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. The job of shepherding the project was given to Nancy-Ann Min DeParle, the director of the White House Office of Health Reform and a very wonky wonk who happens to be married to one of my favorite writers. According to one official, the president believed that “if you were to design a person in the lab to implement health care, it would be Nancy-Ann.”
- 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 (and, as I understand it, also restricted the ability of HHS to transfer funds from other areas). Funding instead had to be jerry-rigged and the job run out of CMS, which could get bureaucratic authority for the spending.
- 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:
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