Public policies can fail for a host of reasons. For example, policymakers may fail to understand the causality underlying the problems they wish to address or employ the wrong policy instruments. They may fail to understand the unintended consequences of policy or some of the critical trade-offs. They may design policies that will only succeed if a highly stylized set of assumptions hold. Even if they get the basic model right, there may be failures in implementation. There are obviously significant concerns along all of these fronts with respect to the Affordable Care Act, but let us focus on implementation and more specifically, the rollout of the HealthCare.gov.
Amy Goldstein and Juliet Eilperin have a wonderful piece “HealthCare.gov: How political fear was pitted against technical needs.” (Washington Post). The article provides an analysis of the implementation of the Affordable Car Act that explains some of the problems that have plagued HealthCare.gov. Here are some key insights (but I suggest you read the entire piece):
1. Implementation tasks were assigned to White House insiders with no experience. In the words of David Cutler (health advisor to Obama’s 2008 campaign): “They were running the biggest start-up in the world, and they didn’t have anyone who had run a start-up, or even run a business.” Those in the administration that argued for turning implementation over to a healthcare czar were ignored in large part because the administration wanted to retain control.
2. Fear of the political opposition: “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.” One example: administration officials refused to release diagrams (a.k.a. “concepts of operations”) to show the states how the federal exchange would function 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, “the White House quashed the diagrams, telling CMS, instead, to praise early work on those state exchanges that matched the hidden federal thinking.” This fear also led the administration to limit the dissemination of information to allies on Capitol Hill and to contractors.
3. Bureaucratic Fragmentation: “the work of designing the federal health exchange — and of helping states that wanted to build their own — became fragmented.” In the words of a former administration official: “There wasn’t a person who said, ‘My job is the seamless implementation of the Affordable Care Act.’ ” It appears that no one was responsible for integrating all of the decisions that had to be made in implementing this complex statute.
If the only problems facing the Affordable Care Act were tied to the technical features of HealthCare.gov website, advocates might look forward to a day in late November or December when things would be on track. But the problems identified in the Goldstein/Eilperin article seem emblematic of a larger culture that is finding a host of expressions in different policy arenas. To the extent that this is the case, the problems are likely to extend well beyond the rollout of the ACA (and beyond the ACA itself).