Getting Ready for the Oscars: Three Things that the Movie “Gravity” Has in Common with Health Insurance Exchanges

Feb 18, 2014, 10:32 AM, Posted by Susan Dentzer

The Academy Awards are just a few short weeks away, much as is the end of this year’s open enrollment period for the health insurance exchanges. We health policy geeks who also love movies can now give out our own award—for the film that most closely resembles the rollout of the marketplaces under the Affordable Care Act.

As far as I’m concerned, there’s only one real candidate: “Gravity,” the science-fiction space drama directed by Mexican-born Alfonso Cuaron and starring the actors Sandra Bullock and George Clooney.

The film wins because its big themes are the same ones reflected in the experience of the exchanges: the omnipresence of Murphy’s Law and human perseverance overcoming calamity. What’s more, gravity—the real star of “Gravity”—is a universal force that can’t be overcome (and is one of the few scientific aspects of the movie that the critics agree the filmmakers got right). Is it too much to see a parallel to the Affordable Care Act’s coverage expansion, which is inching forward despite the formidable odds stacked against it?

For those who haven’t seen “Gravity,” here’s a partial plot summary. Dr. Ryan Stone, a medical engineer played by Bullock, is on her first mission aboard the Space Shuttle Explorer along with longtime astronaut Matt Kowalski, played by Clooney. While they are on a spacewalk, Mission Control in Houston notifies them that Russia has shot down one of its own defunct satellites with a missile, triggering formation of a cloud of space debris. The debris strikes the Explorer, Stone spirals into space, and the movie’s most heart-thumping action begins.

We’ll skip the rest of the story and thereby avoid the spoiler alert, but suffice to say that Stone takes an unimaginably tortuous route back to Earth. Meanwhile, here is more on the three things that the hair-raising plot has in common with the health insurance exchanges.

First, stuff happens: In the movie, the astronauts’ experience begins to go south when the Russians’ act of shooting down the satellite causes an unforeseen chain reaction, demolishing other communications satellites and sending tons of space junk into orbit.  Such a disaster is in the great tradition of many actual human misadventures. The Wikipedia entry for Murphy’s Law quotes the Victorian-era engineer and ship owner Alfred Holt: “It is found that anything that can go wrong at sea generally does go wrong sooner or later.”

Sound similar to the experience of the health insurance exchanges?  It wasn’t just, the federal marketplace that experienced serious start-up problems; so have those in at least five states: Maryland, Minnesota, Massachusetts, Hawaii and Oregon.  A key reason, noted consultant Dan Schuyler of Leavitt Partners at Academy Health’s recent National Health Policy Conference, is that insurance exchanges are “one of the most complex information technology projects ever initiated” by the government.  And University of Minnesota economist Stephen Parente observed that the still-evolving program to transfer federal subsidy dollars to health insurance exchanges is probably one of the largest “funds transfer” programs ever created.

These facts may not excuse errors and delays resulting from the actions of federal and state officials or private vendors, but they should help us keep the difficulties that have cropped up in exchange operations in context.  As in “Gravity,” when human beings attempt something new with technology, things often go wrong and the untoward consequences aren’t always predictable.

Second, the rollout of the marketplaces is prevailing through perseverance. As Bullock’s Dr. Ryan fights her way back to earth, at one point she concludes her death is inevitable and prepares to commit suicide.  The process of making the movie apparently underwent similar near-death experiences; for example, for months of filming, it wasn’t clear if the special light box and two-ton robot built to simulate the film’s space environments would actually work).

Such tales of trial and error, and perseverance, sound eerily similar to what state health insurance exchange directors describe.  At a recent health reporters’ roundtable sponsored by the Robert Wood Johnson Foundation, Peter Lee, executive director of Covered California, told of ramping up outreach toward the state’s Latinos, since as of the end of January the exchange had only achieved half of its goal for Latino enrollment. Mila Kofman, executive director of the District of Columbia’s Health Benefit Exchange Authority, described experiencing a huge volume of phone calls to the exchange’s call center—then discovering that 60 percent of the calls were from people who had created user names and promptly forgotten them. The exchange fixed that problem by devising a feature that allowed consumers to reset their user names by themselves.

All in all, “There will be books written about the lessons learned at both the federal and state levels, and there should be,” said Christine Ferguson, director of the Rhode Island Health Benefits Exchange.  These books’ heroes may turn out to be some of the same exchange directors and their colleagues who persevered despite setbacks.

Third, gravity wins. At the movie’s end, Bullock’s Dr. Ryan makes it back to earth, propelled not just by her own renewed determination but also by the overwhelming force of gravity. It’s tempting to see another parallel with coverage expansion; after all, despite the rocky start, as of mid-February 3.3 million Americans had picked a private health plan on an exchange and millions are also newly enrolled in Medicaid and the Children’s Health Insurance Program. As D.C. exchange director Kofman put it at the reporters’ roundtable, this “fundamental effort to make sure that all Americans have access to high quality, affordable coverage” will take a while, but is gaining steam. “We are all in this to improve people’s lives and health and make sure that over time people have access to the health care and the kind of financial security they need,” she said.

To which many Americans are likely to say—as Bullock’s Dr. Ryan does at the end of the movie—“Thank you.”