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Health Reform Implementation: A Little Historical Perspective, Please | Jared Bernstein

This post originally appeared at Jared Bernstein’s On The Economy blog.

Posted: 10/22/2013 5:01 pm

I yield to no one in my anger around the performance of some of the websites where far too many people are enduring deep frustration to sign up for coverage on the new health care exchanges. But there is an obvious danger of over-interpreting this unfortunate, time-limited episode.

Perhaps I should address this post to people over 45 (I’m almost 58… eeks!), but can we get a little historical perspective here in at least two dimensions, with the second being most important?

First, the introduction of big, complex policies like this always invoke big implementation challenges. I well remember the numerous delays to the rollout of the Medicare Prescription drug program, a benefit that is now highly valued by its recipients. Back when we introduced Medicare, we were sending forest rangers out into the woods to enroll hermits.

But the larger point is this: many of us have literally been working on health care reform for decades — three decades, in my case. With the passage of the Affordable Care Act, advocates in particular and the nation in general scored a milestone victory. That’s not saying the law is perfect by a long shot (it’s too complex for one, a function of embracing an architecture that avoids single payer).

But its structure meets the fundamental requirements of reform: an individual mandate to ensure a large risk pool, and subsidies to ensure that economically disadvantaged households can meet the mandate.

Of course, these rotten, horribly timed glitches should be fixed ASAP. Especially in this political climate, the idea that progressives would score an “own goal” on this is absolutely unconscionable.

But no one should let a few weeks or even a few months of computer glitches undermine a legislative victory that was so many years in the making.

A final thought, just on the mechanics of government. In my tenure, I learned that presidential administrations are not designed for optimal implementation of anything complicated. A tax or formula change, no problem. But a Recovery Act, financial market reform, ACA — much tougher. At that level, you put all your energy into program design and then the legislative fight. Once you win or lose the votes, you’re on to landing all the other airplanes that were circling while you were otherwise engaged.

The tendency is to shove off the implementation on the agencies, who then cascade it down the line, in the case of the ACA, to private contractors who demonstrably weren’t up to the task.

The key, at least in my limited experience, is to put someone in charge of the process who’s willing to ride herd at the most granular level. I saw VP Biden do that close up on the Recovery Act. I mean, the dude had weekly calls with governors and mayors, making sure stuff got done, and with high levels of accountability and transparency.

In an important way, I’m sure building the ACA websites was harder to oversee than the Recovery Act, because while the VP knew what it meant to have fiscal relief get to states or to get construction projects underway, high-level administrators can’t be expected to understand database architecture. But knowing of implementation-risk at this level of government should have led those involved to provide more oversight.

Still, it’s good to see that the screw-ups have gotten administrators’ full attention and they clearly understand the urgency of the moment. And let’s not lose sight of the fact that both the Medicaid expansions and the state-run exchanges appear to be going well. In his speech yesterday, the president pointed out the absolutely remarkable result that the Medicaid expansion in Oregon “…helped cut the number of uninsured people by 10 percent just in the last three weeks. Think about that. That’s 56,000 more Americans who now have health care.”

Most importantly, as Kentucky’s Gov. Beshear advises here, let’s take a deep breath (be sure to watch this). With the construction of the exchanges, we’ve built what I believe will come to be seen as a uniquely effective shopping center. It’s just that the road to get there in a bunch of states is fraught with potholes or worse. That can and will be fixed.

In the meantime, for the majority of us who are not rabid haters of the program, let’s remember the decades it took us to get here. Fixing a website, while obviously essential, unquestionably pales beside that accomplishment.

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