NOW that we are past the government shutdown and debt ceiling debacles, all eyes are on Obamacare. For the last three weeks, the rollout of the federal exchange Web site, a centerpiece of the law, has been riddled with problems, leaving millions of Americans frustrated and dismayed.

What went wrong? My diagnosis is that there were three big mistakes.

First, the Obama administration acted too slowly. It waited too long to release specific regulations and guidance on how the exchange would work. It also waited too long to begin building the physical Web site. These delays were largely because the administration wanted to avoid election-year controversy. This may have been a smart political move in the short term, but it left the administration scrambling to get the IT infrastructure together in time, robbing it of an opportunity to adequately consult with independent experts, test the site and fix any problems before it opened to the public.

Second, the ostensible quarterback of the federal health care exchanges, with responsibility for integrating all the various components, is the Centers for Medicare and Medicaid Services. While the agency has expertise in issuing reimbursement rules and overseeing large-scale claims-processing operations, it has little expertise in creating a complex e-commerce Web site. More important, there was no single senior person in the agency tasked with running the exchange rollout.

Finally, this was not the first health insurance exchange ever created. Massachusetts has had years of experience with its exchange, and there are private exchanges, like eHealth, where individuals can shop for insurance. In addition, many states, like California, Connecticut and Kentucky, had already spent around two years building their exchanges, gaining experience and proving it was possible to create a good customer shopping experience. It does not appear that the Centers for Medicare and Medicaid Services or its contractors spent much time reviewing these models and adopting best practices.

Now what should be done? On Monday, President Obama both criticized and defended the Web site. While he conveyed an all-hands-on-deck attitude and his commitment to solving the problems, he did not give sufficient specifics.

But there are five things we can do now to right the ship of Obamacare.

The president should create a new position: an independent chief executive of the federal exchange. On Tuesday, the White House announced that the economic adviser Jeffrey D. Zients will oversee the “tech surge” in the short term. Mr. Zients is a great manager and was a health care industry consultant, but he is also about to take on an important job as director of the National Economic Council. We need someone who can not just begin the repair process, but also run and refine the exchange’s operations for at least the next two years.

This C.E.O. should meet one on one with the president every week to ensure he or she has full authority to carry out the job. The candidate should have management experience, knowledge of how both the government and health insurance industry work, and at least some familiarity with IT systems. Obviously this is a tall order, but there are such people. And the administration needs to hire one immediately, while Mr. Zients works to put out the fires.

Second, the system needs to borrow from other exchanges. While the federal exchange has been a fiasco, many state exchanges have been working well since they launched earlier this month. One of the assignments for the students in my health policy class at the University of Pennsylvania this semester was to window-shop for insurance policies on the California exchange. They found the site easy to use and said there were many choices and the prices were competitive, even before subsidies. These students are the key demographic — young and healthy — that the sites need if they are going to succeed. Mr. Zients and the new C.E.O. should be looking carefully at the California, Kentucky, Massachusetts, Maryland, New York and any other successful state-run exchanges, and seeing which aspects can be adopted into the federal exchange, without reinventing it wholesale.

Next, the administration needs to be candid with the public. Given the disappointing rollout of the Web site, Americans are justifiably suspicious. Starting now, the administration needs to initiate a concerted effort to win back the public’s trust. There should be twice-weekly briefings that feature honest and complete descriptions of both the problems and solutions that the tech team is working on — in all the gory detail. We need to hear from those “best and brightest” experts whom President Obama has enlisted in the tech surge. Transparency is the only way to convince the American people that the situation is under control.

Fourth, delay what can be delayed to focus on the absolute top priority: the customer shopping experience, especially the ability to compare coverage, deductibles, co-pays, subsidized premiums and other information side by side. But there are certain parts of the exchange that can be postponed. For instance, the site doesn’t have to provide the enrollment data of each individual to insurance companies right away. That could be delayed until mid-November.

Finally, once the Web site is working reasonably well, there needs to be an enormous P.R. campaign to engage those young invincibles.

When President Obama spoke about the Web site issues on Monday, he argued that health care is so important, people will put up with the glitches to get it. That may be true, but the Americans who are likely to endure the frustrations are those who most need coverage — older people with expensive health problems. If the site is too much of a hassle, the healthy 20- and 30-year-olds the system desperately needs to enroll won’t go through the trouble. Everything should done to make their purchasing experience smooth.

Thanksgiving week is probably the time when most Americans will begin to purchase health insurance. The Web site has to be working well by then. If all goes well, by 2015, shopping on the exchanges should feel like shopping on Amazon.

Health care reform has succeeded in generating competition and lowering premiums. If the Web site doesn’t start getting its act together in the next five weeks, it risks losing the interest and good will of the American public, thereby jeopardizing these tremendous gains.


Ezekiel J. Emanuel, a vice provost at the University of Pennsylvania and a contributing opinion writer, is an oncologist who advised the White House on health care reform.