In the District, the DC Health Benefit Exchange Authority’s (HBX) initial technology strategy was the same as the other SBEs—to repurpose COTS products to support the new requirements introduced under the ACA. These systems competently operated in their respective markets and provided out-of-the box baseline capabilities, so extending them to meet new but related requirements seemed the safe choice. But when they were customized and integrated, they didn’t work. The Systems Integrator was unable to oversee the project effectively and ensure that the pieces of the system worked once merged together. The COTS products proved too rigid in their application to the Exchange program. Despite DC’s contractor supplying both ACA and COTS product experts to the project, its limitations were clear. HBX subsequently engaged independent local technology experts to supplement and augment the contractor’s team, but even that couldn’t save the system. The COTS products selected to host the website that registered and managed customer accounts were simply unable to manage the customer count and volume of requests encountered in production. A second COTS product responsible for benefit plan shopping was unable to calculate premium comparisons for employers with more than a few employees. The more that customers tried to get through the system, the more COTS-related and integration problems that surfaced.

The District was facing these obstacles at the same time that it was dealing with a layer of political challenges that most other states did not face. While most states were focused primarily on ensuring a successful open enrollment for their individual market, there was even more pressure on the District to ensure that its small group marketplace could function well. That’s because under regulations issued by the U.S. Office of Personnel Management, the District had to provide health insurance coverage to Members of Congress and their staff starting in November 2013, while simultaneously managing the first open enrollment period for individuals and small businesses in the District. In addition, District policymakers required all individuals and small groups purchasing health insurance coverage in the District to use the HBX system, rather than allowing them to purchase coverage directly from health insurance carriers, as they can in every other state and as had been the practice for decades (the “one big marketplace” policy). These well-reasoned decisions were nonetheless politically controversial, as they caused significant disruption in the health insurance marketplace. There was substantial resistance by major stakeholders in the District, and attention at the national level, to moving Members of Congress to DC Health Link and to requiring customers (small businesses, in particular) to purchase their coverage through DC Health Link, rather than direct from the carriers.

Through hard work and determination by the DC Health Link team, the Exchange survived two congressional open seasons under the legacy system. During that time, IdeaCrew provided essential support, including, among other things, developing technical workarounds to complex problems, providing operational and customer service support, taking over responsibility for relationships with the trading partners (including four national health insurance carriers), and developing a data strategy and ensuring that the HBX had access to the data it needed to run the program. But system performance during the second open season was so poor that the DC Exchange called on IdeaCrew to deploy a new system over the 2014 winter holidays to enroll new Members of Congress and staff following the 2014 midterm elections. IdeaCrew delivered, developing – in just a few weeks – a prototype that the DC Exchange used to successfully serve these new customers through the winter of 2015. Following the successful experience with Congressional enrollment, IdeaCrew built out this prototype into Benefits Marketplace, which was successfully deployed in October 2015, prior to the third open enrollment period.

Benefits Marketplace was even more essential to implementation of the District’s “one big marketplace” policy. This policy was implemented using a phased approach, meaning that until July 1, 2016, small businesses were able to renew existing health insurance coverage directly with their carriers, rather than going through DC Health Link. But beginning with policies having July 1, 2016 effective dates, all of the small businesses had to renew their coverage through DC Health Link. Over a year’s time, enrollment on DC Health Link’s small business platform grew from 20,000 covered lives to over 75,000 covered lives. IdeaCrew’s Benefits Marketplace platform and its management of the data conversion process were essential to this huge success for the District. As a result, DC Health Link’s small group marketplace is now the largest among any Exchange in the country, more than double the size of the second-largest (California).