Tuesday, October 15, 2013

Obamacare's Self-Inflicted Wounds

The good news is that Obama is a lot better in policy and execution than his predecessor, G.W. Bush. The bad news is that he is a lot worse than his predecessor's predecessor, Bill Clinton.

The good news is Obamacare (ACA) is much better than no safety net for non-seniors.  The bad news is this complex law is far inferior to "Medicare for all."  Obama instead could have pushed to lower the age for Medicare needing only 50 Senate votes or else insisted on a cleaner bill with a strong public option.

The good news is Obamacare should survive and desirous applicants should eventually be able to enroll before coverage starts on Jan. 1, 2014. The bad news is the awful, glitch-ridden debut of these online exchanges gives House Republicans behind the government shutdown some legitimacy in attacking the law.

This last self-inflicted set of wounds in the high profile rollout of Obamacarethat has little to do with politics or Washington gridlock.  Earlier health care shortcomings of HHS and Secretary Kathleen Sebelius are listed in my previous post.  There have also been outbreaks of infectious diseases and preventable veterans deaths in VA hospitals. And now this.  Even the generally Obama friendly Jon Stewart to his credit has excoriated the administration including in this Oct. 7 interview of Sebelius who looked as if she did not want to be there. 

She also couldn't properly answer his reasonable, easily anticipated and repeated question about why the businesses were given a one year waiver from the provisions of the Act, but individuals are not. (The best reason is that to make private insurers cover pre-existing conditions and less healthy people without discrimination you have to make everyone including healthier people participate.  Otherwise it's like allowing people to buy auto insurance to cover an accident that has already occurred, which is neither fair nor viable for insurers.  Such problems of adverse selection don't apply to businesses, unless all their employees get seriously sick simultaneously.)

Another of Stewart's questions Sebelius needlessly fumbled with was why wasn't single payer a much better solution than the present complex law with a big role for private insurance.  She could have simply agreed, explaining that this law was the best achievable compromise given Republican opposition and privately insured Americans' discomfort with changing the whole system. 

Of course the primary problem is not about giving bad answers in interviews, but the ineptness of Sebelius and HHS in implementing the law.  The blame shouldn't stop with them.  The effective execution of Obama's centerpiece legislation is so vital that he and his other close advisors should have been closely engaged in it.  I cited instances of Team Obama's administrative failings in the later part of my March 26 post and this is another - and much bigger - instance of his team's flubs. 

The Times on Oct. 12 reported on ignored warnings and repeated mistakes behind the dismal opening of the federal health care exchange.  The problems are so severe and widespread ("it's awful, just awful"), the article quotes, that they cannot even be categorized as "glitches".  Repeated warnings and missed deadlines have been ignored by HHS officials and the White House.

Obama and Sebelius seem to have made bad judgments and obvious mistakes even in basic decisions like assigning priorities and whom to shortlist for doing the job.  Considering its crucial role in implementing Obamacare the online system should have been vastly overdesigned for handling traffic volumes, complexity and even hacker attacks.  No expenses should have been spared - after all what's a billion dollars or two of initial outlay compared to the Medicare and Medicaid annual budget (Table 3 here) of over $1 trillion? 

Only the best IT services vendors should have been considered as lead implementer and integrator.  I'd have limited the choice to just the reputed heavyweights IBM and Accenture, with just may be HP (which acquired EDS) as a third possibility. These have the heft, the expertize and the reputational stakes to ensure they deliver well, and any subcontracting and resultant responsibility should have been left to them.  Instead, HHS seems to have invited  bids from multiple vendors with doubtful credentials and selected the lowest cost bidder, Canada's CGI Group which - no surprise - has flubbed the job.  HHS compounded the problems by having its own under-resourced and ill equipped CMS be the lead integrator and coordinator of 55+ contractors and being slow to lay down the specs.

Where do we go from here?  While a lot of his routine administration has been far from satisfactory Obama has shown he can deliver on matters that he intensely focuses on.  Examples include his getting Bin Laden and FEMA's effective response to Hurricane Sandy (a contrast to GWB's "Heck of a job, Brownie" 2005 Katrina debacle) that enormously helped his re-election.  Now he and his team need to have the same focus and oversight over implementing Obamacare and not leave it largely just to Health Secretary Sebelius and the HHS.  The online exchanges should work smoothly before December 15 and in any case easily complete all enrollments by the extended deadline of March 31, 2014.  This should help people overlook the earlier troubles like they did with GWB's drug plan for seniors.   It will improve Obamacare's standing in the polls and solidify President Obama's legacy of transforming health care for the better.


AmOK said...

Good write up. Esp the Stewart reference. The bad load problems are a shame. Some of it could have been averted perhaps by having a staggered sign up system. The way it happened was more like a Denial of service attack. Come to think of it perhaps ...but no! Can Republicans sink so low?

Sandip Madan said...

I don't think the fumbling HHS needed Republican hackers' "help" to sabotage the online exchange's debut. :-) After I wrote this I've seen several TV shows where IT experts have talked of very poor coding, basic mistakes and awful project management that's led to all the problems. Some said the present management has to be replaced since they've shown they're incapable of coming close to delivering.