Health Reform Implementation: A Little Historical Perspective, Please

October 22nd, 2013 at 2:04 pm

I yield to no one in my anger around the performance of some of the websites where far too many people are enduring deep frustration to sign up for coverage on the new health care exchanges.  But there is an obvious danger of over-interpreting this unfortunate, time-limited episode.

Perhaps I should address this post to people over 45 (I’m almost 58…eeks!), but can we get a little historical perspective here in at least two dimensions, with the second being most important?

First, the introduction of big, complex policies like this always invoke big implementation challenges.  I well remember the numerous delays to the rollout of the Medicare Prescription drug program, a benefit that is now highly valued by its recipients.  Back when we introduced Medicare, we were sending forest rangers out into the woods to enroll hermits.

But the larger point is this: many of us have literally been working on health care reform for decades—three decades, in my case.  With the passage of the Affordable Care Act, advocates in particular and the nation in general scored a milestone victory.  That’s not saying the law is perfect by a long shot (it’s too complex for one, a function of embracing an architecture that avoids single payer).

But its structure meets the fundamental requirements of reform: an individual mandate to ensure a large risk pool, and subsidies to ensure that economically disadvantaged households can meet the mandate.

Of course, these rotten, horribly timed glitches should be fixed ASAP.  Especially in this political climate, the idea that progressive would score an “own goal” on this is absolutely unconscionable.

But no one should let a few weeks or even a few months of computer glitches undermine a legislative victory that was so many years in the making.

A final thought, just on the mechanics of government.  In my tenure, I learned that Presidential administrations are not designed for optimal implementation of anything complicated.  A tax or formula change, no problem.  But a Recovery Act, financial market reform, ACA—much tougher.  At that level, you put all your energy into program design and then the legislative fight.  Once you win or lose the votes, you’re on to landing all the other airplanes that were circling while you were otherwise engaged.

The tendency is to shove off the implementation on the agencies, who then cascade it down the line, in the case of the ACA, to private contractors who demonstrably weren’t up to the task.

The key, at least in my limited experience, is to put someone in charge of the process who’s willing to ride herd at the most granular level.  I saw VP Biden do that close up on the Recovery Act.  I mean, the dude had weekly calls with governors and mayors, making sure stuff got done, and with high levels of accountability and transparency.

In an important way, I’m sure building the ACA websites was harder to oversee than the Recovery Act, because while the VP knew what it meant to have fiscal relief get to states or to get construction projects underway, high-level administrators can’t be expected to understand database architecture.  But knowing of implementation-risk at this level of government should have led those involved to provide more oversight.

Still, it’s good to see that the screw-ups have gotten administrators’ full attention and they clearly understand the urgency of the moment.  And let’s not lose sight of the fact that both the Medicaid expansions and the state-run exchanges appear to be going well.  In his speech yesterday, the President pointed out the absolutely remarkable result that the Medicaid expansion in Oregon “…helped cut the number of uninsured people by 10 percent just in the last three weeks. Think about that. That’s 56,000 more Americans who now have health care.”

Most importantly, as Kentucky’s Gov. Beshear advises here, let’s take a deep breath (be sure to watch this).  With the construction of the exchanges, we’ve built what I believe will come to be seen as a uniquely effective shopping center.  It’s just that the road to get there in a bunch of states is fraught with potholes or worse.  That can and will be fixed.

In the meantime, for the majority of us who are not rabid haters of the program, let’s remember the decades it took us to get here.  Fixing a website, while obvioulsy essential, unquestionably pales beside that accomplishment.

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11 comments in reply to "Health Reform Implementation: A Little Historical Perspective, Please"

  1. smith says:

    It’s very likely there is a cover-up going on of gross incompetency. The New York Times editorial page said as much today, but was overly polite in giving Obama more time for an explanation. The administration is refusing to reveal details. We know there was a reliance on private contractors, failure to implement following a great victory, secrecy surrounding setbacks, a president’s reputation riding on success. Sound familiar? The damage is nothing like a war gone wrong, Iraqi, Afghanistan (civil war, civilian deaths, millions displaced), but there are consequences.

    One surmises the only reason questions aren’t being answered is because the information is embarrassing. It’s going to leak out eventually, but they’re hoping to have it fixed by then.

    Unlike a war situation, it should be easy to give all the information available about a software application’s shortcomings. It’s not risking lives.

    Unlike a commercial venture, the executives in charge don’t have a right to withhold information to salvage market share and investor confidence.

    Kathleen Sebelius should resign, the failure very definitely threatens the entire program’s success. That it involves a complex computer system is no excuse.

    Good that we have a federal government, so that states have shown it can be done (California, as Krugman keeps reminding us)

    How can the press expose our counter-terrorism hacking, thus risking lives, but has trouble finding software developers working on public websites? I guess we’re all waiting for the ACA Snowden, won’t be long.

  2. Dave Roberts says:

    I’m an enthusiastic supporter of Obamacare, but the screw up of the Federal exchanges is neither a partisan issue nor an indictment of the ACA in general. Start with Sebelius if you like, but President Obama has to bear some of the responsibility for this botched introduction to his most treasured program. If the reports are true that full scale, end to end testing only began a week before the site went live, the people in charge of the project management team should be fired and banned from working for the Federal government again. People who covered up the severity of the problem from their superiors deserve the same fate. My strongest feelings are a deep embarrassment on behalf of the computer science profession. This is not work to be proud of. Best practices were not followed. It’s time to dump our IT procurement system and start over.

  3. Mark Ogilvie says:

    The idea that you don’t have to get it right, just get it out there is a typical government idea. After all what have they got to worry about? Someone will get a golden parachute or shuffled off into another agency. The nobility in the congress has already exempted themselves from what the peasants will have to deal with. The peasants after all don’t have a choice in this. It’s one stop shopping or face the IRS (an agency that historically makes the Inquisition look merciful).
    I’m sure they will get it fixed and the system will be badly run, badly maintained and will probably never work right. But this is the US government, they don’t have to make it work right, they just have to make sure it keeps working. Or at least sort of working.

  4. Tom in MN says:


    This idea that private is always better is just wrong. We’ve been had to the tune of trillions of dollars on this, Iraq reconstruction, you name it. The idea that Government can’t do things itself it a con to dump money on the likes of Halliburton — just another way to give the rich our money.

    And to complain the Government can’t get something right the first time when the funds have been repeatedly cut over decades is completely unfair. At this point all government agencies are operating on way less than they need to do their jobs competently and with proper oversight, etc. This is the GOP’s self-fulfilling prophecy: government is bad, so keep cutting funding until it improves.

  5. save_the_rustbelt says:

    Every aspect of ACA is incredibly complicated, remember Krugman’s Rube Goldberg comment?

    When ACA was passed I did what an old consultant would do, tried to flow chart the program, find a critical path, look for bottlenecks, etc. This is a very bad piece of legislation.

    And we are just getting started on the unintended consequences on the provider side.

    • Jerryville Ray says:

      You do your due diligence and pronounce the ACA a “very bad piece of legislation” yet offer not one bit of supporting evidence. The spirit of it is not incredibly complicated because Jared expressed it in a single sentence. The automated implementation of the exchanges is, on the other hand, incredibly complicated because of the involvement of multiple back end systems and was horribly botched by several known incompetent IT providers like SAIC.

  6. Mark Ogilvie says:

    Private isn’t always better, public isn’t always better, but competency is Always better. They had all of the time that they needed to do this, they had all of the money they needed to do this. But they didn’t have to worry if it didn’t work because there are never any consequences. They’ll have to endure a few angry columns -possibly even some in the left leaning press- but that’ll die down and it will become a cliche that the websight and the system doesn’t really work. It’ll be like the jokes about the DMV. When government gets it wrong the people who suffer for the mistakes are rarely those who actually work in the government.

  7. Noni Mausa says:

    What no one has said, that I have run across anyway, is that the old-style insurance policies are just as awful to deal with, only not on the entry side, but on the coverage side And they are designed to be so.

    Trying to be reimbursed or paid for health care from these insurance companies is often so difficult that a sizable percentage of patients and their families either find out in the fine print that they don’t qualify, or give up trying out of exhaustion or confusion, or die before being approved. Their paperwork gets lost, their diagnoses are challenged, their treatments are disallowed…

    I am surprised that a population experienced in dealing with the for-profit insurers would be daunted by a hurry-up website which will, in a few months, be improved to become stable and intuitive. I never heard the Republicans yelling about the opaque for-profit system, why such a noise now? /rhetorical question


  8. Maria Cadwallader says:

    Please help clarify the ACA and calm some fears by explaining in detail how and on what schedule income-qualified folks will receive their govt financial help for health insurance. Will their monthly payments be lowered by amounts the govt pays? Will they have to pay the full monthly fee and wait for a quarterly rebate or, worse, an annnual tax credit?

    Also what are the income levels that qualify individuals, couples, various sizes of families for subsidies?

    Would appreciate written answers here to link to our library’s website & facebook page. Also would like to hear you explaining on various news shows.

    Your clarity & thoroughness do a lot of good.

  9. jeff says:

    The website implementation is part of the rot that passes for elite decision making and implementation in the U.S. today. I mean, no one is even really surprised by this disaster.

    The website will have to be rebuilt completely.