As the first website to be demonstrated by a sitting President of the United States, Healthcare.gov already occupies an unusual place in history. In October, it will take on an even more important historic role, guiding millions of Americans through the process of choosing health insurance.
How a website is built or designed may seem mundane to many people, but when the site in question is focused upon such an important function, what it looks like and how it works matter. Last week, the United States Department of Health and Human Services (HHS) relaunched Healthcare.gov with a new appearance and modern technology that is unusual in federal-government websites.
"It's fast, built in static HTML, completely scalable and secure," said Bryan Sivak, chief technology officer of HHS, in an interview. "It's basically setting up a web server. That's the beauty of it." What makes such an ambitious experiment in social coding more unusual is that the larger political and health-care policy context that it's being been built within is more fraught with tension and scrutiny than any other arena in the federal government.
The implementation and outcomes of the Affordable Care Act -- AKA "Obamacare" -- will affect millions of people, from the premiums they pay to the incentives for the health care they receive. "The goal is get people enrolled," said Sivak. "A step to that goal is to build a health insurance marketplace. It is so much better to build it in a way that's open, transparent and enables updates. This is better than a big block of proprietary code locked up in a CMS [content management system]."
Thinking differently about a .gov
The new site has been built in public for months, iteratively created on Github using cutting edge open-source technologies. Healthcare.gov is the rarest of birds: a next-generation website that also happens to be a .gov.
"We needed to evolve from the previous site but didn't want a total departure," said Ed Mullen, a user experience designer who has worked on Healthcare.gov since it was first launched, in an interview. "The web has changed dramatically in that time. Part of adapting to that [change] has been creating a site that really understands consumers. Today, consumers are doing all kinds of things across the web. We're comparing ourselves to Rdio and similar services. We want to be aligned with the current thinking of the Web."
The people that helped to build the new Healthcare.gov are unusual: Instead of some obscure sub-contractor in a nameless office park in northern Virginia, the site was iteratively created by a cross-disciplinary team of developers and editors at HHS, and contractors at Teal Design, Edward Mullen Studio, and Development Seed, a scrappy startup in a garage in the District of Columbia.
"This is such a lean site," said Jon Booth, head of the web and new media group at the Centers for Medicare and Medicaid Services (CMS), in an interview. "HHS had a blanket contract when we when awarded this. Aquilent got creative and brought people on with powerful skills, like Ed and Jessica, a designer at Teal Media, and Development Seed. Most of my team is working on this site; we have internal UX, information architects, designers, developers, and infrastructure people that stood up the cloud environment. Their collaboration is one of the high points of this process."
The involvement of Development Seed drove specific technology choices that led to substantial improvements in design and function. The startup first made its mark in the DC tech scene consulting on Drupal, an open source content management system that has become popular in the federal government over the past several years. Recently, Development Seed has been pushing the limits of lightweight Web design, open data-driven maps and open-source code.
"This is our ultimate dogfooding experience," said Eric Gundersen, the co-founder of Development Seed, in an interview. "We're going to build it and then buy insurance through it."
"The work that they're doing is amazing," said Sivak, "like how they organize their sprints and code. It's incredible what can happen when you give a team of talented developers and managers and let them go."
The new Healthcare.gov will fill a yawning gap in the technology infrastructure deployed to support the mammoth law, providing a federal choice engine for the more than 30 different states that did not develop their own health-insurance exchanges, but the site is just one component of the insurance exchanges. Others may not be ready by the October deadline. According to a recent report from the Government Accountability Office, the Department of Health and Human Services' (HHS) Centers for Medicare & Medicaid Services (CMS) is behind in implementing key aspects of the law, such as training the workers who will help people navigate the process, certifying the plans that will be sold on the exchanges, and determining the eligibility of consumers for federal subsidies. Despite all this, HHS expressed confidence to the GAO that exchanges will be open and functioning in every state on October 1.
On that day, Healthcare.gov will be the primary interface for Americans to learn about and shop for health insurance, as Dave Cole, a lead developer at Development Seed, wrote in a blog post this March. Cole, who served as a senior advisor to the United States chief information officer and deputy director of new media at the White House, was a key part of the team that moved WhiteHouse.gov to Drupal. As he explained, the code will be open in two important ways:
First, Bryan [Sivak] pledged, "everything we do will be published on GitHub," meaning the entire code-base will be available for reuse. This is incredibly valuable because some states will set up their own state-based health insurance marketplaces. They can easily check out and build upon the work being done at the federal level. GitHub is the new standard for sharing and collaborating on all sorts of projects, from city geographic data and laws to home renovation projects and even wedding planning, as well as traditional software projects.
Moreover, all content will be available through a JSON API, for even simpler reusability. Other government or private sector websites will be able to use the API to embed content from healthcare.gov. As official content gets updated on healthcare.gov, the updates will reflect through the API on all other websites. The White House has taken the lead in defining clear best practices for web APIs.
Putting open source to work
According to Sivak, his team didn't get directly involved in the new Healthcare.gov until November 2012.
After that, "we facilitated the right conversations around what to build and how to build it, emphasizing the consumer-facing aspects of it," he said. "The other part was to figure what the right infrastructure was going to be to build this thing."
That decision is where this story gets especially interesting, if you're interested in how government uses technology to deliver information to the people it serves.
Government websites have not, historically, been sterling examples of design or usability. Unfortunately, in many cases, they're also built at great expense, given the dependence of government agencies on contractors and systems integrators, and use technologies that are years behind the rest of the web.