Another Sunday, another amazing reported piece on the rather amazing history of the Patient Protection and Affordable Care Act's health insurance exchanges. You’ll have to read the whole thing, because summary won’t do it justice. But here are a few highlights:
- David Cutler, one of the top health-care economists in the U.S., wrote a memo to Larry Summers in 2010 warning him that the team in charge of implementing Obamacare was not up to the job. The memo makes it clear, though not quite explicit, that Cutler was writing to Summers, rather than someone on the health-care policy team, because the team had ignored his concerns. The memo is eerily prophetic: The key people were analysts with no experience in project management, technology, startups or the insurance business; responsibility was too diffused; the staff didn’t understand either the magnitude or the urgency of what they had taken on; and neither the Department of Health and Human Services nor the Centers for Medicare and Medicaid Services, to which most of the job had been delegated, had the personnel or technical experience to manage it well...
- Parts of the implementation were hamstrung by the assumption that all the states would build their own exchanges, and because it was a draft bill that no one had expected to pass, it didn’t contain funding for federal exchanges or, apparently, for the policy wonks needed to put the law together. The Republicans, who continued to oppose the law to the apparent surprise of its architects and supporters, declined to provide funds on top of the nearly $1 trillion that had already been allocated...
- But many of the bad decisions were designed to avoid Republican criticism. There was another reason that the exchanges' architects were tucked away inside CMS: to try to stay out of the public eye. Other such decisions followed. CMS carefully obscured the unwillingness of a large number of states to build exchanges -- despite the fact that this would greatly increase the complexity of the job -- lest Republicans seize on that fact. Then CMS kept extending the deadline to declare, in the hopes that some states would decide to build exchanges after the 2012 elections. The agency also refused to issue a bunch of regulations until after the election. But this is by far the most incredible: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...
This has, rather predictably, triggered opposite reactions from left and right. The response from the right is somewhere between schadenfreude and slack-jawed amazement. The response from the left is, I think, summed up by Kevin Drum in “The Lesson of Obamacare: Sabotage Works”:
- The White House was heavily focused on regulations, rather than exchange design, for the first two years... They didn’t even begin writing the specifications for the contracts until spring of 2011. Then they kept changing deadlines and requirements, seemingly oblivious of the havoc they were wreaking on an already impossibly late system...
- Congressional Democrats were not given as much information as you’d expect, which is one reason that Max Baucus started worrying about a “train wreck”; apparently, they found out that the employer mandate was being delayed just a half-hour before the rest of us...
...No federal program that I can remember faced quite the implacable hostility during its implementation that Obamacare has faced. This excuses neither the Obama administration's poor decisions nor its timidity in the face of Republican attacks, but it certainly puts them in the proper perspective.Andrew Sullivan echoes this interpretation.
You will perhaps be unsurprised to hear me say that this response is overblown. Let’s remember what this “sabotage” consists of:
...But Obamacare’s biggest problem, as I have written, was that the architects of the law demanded an enormously ambitious software project on an impossibly hubristic deadline. Whatever slim chance this had of working was ultimately doomed -- not by Republicans, but by the administration’s own paranoid and self-destructive decisions to manage a software project as if it were a top-secret campaign strategy rather than a mission-critical component of the most ambitious federal entitlement expansion in almost 50 years.
- Many states not building their own exchanges, as permitted under the law.
- Republicans did not join together with Democrats to pass extra funding for a law that was already spending nearly a trillion dollars over 10 years.
Remember that when Cutler wrote that devastating memo, Democrats still had control of both houses of Congress. The administration failed to rectify the shortcomings he identified because it did not understand that making a program happen is very different from writing out a description of it.
The administration did not refuse to issue key regulations and guidelines, or to announce the final number of states that would be building their own exchanges, because Republicans used secret mind-control rays or stole the notebooks they had used to write the draft memo. They delayed because they did not want Republicans to be able to tell the public about them before Barack Obama was safely re-elected to a second term.
In other words, most of the damage was done not by lack of funding, but because the administration was either incompetent or trying to insulate itself from the perfectly ordinary, natural, legitimate and, dare I say, patriotic function of an opposition party, which is to point out to the public when the party in charge is doing something that the public wouldn’t like. Reframing “criticism of the administration” as “sabotage” deserves an Oscar for outstanding lifetime achievement in the field of political spin.
...Unsurprisingly, the massive and unpopular transformation failed to attract any Republican votes. When Republicans had faced similar electoral math on Social Security reform -- an opposition party implacably opposed, and the electorate clearly against it -- they’d abandoned their efforts. That is what parties do when they reach such an impasse; it’s what Democrats did on Clintoncare. No program this large had ever passed on a party-line vote, because this was correctly viewed as political suicide. Nancy Pelosi managed to get it through the House anyway, which should go down as one of the most impressive political achievements in history, and Harry Reid shepherded another version through the Senate. When Republicans protested, they were rather smugly told that “elections have consequences.”
Then Ted Kennedy died. Massachusetts -- Massachusetts! -- elected Republican Scott Brown in an election that often seemed to revolve around the health-care bill. Democrats still pressed forward. Without the votes to overcome a Republican filibuster, they had the House pass a draft Senate bill that had never been meant to become law and used some procedural tap-dancing to push some fixes through the Senate. Such maneuvering wasn’t unprecedented, but it wasn’t popular, either. And the limitations of the method they used left the bill with all sorts of problems, many of which we are dealing with now...Fukushima!
Hat tip: Mtntoppatriot