Today’s WaPo story seems to vindicate my instinct to blame the project organization, not the technical people.
Recall what I wrote in my letter to the editor.
I doubt that presidential anger can do much to cure the dysfunctional organizational dynamics that I suspect are at the heart of the Web site problems.
Today’s story is about those dysfunctional organizational dynamics. Most devastating is a 3-year-old memo from health economist David Cutler. He barely even touches on the technical issues of implementation. He sees the Administration dropping the ball on preparing the health industry and the public for the new system.
Running exchanges is a collaborative process. As just one example, the person who ran the Commonwealth Connector in Massachusetts estimates that he had 500 town meetings to discuss reform, the equivalent of 17,000 meetings nationally – and this was in a state where two-thirds of people, along with insurance companies, supported reform. The person newly appointed to head the insurance oversight office has a reputation as an insurance bulldog, not a skilled facilitator. Remember that most people will get their information about reform from their doctor and their insurance agent. If you cannot find a way to work with hesitant states and insurers, reform will blow up.
An important implication is that even if the Web site were working perfectly, we would have plenty of implementation problems. Has there been enough consumer education to enable people to understand which plan to choose? Have doctors been coached about how to help with the process? etc.
Later, he writes,
Above the operational level, the process is also broken. The overall head of implementation inside HHS, Jeanne Lambrew, is known for her knowledge of Congress, her commitment to the poor, and her mistrust of insurance companies. She is not known for operational ability, knowledge of delivery systems, or facilitating widespread change. Thus, it is not surprising that delivery system reform, provider outreach, and exchange administration are receiving little attention. Further, the fact that Jeanne and people like her cannot get along with other people in the Administration means that the opportunities for collaborative engagement are limited, areas of great importance are not addressed, and valuable problem solving time is wasted on internal fights
The WaPo story makes it seem as if no one was really in charge.
The Medicaid center’s chief operating officer, a longtime career staffer named Michelle Snyder, nominally oversaw the various pieces, but, as one former administration official put it: “Implementing the exchange was one of 39 things she did. There wasn’t a person who said, ‘My job is the seamless implementation of the Affordable Care Act.’ ”
That last sentence gets to the heart of the matter. As I wrote here,
I suspect that the technical problems are mere symptoms. Probably what is fundamentally messed up in this health insurance brokerage business is the org chart.
Cutler’s memo includes a recommendation for a functional org chart. I think that anyone with business experience or common sense would think along similar lines. President Obama’s supporters can spin like Dervishes, and yet it will be difficult to escape the inevitable inference that the White House clique lacks business experience and common sense.
I am reminded of Richard Feynmann’s great quote that closed his study of the Challenger’s tragic failure:
“For a successful technology, reality must take precedence over public relations, for Nature cannot be fooled.”
It applies not only to the abortive Obamacare exchange rollout, but also to the whole law’s basic concept of simultaneously (i) extending health care/insurance coverage to more people, (ii) claiming to maintain the same or better quality of care and service, and (iii) asserting that prices will not increase. You may attain two of those three objectives, but you will never satisfy all three. The math doesn’t work, and will never work, and giving speeches that it will work is trying to “fool Nature.”
That last sentence gets to the heart of the matter.
Indeed it does. The fact that we didn’t know the name of the person responsible for ACA implementation before the roll out, or even now, says that the administration had no clue some general manager was needed.
It’s hard to sympathize with such a wretched piece of legislation. But if they had just left the clearinghouses in private hands, like so many insurance clearinghouses before, while prescribing the policy choices the clearinghouse could offer, they would have avoided all this effort and failure. But then, I guess, the percentage the clearinghouses took would have looked like overhead given to non-health-care dispensing private concerns, which is one of the favorite whines against health insurance.
So instead the state and federal governments do it, at an order of magnitude more cost, and without a GM. Lack of business experience and common sense doesn’t even begin to cover it.
In this case, it’s unfortunate (for the administration) that they *weren’t* operating in ‘permanent-campaign’ mode. I bet there isn’t ‘org chart confusion’ among the campaign staff!
In reality, there is no such thing as Obamacare in that there is no coherent program driven by any vision of a good system. Instead, there are thousands of pages of laws and regulations written by various interest groups — insurers, providers, groups of clients, ideologues, academics — with each promoting its interests and visions as opportunity permitted, and without regard to the overall structure.
Why would anyone expect this process to produce anything except a monstrosity? Max Baucus recently analogized the law to Humpty Dumpty, but he does not want to delay — he wants to see if it can be put back together. (A weird hope, what with HD now being a scrambled egg.) But the real Humpty is the health care system, which may well be reduced to chaos.
Reread Cutler’s memo. Note the plaintive animus of the second paragraph: If only, if only … after all I did, they had only put me in charge … But still Larry, I owe it you (but only you, or so it seems), the cause, and my conscience to make the, following observations.
What follows is a timely memo which, without gainsaying its sincerity, could have been written by any of the thousands of us who, over the past three or four decades, have been involved in the design, production, and implementation of complex systems.
Yet is should be obvious that Cutler ‘s behavior here was ultimately of a piece with the politics first mentality which, although only a symptom of far more serious design problems, drove the administrations fatal conceit.
I leave it to practitioners of public choice theory to theorize why Cutler and Summers did not write op eds like this for the Post, Times or, heaven forbid, the WSJ. As for me, to indulge in a Ciceronian disclaimer: I will not say they are meretricious sycophants . . .
I already have insurance, but just as an experiment i checked the site last week.
I was able to sign in, get pricing (w/out providing personal details besides my zip code) in a couple of minutes.
Pricing? I have an inexpensive plans with high deductibles but low co pays for checkups and dental. There were many options to choose from (at least 10), the website was in general far easier to to read and follow than most insurance companies’ websites. I did not experience any outtages or slowness I heard about in the media. I did not attempt to create an account nor did I purchase insurance however, so I can’t speak to that.
In terms of options…. All the plans listed were more expensive, but on glance seemed to provide more coverage and lower deductibles. The cheapest plan was about 15% more expensive than what I pay presently. Is this insignificant? No, although many years my plan will increase 20-30% even if I don’t use the deductible (my provider usually attributes this to rising costs in the entire system). Is it worth paying 20% more to ensure I can’t be denied health insurance in the future, and to lessen other people having to declare bankruptcy? Sure, I’m not opposed to it especially if it slows my average annual health insurance increase. If they keep improving the system I’m open to any ideas that improve things. The exchanges definitely are nice feature competitively because they force insurers to compete more head-to-head and the exchange (at least the portion I used) was very easy to use and navigate.
Anyways I found this interesting and promising after hearing lots of horror stories, they appear to have fixed a lot already.
Can you tell us more? Did you use a state exchange or the Federal exchange? If the Federal exchange allows you to shop without creating an account, this news has not been widely reported.
How does the silence substantiate your priors?
Here is a story that says that the web site now does allow you to shop. http://www.cnn.com/2013/11/05/politics/obamacare-hearing/?sr=google_news&google_editors_picks=true