For four years we've watched the public political spat over President Obama's Affordable Care Act, but the Washington Post has given us a view into what it looks like when a political fight gets into the twitch muscles of an administration.
In an in-depth investigation into the implementation of the president’s health care law, the paper's reporters describe the creation of a jalopy built by a deeply flawed system. The problems piled up over years, flowing from both Republican obstructionism and the hyper political sensitivity of the Obama administration. This mix led to decisions based on politics instead of efficiency, which created the complexity and delay that contributed to the problems the president is scrambling to fix today.
Healthcare.gov’s collapse touches on the big issues of the Obama administration because the website represents a multiyear effort to implement the president's greatest vision. As the Washington Post outlines, three years before the site became an embarrassment, the seeds of its destruction were evident. The ingredients are familiar: partisan hurdles thrown up by the GOP, the jumpy political instincts of administration aides, administration insularity, spin that borders on deception, bureaucratic clots, and the bold and sprawling scope of the project. The question at the heart of this story—and, in a sense, of the entire Obama administration—is, what percentage of each element contributed to the ultimate outcome?
The hero of the Post narrative is David Cutler of Harvard, an Obama adviser who wrote a four-page memo in 2010 outlining a number of structural flaws he saw in the implementation of the Affordable Care Act. Many of those structural flaws led to the public mess we're now witnessing. “I am concerned that the personnel and processes you have in place are not up to the task, and that health reform will be unsuccessful as a result,” he wrote to the president’s top economic adviser, Larry Summers. The memo would seem to refute those who suggest that the failure of healthcare.gov is simply the kind of rocky rollout that attends any product launch.
The problems were deep and predictable. Cutler suggests one big flaw was that there was no central person leading the charge who had experience implementing anything of that size and complexity in the nongovernmental world. This critique gets to the heart of the question about the difference between campaigning and governing. The modern political campaign is seen as a proxy for governing. For most of American history, it was seen as the opposite, because the talents of one often have little to do with the other. Can the team that runs a successful campaign—whether it's for office or selling a piece of legislation—also run a successful product launch? If the team members can't, do they know enough to bring in a person who can? When healthcare.gov imploded, the president knew to call in the experts and put a seasoned troubleshooter at the head of the cleanup effort. Why wasn't that done before?
Apple and Google would never have allowed the problems that Cutler outlines in his memo to fester. But then again, Apple and Google would not have had to deal with an environment where their rivals were plotting to remove all the equipment from their product laboratories every night. The implementation of Obamacare didn't happen in a corporate environment. It happened in a toxic political arena where Republicans were working to undermine the law at every turn. That created hurdles real and imagined. A number of Republican governors did not open their own exchanges, adding to the federal burden. Republicans in Congress tried to defund the law any possible way they could, which meant administration officials had to house health care operations in parts of the government that would be protected from the defunding effort. The topsy-turvy organization decentralized responsibility for the law’s implementation throughout the bureaucracy.
Of course, that doesn’t mean having a team of proper eggheads leading the effort would have made everything work. They might have gotten the implementation to look pretty on the whiteboard while failing to see the partisan traps. That would have made the law more efficient but also more politically vulnerable. On the other hand, administration officials may have been jumping at shadows, contorting decisions at every turn to avoid imagined political perils. The Obama administration needed someone to balance political considerations and operational ones. That position appears to have never existed.
But the political problems facing the Affordable Care Act weren't just about avoiding specific attacks on the legislation to keep it alive. Obama aides wanted to keep the president's second-term prospects alive. That added complexity to the process as crucial regulations were delayed so that their publication didn’t cause public relations headaches. The president needed to get re-elected to make sure his signature program was implemented, but how much did getting him re-elected warp the ability to implement the signature legislation?
President Obama and his team won the political fight to pass health care reform, but they are failing at the implementation. Figuring out what variables matter most could do more than just tell us why the rollout was botched; it could tell us how to improve the state of things in Washington, where even basic legislation can't pass and when it does it isn’t executed well. That's information we should take into the next election and pose to lawmakers making big promises about what they will get done. The president is right: The collapse of healthcare.gov is about much more than a website.
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