By Nicholas J. Diamond

The Centers for Medicare & Medicaid Services (CMS) recently celebrated its 50th anniversary. With the implementation of the Affordable Care Act (ACA), the past few years have been especially busy for CMS. In particular, it was tasked with implementing the Health Insurance Marketplaces (“Marketplaces”), which some consider the most significant shift in the health insurance industry since managed care.

The Marketplaces support other ACA initiatives aimed at reducing the number of uninsured, like the expansion of Medicaid and the Children’s Health Insurance Program, by offering affordable health insurance coverage and, for those eligible, subsidies and cost-sharing reductions to reduce the overall expense of getting coverage.

The Marketplaces had to be fully operational in time for the first open enrollment period to begin in October 2013. Without a roadmap for a project of this complexity and magnitude, CMS had to create a complex technological infrastructure, including an eligibility and enrollment system, with a consumer-facing website ultimately called “”. would need to be a fully transactional, secure system to enable people to shop and apply for coverage, as well as apply for subsidies and cost-sharing reductions.

Behind, CMS had to create a complex infrastructure to manage how consumers interacted with the website. Eligibility and enrollment processes required building a Data Services Hub (DSH) to interface with numerous disparate Federal authoritative data sources, including the Social Security Administration, the Internal Revenue Service, the Department of Homeland Security, and several other Federal agencies. For instance, the DSH would need to communicate with these Federal agencies to verify citizenship status and income. Because the DSH would be used by all of the Marketplaces, including those established by individual states, it would also need to communicate with appreciably different state-level information systems. Finally, the DSH would need to perform all of these transactions securely and in real-time.

Implementation of the Marketplaces required an extensive network of contractors to assist CMS. CMS initially relied on traditional relational database technology to build key components of the Marketplaces. But after that technology struggled to enable CMS to satisfy shifting requirements under a tight timeline, it realized that it needed a new approach. CMS adopted a new type of database technology, NoSQL (Not-only SQL), that would afford the flexibility to get the Marketplaces ready for the first year of open enrollment.

CMS chose an Enterprise NoSQL database provided by MarkLogic because it had the right combination of functionality and enterprise-grade capabilities. It enabled the DSH to more seamlessly communicate with disparate Federal and state-level systems. It also enabled CMS to adapt the legacy architecture for and start to build better functionality in the system, such as the ability to easily scale out to accommodate higher data volumes during busy open enrollment periods.

At the beginning of open enrollment in October 2013, the rollout of the Marketplaces had both well-publicized struggles and less well-known successes. Although it did not receive media attention at the time, the DSH functioned as intended, providing for seamless information exchange between various Federal agencies and programs, and numerous state-level systems., however, experienced difficulties as a result of the enduring ramifications of early architectural issues from the legacy platform and last-minute changes to components of the website.

By relying on the adaptability of the Enterprise NoSQL database platform and the technical expertise of both contractors and Federal government staff, CMS rapidly corrected these issues in less than ten weeks. After success in the first year of open enrollment, the second year resulted in approximately 11.7 million enrollments or automatic re-enrollments, with most coming through, according to CMS figures released earlier this year. And with support from other ACA initiatives, the Marketplaces have been helping to reduce the number of uninsured, down from 16.4 percent in 2010 to 11.9 percent through the first quarter of 2015, according to recent Gallup research.


About the Author: Nicholas J. Diamond, JD, MBE, leads MarkLogic’s market strategy and messaging in the healthcare and life sciences sectors. Before joining MarkLogic, Nick worked in advisory and consulting roles at the MITRE Corporation and Booz Allen Hamilton, respectively, where he supported the Federal government with policy and operational challenges around implementation of the Affordable Care Act. He can be reached at

For more than a decade, MarkLogic has delivered a powerful, agile, and trusted Enterprise NoSQL database platform that enables organizations to turn all data into valuable and actionable information. Organizations and governments around the world rely on MarkLogic’s enterprise grade technology to power the new generation of information applications.


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