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Government, Politics & Issues

Commentary: Obama trusted, should have verified that bureaucrats were on top of ACA rollout

This article originally appeared in the St. Louis Beacon. - Too frequently those who examine public policy dwell on the creation of a law and then on results, usually quantifiable. How the law is implemented is overlooked. Yet, implementation may be key to policy success or failure.

Without gauging the performance of government agencies and their incentives or their interaction with contractors, one cannot make a clear judgment about policy success or failure. This black box of implementation also pertains to legislators, pundits and sometimes the citizens who are affected by government policy. The Affordable Care Act represents a perfect case in point.

The ACA, a signature piece of the Obama presidency, is very complex and involves a myriad of actors. Its rollout will soon become a classic case study of things not to do.

In their pathbreaking study of implementation, Pressman and Wildavsky pointed out that the more decision points a program has and the more actors that are involved, the higher the likelihood of failure. With the ACA, two entities within the Department of Health and Human Services are directly involved as well as the Internal Revenue Service. In addition, 35 states did not set up exchanges. That the federal responsibility would grow by so much may not have been clearly anticipated. Then you have other states that have their own exchanges and different potential insurers within each of the states.

Cooperation among such multiple actors has always been fraught with difficulty. Bureaucracies frequently exhibit turf rivalry; they do not play well with others. Maintaining their prerogatives and privileges is often paramount.

The basis for some of the problems can be found in the fact that the ACA is being implemented by existing agencies. A number of scholars have shown that such entities will try to bend a new program to fit within their existing standard operating procedures, which can distort program purposes.

Although the ACA was passed in 2009, most provisions were to take effect Jan. 1, 2014. And regulations were not issued until after the 2012 presidential election. Agencies have to wait for regulations to become official and are published in the Federal Register before they can act. This cut the time to prepare for implementation significantly.

The government hired private contractors to create a website, a one-stop shopping affair, where millions of people, often uninsured, could sign up for coverage. In a Dec. 1 article, The New York Times reported flaws in the creation process: The different contractors did not get along and the HHS staff didn’t get along with the contractors. There was no overall czar to prioritize and force the parts to mesh.

Since the Eisenhower administration, the federal government has relied on private contractors to handle a great deal of its work. The liabilities inherent in this approach include a reduction in effectiveness and in attention to policy goals.

In Donald Kettl’s outstanding book about the process, Sharing Power, he noted that business and government do not behave in similar fashion. Profits govern one, politics the other. Kettl includes such examples as the Superfund (EPA), production of nuclear weapons and state and local government use of contractors delivering services. Too often government is not a smart buyer. It may not specify the work to be done in the best fashion and it may not have the best staff for contract drafting and supervision.

Oversight of contractors is vital to success. We are not sure what went on in HHS for the preparation of the website except for difficulties in cooperation. But monitoring the contractors’ web work seems to have been abysmal. It does not seem that the president or his aides were hands on about looking at where progress was and finding out whether the program would really be ready to begin enrollment on Oct. 1. One can assume that there was blind-siding but where was Oval Office curiosity? The ACA is the principal legislative accomplishment of this administration. It had a legion of critics ready to jump on any and all inadequacies.

The president would have done well to study the management style of FDR. He never assumed compliance but was always checking on implementation, using a variety of sources of information. Roosevelt saw multiple programs created during his first few years in office. He does not appear to have dropped the ball. He would ask a cabinet secretary about programs or policy from another department.

He picked up the federal telephone directory and would call lower level employees directly to see how things were going. He sent his wife across the country to examine conditions and program responses. For most of his new programs, he created new agencies to prevent the programs from being stifled by existing structures and staff.

We live in a far more complex and challenging time than FDR but perhaps an MSNBC commenter was correct when he said President. Obama would have been better served if he had attended the Kennedy School of Government at Harvard instead of its law school. Getting elected and passing laws do not matter if implementation does not receive the attention it deserves.

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