1. Healthcare.gov Background:
Healthcare.gov is overseen by the Centers for Medicare and Medicaid Services, or CMS. CMS is a federal agency within the Department of Health and Human Services, and is responsible for the implementation of healthcare.gov—the key part of the implementation of ACA. ACA was signed into law by the President on March 23rd, 2010, with the intent to provide insurance to millions of Americans, and eventually help reduce costs and improve care in a nationwide healthcare system that has serious problems (The U.S. spends over 17% of its GDP on healthcare but key metrics indicate the high rate of expenditures does not equate to healthier outcomes).
Initially, no one imagined how difficult it would be to implement the ACA. Healthcare.gov has been described as “one of the most complex IT projects the federal government has ever undertaken,” by a senior technology expert ( Many people didn’t think the project would even get off the ground.
In fact, the majority of major government IT projects are not successful. One study showed that only 6.4% of government IT projects were successful (Of 3,555 projects from 2003 to 2012 that had labor costs of at least $10 million, only 6.4% were successful. The Standish data showed that 52% of the large projects were "challenged," meaning they were over budget, behind schedule or didn't meet user expectations. The remaining 41.4% were failures -- they were either abandoned or started anew from scratch,
The healthcare.gov website was not just a website. It was an extremely complicated project involving lots of players, with a strict deadline governed by policy makers. And, unlike sites such as Amazon, Facebook, and others, the healthcare.gov website had to scale from day 1. There was no slow ramp-up period to work out any glitches. The site had to process transactions to provide health insurance for millions of Americas right out of the gates.
As we go through this case study, you’ll see why the traditional approach to building a large-scale web application was impossible, why healthcare.gov required a NoSQL solution, and why MarkLogic was the perfect fit for the project in order to make it successful.
Interesting to Note:
HHS is in fact responsible for about 25% of all federal outlays. For CMS and the implementation of ACA in particular, the 2014 budget request is for $1.9B pg 29). But, the success or failure of the entire program depends on the underlying database to some extent, which is only about .01% of that entire budget.

2. Health insurance for millions of Americans
Before MarkLogic
Unable to handle complexity
Impossible data model
Development too slow
Limited scalability
Inflexible to change
After MarkLogic
Built for Today’s Data Schema-agnostic data model that could handle various data sources and adapt to later changes with policies and regulations
Agile Development 18-month timeframe from procurement to launch for what has been called “the most complex government-IT project of all-time”
Secure and Trusted Did not have to sacrifice any of the enterprise features required, and could rely on a system with government-grade security, ACID transactions, and HA/DR
Successful Deployment Over 8 Million people signed up for health insurance in less than 5 months
Before ML Narrative:
The Centers for Medicare and Medicaid Services was mandated by ACA to launch healthcare.gov in November 2014, but had a problem. It was 18 months before launch and development was moving too slow, and the team could not develop a viable data model using Oracle. They had to develop a Health Insurance Marketplace (HIM) and Data Services Hub (DSH) that would allow millions of Americans to shop for insurance, check their eligibility against dozens of federal and commercial data sources, and provide a way for state health exchanges to connect as well.

3. Impossible data model HIM DSH Health Insurance Payers
Data Services Hub
DSH
Impossible data model
Millions of Subscribers
Income and Eligibility Confirmation
HIM
Whiteboard Built-Out Script:
When the Affordability Care Act passed, it required that the Centers for Medicare and Medicaid Services (CMS) build a health insurance exchange (HIX) which would allow everyone in the US to search, select and enroll in an insurance plan. CMS needed to aggregate data from 50 states and many more insurance providers, and present the information in an easy-to-read format for subscribers/patients.
Thousands of Insurance Companies
Eligibility Sources from 50 states, federal agencies, and medical providers and payers all supplying data in various XML formats.
30-50 Million Citizens to apply
CMS wanted widespread adoption of Federal Health Insurance Marketplace vs. individual states building their own
The whiteboard shows a bunch of people and data sources to be followed by a MarkLogic database and arrows pointing into it.
The HIM:
The HIM is used to gather and manage health insurance plan information delivered through healthcare.gov. Twenty-seven states are leveraging this platform directly, while 16 states and the District of Columbia opted to build their own health insurance exchanges. Seven states chose to operate in hybrid state and federal partnerships.
The DSH:
The DSH enables communication between the state exchanges and various federal agencies (e.g. Department of Homeland Security, Internal Revenue Service and Social Security Administration) to assess individual eligibility and facilitate enrollment. The DSH provides a front-end application that allows CMS to perform operational reporting. States can plug directly into the DSH; they don’t have to develop their own systems to perform income verification and eligibility determinations. This reduces costs and improves reliability.
Problems in Oregon:
Most states were unable to meet the challenge of building an exchange that would be operational by October 1, 2014, even with large federal subsidies including a 90/10 match of funds. The irony is that all the blue states that tried to build their own exchanges in compliance with the law generally failed to create anything that worked. In fact, Oregon is suing Oracle because they spent $200M on a site that never worked.
Link to actual healthcare relational model shown above:
State Exchanges

4. Straightforward data integration
Health Insurance Payers
Data Services Hub
DSH
Millions of Subscribers
Income and Eligibility Confirmation
HIM
Whiteboard Built-Out Script:
CMS eventually chose to use MarkLogic and with 18 months until the launch deadline, the team began building on MarkLogic, using it for both the HIM and DSH. (Note: The Deputy CIO at CMS, Henry Chao, who championed the NoSQL approach, and MarkLogic in particular).
Because of MarkLogic’s flexible schema, they had a future-proof database that could adapt to changing policy and to the different data models being used by the dozens of entities engaging with the site’s backend. The site was also incredibly scalable and the backend database portion of the site never experienced any issues with scaling. The HIM had issues at the start, which were primarily due to poor decision making in using a model driven architecture. The DSH did not use that approach, and thus never had any issues, even at launch.
At the end of the day, MarkLogic performed extremely well under high load volumes, performing thousand of transactions per second and supporting hundreds of thousands of concurrent users. And, CMS didn’t require an army of DBAs to manage MarkLogic either. They may have needed that army for the other components, but not MarkLogic.
CMS trusted MarkLogic from the start, and continues to trust MarkLogic in every way. Where the project went wrong at the start has been made clear, and there are new contractors in place. The government has increased its investment in MarkLogic, and MarkLogic will continue to serve as the underlying database for various components across the healthcare.gov infrastructure.
State Exchanges

5. 8,000,000+ new beneficiaries 150,000+ concurrent users
0 zero data loss
Numbers verified:
8,019,763 people selected Marketplace plans from October 1, 2014, through March 31, 2014, (including additional Special Enrollment Period activity through April 19th).  Nearly 2.6 million signed up in the State Based Marketplaces and over 5.4 million in the Federally-facilitated Marketplace. About 3.8 million people, including nearly 1.2 million young adults (ages 18 – 34), enrolled in the Health Insurance Marketplace plans in the sixth and final reporting period, which began March 2 and concluded on April 19. Those 3.8 million individuals represent nearly 90 percent growth over February’s cumulative enrollment.
Of the more than 8 million:
54 percent are female and 46 percent are male;
34 percent are under age 35;
28 percent are between the ages of 18 and 34;
65 percent selected a Silver plan, while 20 percent selected a Bronze plan; and,
85 percent selected a plan with financial assistance.
Other numbers verified by MarkLogic team members as of August 2014.