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Sunday, November 03, 2013

Subtext to the WaPo healthcare.gov disaster narrative: Sabotage works

The Washington Post's tick-tock by Amy Goldstein and Juliet Eilperin on the decisions leading to the dysfunctional launch of healthcare.gov is cast in a familiar genre: an anatomy of politicized administrative incompetence. And the piece does capture some likely bad decisions.

But the narrative documents a more basic fact, not hidden but acknowledged only secondarily: sabotage works. More specifically: in a two-party system, if one party gives itself over with fanatic single-mindedness to sabotaging the enactment of a major reform, it will succeed in some degree.

The article leads with a theme-setting premise: that putting healthcare policy expert and seasoned administrator Nancy-Ann  DeParle in charge of implementation, instead of a "business leader" as some officials and consultants (and article sources) urged -- bespeaks a tragic "insularity" that is a "central factor in the disastrous rollout."  Then, secondarily:
...the project was hampered by the White House’s political sensitivity to Republican hatred of the law — sensitivity so intense that the president’s aides ordered that some work be slowed down or remain secret for fear of feeding the opposition.
Goldstein and Eilperin do a good job documenting the effects of sabotage, though persistently in the  narrative key required in debacle journalism: "if only the protagonists had chosen x and y instead of a and b." The dominant charge in the incompetence indictment is that political considerations drove policy.

But in this case, the "political considerations" consisted of sidestepping sabotage or trying to avoid providing new fodder for it. Perhaps in some cases, fear of taking propaganda hits should not have trumped operational considerations. But that's easy to charge in hindsight. And the "political" considerations -- evading sabotage -- were in service of getting the law implemented well.

The first decision (after project leadership) that Goldstein and Eilperin spotlight was to put the Centers for Medicare and Medicaid Services in charge of the website buildout. The reasons to do so are telling:
Soon, however, it became evident that the office — with more than 200 people — would not survive on its own. It lacked tools, such as the ability to award grants and outside contracts, that were vital to its mission, said Richard Foster, Medicare’s chief actuary for nearly two decades before he retired early this year. So the office, with a slightly new name, moved in early 2011 into the Centers for Medicare and Medicaid Services (CMS), a large agency spread among locations in the District, Bethesda and Baltimore.

The move had a political rationale, as well. Tucked within a large bureaucracy, some administration officials believed, the new Center for Consumer Information and Insurance Oversight would be better insulated from the efforts of House Republicans, who were looking for ways to undermine the law. But the most basic reason was financial: Although the statute provided plenty of money to help states build their own insurance exchanges, it included no money for the development of a federal exchange — and Republicans would block any funding attempts. According to one former administration official, Sebelius simply could not scrounge together enough money to keep a group of people developing the exchanges working directly under her.
Note that the "financial" reasons for the decision were also "political" -- that is, driven by GOP sabotage. First, the very fact that the federal government was tasked with building exchanges for 34 states itself points to the foundational act of sabotage: GOP-led state governments' determination that "we won't build that." The websites are for the most part working well in those states that did commit to building their own and making the law work.  Next, the whole massive project has had to operate on a shoestring because the GOP House has kept it starved as funds. It's not at all clear that CMS as project home was not the best alternative under these circumstances.

The next chapter concerns collaboration with the states. Here, the charge is politicized decision-making:
White House officials contend that the political sensitivities did not influence the substance or pace of the work. But others who were involved say otherwise.

According to two former officials, CMS staff members struggled at “multiple meetings” during the spring of 2011 to persuade White House officials for permission to publish diagrams known as “concepts of operation,” which they believed were necessary to show states what a federal exchange would look like. The two officials said the White House was reluctant because the diagrams were complex, and they feared that the Republicans might reprise a tactic from the 1990s of then-Sen. Bob Dole (R-Kan.), who mockingly brandished intricate charts created by a task force led by first lady Hillary Clinton.

In the end, one of the former officials said, the White House quashed the diagrams, telling CMS, instead, to praise early work on those state exchanges that matched the hidden federal thinking.
The drafting and selling of the ACA was deeply informed by the mistakes -- and the effects of GOP sabotage -- in the failed Clinton-era effort to pass a universal healthcare bill. We're all prone to fighting the last war, and perhaps the rhetorical heat would in this case have been worth the operational payoff -- that decision can't be assessed on the basis of the information provided in this one article. But again, the "political" considerations were not in competition with the goal of effective implementation. They were grappled with in service of the goal of a successful rollout.

The next chapter portrays a similar struggle between political defense and optimal execution:
That spring, CMS had begun writing specifications for the IT contracts to build the federal exchange, but the White House again insisted on caution. A larger number of states than expected were signaling that, under Republican pressure, they would refuse to build their own online insurance marketplaces and would rely on the federal one. The more states in the federal exchange, the more complex the task of building it. Yet, according to several former officials, White House staff would not let this fact be included in the specifications. Their concern, one former official said, was that Republicans would seize on it as evidence of a feared federal takeover of the health-care system.

So that September, when the administration issued the “scope of work” for the largest IT contract, the specifications skirted the question — saying only that “CMS will not know for certain how many states will apply” to run their own insurance exchanges.
It's arguable that throughout his time in office Obama has expended political capital and lost strategic advantage by trying to woo Republican cooperation.  He allowed Max Baucus's vain attempt to win buy-in for the ACA from GOP Senate Finance Committee members to drag out the bill's drafting, thus helping the GOP demonization campaign to ripen. Earlier, in the design of the stimulus bill that kicked off his presidency, he tossed a huge preemptive sop to the Republicans by making tax cuts one third of the package -- here too reaping only demonization of the bill.  He agreed in 2011 to negotiate a budget under threat of debt ceiling default in vain pursuit of a grand bargain. Perhaps the decision chronicled above is another instance: trying to woo states when it was obvious that Republican governors and legislatures would face insurmountable party pressure to opt out.  But again, this was a hobson's choice, and attempts to woo state governments to build their own exchanges were not "political" in any negative sense.

Goldstein and Eilperin chronicle one decision that was allegedly more purely political -- that is, taken with an election in mind:
the White House also slowed down important regulations that had been drafted within CMS months earlier, appearing to wait until just after Obama’s reelection. Among the most significant were standards for insurance coverage under exchanges. The rules for these “essential health benefits” were proposed just before Thanksgiving last year and did not become final until February. Another late regulation spelled out important rules for insurance premiums.

Such delays were “a singularly bad decision,” said Foster, the former Medicare chief actuary. “It’s the president’s most significant domestic policy achievement,” he said, and the very aides who had pushed the law through Congress were risking bad implementation “for a short-term political gain.”
Very high-minded, Foster. Except that if Obama had not won his election, there would have been no ACA implementation at all. In any case, I seem to remember a regulatory decision or two that had a wee political impact at the height of election season

To circle back to Goldstein and Eilperin's opening premise, the top-level personnel decisions don't look too irrational, either, though the authors frame them as a fatal product of Obama's "insularity." Here's what they have to say substantively about DeParle:
Since the day the bill became law, the official said, the president believed that “if you were to design a person in the lab to implement health care, it would be Nancy-Ann.”..

In the West Wing, the president put his trust in DeParle, who joined the White House two months after Obama took office in 2009 and had overseen the health-care legislation from its infancy. Earlier in her career, she had been a health-care administrator under President Bill Clinton and worked on the issue at the Office of Management and Budget.

Well-versed as she was, DeParle immediately recognized that she needed help, according to a former senior administration official. She tried — but failed — to lure to the White House one of the nation’s top experts, Jon Kingsdale, who had overseen the building of a similar insurance exchange in Massachusetts.

There's a gap in the narrative there. What happened after Kingsdale demurred? If no one similarly qualified was tapped, whose fault was that?  In any case, DeParle's successor for overall oversight of implementation, Jeanne Lambrew, sounds similarly qualified, though there's no information in this article about her decision-making or performance per se [per the update and link below, David Cutler in his 2010 memo, on which the premises of this article are largely based, does disparage Lambrew's ability to manage implementation].


Based on other reading and healthcare.gov's non-performance, it seems clear to me that Obama should have drilled deeper into the administrative structure of the website-building project. Charges that the tech project  did not have the right leadership or management structure seem well founded.  Perhaps the responsibility for failing to find that leadership can be laid at the doorstep of DeParle, or Lambrew, or Sebelius, or Obama, or all of the above.  But the decisions that Goldstein and Eilperin detail are not on their faces irrational. The damage done to the law and to the country by Republican sabotage, on the other hand, is unmistakable.

UPDATE: I confess that I missed the early link in the WaPo article to David Cutler's May 11, 2010 memo to Larry Summers, calling for a new institutional structure to manage ACA implementation. While not focused on development of the website, it does give one pause regarding the alleged management shortcomings in the existing institutions.  The fact that Austin Frakt gives weight to the memo and the WaPo article carries weight with me, too.

I should add, too, that in saying "sabotage works," I mean that it does material damage, not that it will succeed in its ultimate goal.  I believe that the ACA will ultimately succeed notwithstanding the spiteful, intellectually corrupt GOP campaign to destroy it.

UPDATE II (11/4):  Today Brian Beutler shines a spotlight on the broader GOP-inflicted budgetary carnage that has enabled the Party of No to hinder the ACA rollout (though the funding of the law's actual benefits, the premium subsidies and the Medicaid expansion, is untouchable mandatory spending):
Many of the agencies in government that administer the Affordable Care Act receive their funding from the so-called “Labor-H” or “Labor-HHS” appropriations bill. For two years now, the Department of Health and Human Services has operated without a current budget. Congress has simply renewed its out-of-date budgets every time funding has expired. Then in March, HHS’ antiquated budget had its wobbly legs cut out from underneath it when sequestration took effect....

Failing a full-year HHS budget, Democrats should insist on restoring HHS funding to its pre-sequestration levels. Put another way, they should refuse to let the GOP use the budget process to undermine Obamacare by shrinking the entire HHS budget by tens of billions of dollars — by making the Centers for Disease Control and NIH and poor children collateral damage in their war against the Affordable Care Act.

Related
No, 93 million Americans will not lose their health plans under Obamacare
From Palin to Ryan, a short history of demonizing IPAB

1 comment:

  1. The whole small factor of "not winning the election" in the article is the first thing I noticed. When are people going to realize that politics are inextricably linked with policy. That's probably the main reason for Obama's oft repeated "if you like your plan, you can keep it" deception. My guess is that as bright as he is, he knew that wasn't true. But you may have to engage in rhetoric like that when the other side is talking about the "government takeover of health care."

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