Implementing Health Reform. On February 23, 2016, the Office of Inspector General (OIG) of the Department of Health and Human Services released a lengthy overview report analyzing the implementation of the Affordable Care Act (ACA) federal marketplace, Healthcare.gov. Much of the report tells a by now familiar story of the factors that drove the October 1, 2013 disaster—only six consumers were able to sign up and choose a plan on the first day of the first open enrollment period: lack of leadership; lax and ineffective government oversight; poor contractor performance; unrealistic expectations and deadlines and wishful thinking that they would be met; delayed and confused policy development that in turn delayed and confused technical specifications; a transfer of agency authority midstream; constant staff turnover; and a compressed and unrealistic timeframe.
The report, however, also tells the story of how the Centers for Medicare and Medicaid Services (CMS) were able to rapidly recover from this disaster, prioritizing recovery, bringing in new private resources, operating under a “badgeless culture” where all worked as a single team regardless of their employer or job title, prioritizing essential tasks and postponing others, integrating all functions, and planning for problems. It also clarified leadership of the marketplace, focused on quality, and simplified processes. By the end of 2013, healthcare.gov was functional. But CMS continued to improve the marketplace and add functionality, and by the 2015 open enrollment period it was functioning even better, although the “back end” where the marketplace transacts with health plans is only now becoming fully functional.
The report has four sections. The first covers the planning for the marketplace from 2010 to 2012. The second covers the final preparation for the launch, January to September 2013. The third covers the disastrous launch and recovery, October 2013 to March 2014, and the final section covers turnaround and the second open enrollment period, April 2014 to February 2015. The report concludes with a section on lessons learned and CMS’ response. CMS embraces the OIG’s recommendations and is continuing to improve the marketplace.
The report recites a story familiar to those of us who have closely followed the implementation of the ACA, but contains technical details that may have been missed. It is brutal in exposing the faults of CMS leadership and of the private contractors in charge, but also offers high praise to the organizations for being able to right a sinking ship and get it steaming forward again. There is plenty of blame to go around, but also remarkable achievements to honor.
One factor did not get enough attention in the otherwise comprehensive report, however. This was the difficulty of implementing an incredibly complex program in an atmosphere of unremitting political hostility. Except for the initial implementation appropriation found in the ACA itself, Congress refused to appropriate more funds during the four years of implementation. HHS was forced to cobble together funding, which was not proportionate to the task. Dozens of court cases, including two that went to the Supreme Court, left the ultimate implementation of the marketplace constantly in doubt.
Political opposition in Republican states forced HHS to implement a much larger marketplace than was initially contemplated by the statute. HHS officials were constantly called in to testify before hostile congressional committees and had to spend many hours preparing for hearings that could have been spent more productively in giving leadership to implementation. Just as implementation was beginning, Congress shut down the government for two weeks.
There is plenty of blame to go around for the failed launch of Healthcare.gov. The OIG report pulls no punches. I only wish it had looked more closely not only at the governmental officials and private contractors who stumbled in their attempts to carry implementation off, but also at those who tried to trip them along the way.
from Health Affairs Blog http://ift.tt/1XMIdZI
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