I'm arguing that. It's not a question of any one methodology always being better than others, or correlation studies always being wrong. The question is what we should reasonably believe in light of several analyses of various strengths.

[keithwarren]

Aside from the rhetoric, the political opinions and people firing at you now over the 5-10K thing, I do have an actual question of substance.

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?

[brandonb]

The biggest general problem is that people thought of shipping the site the same way they thought of shipping an aircraft carrier -- you write the code, hand it over, and you're done. It wasn't treated as a running service. So, for example, when the site went down, there wasn't a group of people responsible for bringing it back up.

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!

[mbesto]

> The biggest general problem is that people thought of shipping the site the same way they thought of shipping an aircraft carrier -- you write the code, hand it over, and you're done.

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.

[Perdition]

It's amusing because that isn't the way aircraft carriers are made. Something like a tank might just get handed over after only manufacturer testing, but big ticket items like aircraft carriers go through a year plus of acceptance trials and testing.

They don't finish the last coat of paint, load an air wing, and send it out on deployment.

[twistedpair]

Amen. Just watch any documentary about building an aircraft carrier. The systems integration phase is the longest part!

[liyanchang]

The difference here is that they had a very public deadline.

[keithwarren]

What is the biggest issue right now architecturally?

[brandonb]

Complexity. We have 10x more code, 10x more components, and 10x more layers than we need. If the initial architecture had been dirt-simple, I don't think the site would have had so much trouble scaling or staying up. But, of course, removing complexity without breaking things takes longer than adding it in the first place.

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.

[keithwarren]

Was there consideration given to doing a wholesale rewrite and later swapping out for that? Seems that if things are overly complex now, it may be easier to hold it together with band-aids while a true long term build is put together...what is going on behind the scenes with respect to this kind of planning?

[keyhole_downs]

Better call Scott!

[grecy]

My god I wish my company would instigate Rule 2 !

[wooter]

"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."

Hospitals don't let uninsured people die and insuring people doesn't magically save their lives.

[vwinsyee]

> 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.

[trhway]

>mortality rate is significantly higher for uninsured than for insured.

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.

[vwinsyee]

> correlation doesn't mean causation.

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)

[DanielRibeiro]

Please turn this into a blog post and submit it to HN. I'd love to see this comment about correlations see more attention ;)

[Fomite]

I just submitted this: https://news.ycombinator.com/item?id=7317254 which is the CrossValidated (StackOverflow for stats) discussion of whether or not causation implies correlation.

[gizmo686]

All good points, but you also should consider the plausibility of it being a correlation. By this I mean that there seem to be clear candidates for a common cause between no insurance and high mortality, for example: income.

Once you control for this, and other potential common causes, your case for causality becomes much stronger (or non-existent).

[Fomite]

If you had read the paper linked above, you'd note they controlled for income.

[aero142]

Many people believe that the Oregon Health Study is the best chance we have of teasing causation out of the data. It is still in progress but it is being watched closely. http://oregonhealthstudy.org/

[tunesmith]

To clarify, this is because they actually did what would normally be unethical: they randomly assigned citizens to be eligible for the insurance plan. It was a lottery.

[anon808]

so are you saying not having health insurance is better for people? I'll take the common sense angle that having health insurance increases the chances of medical care being applied to a health problem, versus not having any health care insurance.

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.

[trhway]

>so are you saying not having health insurance is better for people?

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:

http://en.wikipedia.org/wiki/Cybernetics

[saraid216]

I completely support the conclusion that we should be fixing our third variables.

[Crito]

Hospitals do "let" uninsured people die because they are not obligated to provide the full extent of their care capabilities to people who cannot afford it. Come in with a hole in your abdomen, and for sure they'll patch you up even if you don't have insurance. Come in riddled with cancer? Don't expect the same as they would give somebody who could pay themselves or had insurance.

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.

[brandonb]

Yes, I meant to say 1 in 1000 uninsured people die each year in ways that could be prevented by insurance coverage. Here's an article that references a few of the reports: http://www.reuters.com/article/2012/06/20/us-usa-healthcare-...

[twistedpair]

> Come in riddled with cancer? Don't expect the same as they would give somebody who could pay themselves or had insurance.

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.

[Crito]

You know that many people actually survive cancer and go on to live otherwise regular lives, right?

[arrrg]

Many people survive cancer or can at least add many years to their life with relatively high quality of life.

Many others don’t survive, obviously, but the chance of survival of many cancers really isn’t so bad.

[twistedpair]

Thx. Spent years working in oncology, so I'm quite familiar that people can survive. My point is that American medicine is insanely expensive because we don't know where to draw the line. Now, more than before, we focus on anything to keep the heart beating and the lawyers from suing, regardless of whether the quality of life and and dignity of the patient is non-existent.

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.

[akiselev]

Yes because chemo is the first thing we give to people with malignant cancers.

[jbooth]

Hospitals don't turn away uninsured at the ER.

However, due to lack of regular care, by the time you show up at the ER it might be too late.

[beat]

I have high blood pressure. Thanks to insurance, I was able to spend a few months with my doctor, experimenting with medications until we found the combination that brought it down to manageable levels. Meds cost me $15 a month or so.

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.

[liber8]

Honest, non-snarky question for you: How is it that you could not afford a half-dozen trips to your doctor, but you could afford your medical insurance premiums? Are your premiums subsidized or free? Is the doctor terribly expensive?

(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.)

[beat]

Honest, non-snarky answer... to be pedantic, for me it's not a question of affordability. I'm a software professional with a very good income, and I could do it on my own.

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.

[hga]

"Medical costs are the leading cause of bankruptcy in the US."

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.

[jdminhbg]

> Without insurance, I couldn't have afforded the half-dozen trips to the doctor or the meds.

> 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.

[ansible]

I'm assuming that your doctor charges $250 or less per visit.

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.

[protomyth]

"Without insurance, I couldn't have afforded the half-dozen trips to the doctor or the meds."

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.

[beat]

The problem with that is that the people with the highest medical costs (the elderly) are retired and no longer generating income to pay for their care. Gotta pay for that somehow. The whole point of insurance is to distribute costs.

[rdl]

The elderly (>65, or >62 in some cases, etc.) are already covered by medicare and social security. The disabled were covered by medicaid and ssi.

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.)

[protomyth]

An expansion of social security / medicare (particularly if they were paying into a health savings account throughout their low risk period) to cover drugs and such would have been quite a bit cheaper. The youth already are paying for the elderly with taxes, we shouldn't run a con job on them too.

The concept of insurance we use for healthcare is broken.

[dragonwriter]

> Hospitals don't let uninsured people die

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.

[brandonb]

An estimated 26,000 people die each year due to lack of insurance coverage. That's part of the reason the Affordable Care Act was passed. For more information, see this Reuters article from 2012:

http://www.reuters.com/article/2012/06/20/us-usa-healthcare-...

[at-fates-hands]

Too bad the people who actually need it, are not signing up. Not to mention the people who HAD coverage are now getting cut off of their insurance and forced into the exchanges. A complete failure anyway you look at it.

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.

[3am]

Did you read the links in your post? The first doesn't strongly support your points, and the second was out of date almost 4 months ago.

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.

[JPKab]

My mother in law has worked for the past 15 years at jobs which employ her for 39.5 hours a week and don't give her health insurance. She suffers arthritis in her hands and knees. She signed up and received health insurance for the first time in 15 years last week. She is now receiving the medical care she needs. Had she not, she would have had to apply for disability benefits. Now, she gets to keep working.

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?

[AutoCorrect]

anecdotal evidence and ad hominem attacks don't help you argue your points.

[JPKab]

Agreed. But partisan hackery is like porn. You know it when you see it.

[runamok]

They don't let them die right there because of the Emergency Medical Treatment and Active Labor Act (EMTALA). But they patch them up and send them home as soon as they're stable. That absolutely leads to significantly worse outcomes which others have referenced.

http://en.wikipedia.org/wiki/EMTALA

[untog]

People have to be inside hospitals for hospitals to help them. If you don't have insurance you're less likely to go in the first place.

[ryanhuff]

I question the validity of your statement. In the US, for many uninsured, the hospital ER is their primary care outlet.

[untog]

But by the time they go to the ER it's too late. People with insurance go for regular checkups that will catch things early. Those without will only go to the ER when their situation is desperate.

[ryanhuff]

Perhaps you misunderstood my comment. Many uninsured in the US go to the hospital ER for minor care, such as for colds and other temporarily ailments. I suspect that these sort of cases far outnumber the visits involving serious care cases.

[Shivetya]

you would be surprised how many with insurance don't go or don't listen to their doctor. it has nothing to do with insurance and more to do with fear or just laziness

[kyro]

You're talking about EMTALA, which is an act that prohibits turning away uninsured patients away who are in need of emergent care. Once the patient is stabilized and either discharged or admitted, they are subject to payments.

The patient with metastatic cancer who needs chemoradiation on an outpatient basis must pay for his/her care.

[dragonwriter]

> You're talking about EMTALA, which is an act that prohibits turning away uninsured patients away who are in need of emergent care. Once the patient is stabilized and either discharged or admitted, they are subject to payments.

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.

[PhasmaFelis]

> Hospitals don't let uninsured people die

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.

[kevincrane]

But if you know you can't afford it, maybe you'd avoid going to the hospital when you really should.

[brandonb]

Update -- wow, a lot of you out there want to help with healthcare.gov, or the government more generally! That's awesome.

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.)

[JustARandomGuy]

Hi Brandon,

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.

[kalvin]

(I'm working with Brandon)

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.

[vinhboy]

So, out of genuine curiosity, why are you doing it? To help the country? It's exciting? For the money? Or some other reason completely?

What about your co-workers. What's everyone motivation to help fix this site?

[lorenyu]

I believe that healthcare is one of the most important issues the country faces, on the same level as education, or climate change. And this was an opportunity for me to help out with that.

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.

[keyhole_downs]

Where do you draw the line on enabling a broken system that awards contracts to ill prepared monolithic RFP generating machines, and start saying, "We need real reform for technology in government and not just half-hearted bloviating about transparency"?

[joshAg]

man, i wish i had come across this offer a few months ago.

[samstave]

The least of my worries is government enforced purchasing of over-priced, broken healthcare.

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.

[vassvdm]

Thanks for the insights. Apparently Accenture has been contracted to help out (or take over) the HealthCare.gov website:

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.

[efa]

> people who wanted health insurance could finally get it

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?

[mlangdon]

You're not allowed to "other than that" preexisting conditions. I'm one and the ACA means I got to quit my shitty telesales job and take a no-insurance-provided-at-a-small-company first software development job.

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.

[efa]

I understand (in fact I have a daughter with preexisting conditions). But I'm referring more to the web site. There is not magic about the website. The law itself brought in some changes that will help some. You don't even have to use the website to take advantage of new law.

[mikeyouse]

    Who couldn't get insurance before this website?

Poor people.

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.

[efa]

Couldn't they have had Medicaid before this?

[jquery]

What if you'd like to help out but aren't an anointed™ one?

[brandonb]

You certainly don't have to be anointed™ or have worked at any particular companies.

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!

[trhway]

just like with any other government contract - being anointed is the deciding factor.

[djKianoosh]

what do y'all mean by anointed? I've been a gov contractor for many years. It doesn't take all that much to get into this space.

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.

[mbrameld]

I think by anointed the parent means a Google or Facebook alum, or other big name from the Valley.

[rhizome]

He asked for "amazing."

[toomuchtodo]

+1

Haven't worked at Google, Facebook, whatever, but would love to help.

[rdl]

Thanks for doing this. I still think completely replacing it from October to ~December, and extending the deadlines, might have been a reasonable choice, and re-architecting to move all PII related stuff away from the "shopping" stage and only into the final request stage, but I guess it's better now. The "replace everything, end all the contracts, etc." option might not have been politically viable, and showing people the pre-subsidy prices with subsidy adjustments later in the process probably would have been a bad political move, too.

(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.)

[djKianoosh]

I'm curious how you're breaking down the work and if you only take full time devs or are bringing in hourly contractors for different pieces. Do you think you'd have better luck finding good devs if you broke it down like that?

[brandonb]

So far, it's been on a rotation -- folks go on leave from their jobs for 1-3 months, move out to DC/Baltimore area, and work as hard as possible while they're here. :)

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.)

[coldcode]

What technology knowledge are required?

[brandonb]

No particular knowledge is required, but all of our new code uses technologies like Backbone, Node, Capistrano, and MySQL.

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.

[blendo]

Is it the existing system the "bad" kind of Java (J2EE 1.4/EJB 1/xml hell/Abstract Factory madness) or the nicer and more modern RESTy/Dependency Injected/JEE6 (or Spring) variant?

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?

[spikels]

Besides the obvious issue that correlation does not imply causation what does the statement "1 in 1,000 uninsured people die each year" even mean given that the overall annual mortality rate in the US is 799.5 per 100,000[1].

Is this in addition to the background rate? If true that would be quite astounding. Or is it just rounding?

[1] http://www.cdc.gov/nchs/fastats/deaths.htm

[rmrfrmrf]

"And, as the motley team of software engineers looked on in admiration, a single tear drop departed from Mikey's eye. As the drop hit the marble floor, it suddenly exploded into a majestic bald eagle, who screetched dutifully and flew out of the White House."

[gadders]

>"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."

Using that logic, how many have died due to the botched rollout of the website?

[joehillen]

Why isn't it open source like it was before?

[brandonb]

The portion that was open-sourced was actually only the static portion of the site (the 'Learn' side). That was taken down before I got here, so I'm not sure on the complete backstory, but I think it confused a lot of people since they assumed it was the source for the whole site.

[AutoCorrect]

So you're saying that with the 6 million cancelled policies, the government has killed approximately 6000 people with this new mandate?

[ctdonath]

Does the extrapolated result include the number of people who are losing their insurance because of this program?