This post is about Obamacare. It’s hardly news anymore, I know. But my focus is less on the details of America’s ongoing efforts to reform its health sector, than on the way the discourse has played out – making the post another in my series on the dysfunctional ways in which we speak about government.
In an earlier post, I explored Great Gatsby-style carelessness. This time, I want to introduce a dance move — the ‘good governance high standards shuffle’, a display of exuberant glee (disguised as disappointment) whenever the real world intrudes, and the outcome of one or another public initiative is less than perfect.
In the same way that it can be difficult to distinguish between real tears of disappointment, and malicious glee hiding behind crocodile tears, sometimes the ‘high standards shuffle’ can be difficult to detect. Sincerity can all too easily get ‘played’ by cynicism in disguise. While some dancers of the standards shuffle are clumsily obvious, others have the moves down pat — making it hard to tell whether or not one is being played. (And some exponents might even be unaware that they’re doing the standards shuffle.)
Each year, as part of my teaching at Johns Hopkins School of Advanced International Studies, I select a ‘live’ example of the challenges of public management. A few weeks ago, as I described in another post in this series, I used the case of Washington’s Metro to explore with my students at SAIS the costs of careless in our discourse about government. In 2014, my focus was on the ongoing American debate on health care reform (also known as “Obamacare”). That debate offers a marvelous opportunity for seeing the high standards shuffle in action – an opportunity that has not diminished with the passage of time. So: come dance with me……
An exchange in the United States Congress early this past summer illustrates what the clumsy version of the standards shuffle looks like. Here (as reported by the Washington Post’s Dana Milbank) is President Obama’s Secretary of Health and Human services, Sylvia Burwell, being grilled by Sam Johnson, Republican Congressman of Texas:
“’It looks like to me everything’s going up’” Johnson said, complaining about health care costs. Burwell pointed out that Medicare spending was $300 billion below forecast and that per-capita health-care costs growth has been the lowest in 40 years.
‘Well, but the insurance rates are going up’, Johnson pressed. Burwell said rates are going up at a lower rate than before enactment.
‘Okay’, Johnson said, ‘Let me just change subjects for a second….’ “
But sometimes the moves can be much harder to detect. Let’s go back to October 1st 2013 — the day the Obama administration launched the online platform for purchasing (subsidized) health insurance. A week before the launch White House officials were assuring the public that the start up would be smooth. But that was not what happened. Over eight million people tried to log on to healthcare.gov in the first three days of the launch. It took hours of trying to get onto the site. In the first month, fewer than 27,000 people actually were able to navigate the site to the point that they could select a plan to purchase.
Then things turned around. In late October, the Obama administration turned to Mr Fixit, Jeffrey Zients, an entrepreneur and former management consultant (including with Bain & Company….). Zients promised that by the end of November four out of five people on the site would successfully complete their efforts to purchase insurance, and that by the end of the year the site would by working smoothly. He delivered. By April 2014, 5.4 million people had enrolled for health insurance via the healthcare.gov site, a number which exceeded Obamacare’s proponents expectations. had succeeded beyond its proponents expectations. As of mid-2015, 16.4 million people who otherwise would have remained uninsured had benefited from one or another aspect of Obamacare – bringing the percentage of the population that remained uninsured down from 16% in 2009 to 9% in 2015.
Yet even if, in broad terms, Obamacare has achieved its objectives, might the messiness in implementation have been avoided? Intriguingly, my SAIS students and I concluded that, for two reasons, it was an inevitable part of the package.
The first reason is technological: Large information technology projects almost never launch as planned, in either the private or public sectors. An October 2013 article in Computerworld reported that only 6.5% of 3,555 projects from 2003 to 2012 with labor costs in excess of $10 million were wholly successful; that 41.5% were failures (either abandoned or started anew from scratch); and that the remaining 52% were challenged (over budget, behind schedule or failing to meet user expectations). Generally, private companies respond to these realities by scaling-up incrementally, with multiple ‘beta’ versions, fixing problems as they arise, and managing expectations along the way.
This brings us to the second reason why the messiness of the launch was likely unavoidable – namely that in the politically toxic environment that prevailed in Washington, an incremental approach was not feasible. Here’s how the political context was described in a November 2013 article in the Washington Post:
“The project was hampered by the White House’s political sensitivity to Republican hatred of the law – sensitivity so intense that the president’s aides ordered that some work be slowed down or remain secret for fear of feeding the opposition…. Republicans also made clear they would block funding…..Tucking [the unit responsible for implementation] within a large bureaucracy, some administration officials believed, [it] would be better insulated from the efforts of House Republicans, who were looking for ways to undermine the law….‘You’re basically trying to build a complicated building in a war zone, because the Republicans are lobbing bombs at us’ a White House official said…”
Reflecting on the Obamacare experience, I am tempted to propose two theorems of public sector implementation in ‘messy democracies’:
- That start-up will rarely be as smooth as proponents promise, and generally messier than in the private sector. (Even without the Obamacare-specific politics, public organizations need to content with a more complex combination of multiple goals and rigid procurement practices than do their private counterparts.). And
- That the true measure of public sector capability is the capacity to adapt when crisis becomes apparent – with the moment of crisis creating the opportunity to cut through the fog of political obfuscation and bureaucratic routines. Whether a public organization can rise to the occasion is the true test of what can be achieved, not judgement against a standard of perfection.
But these theorems imply that public action will almost always be vulnerable to the ‘good governance standards shuffle’. Again, the discourse surrounding Obamacare is revealing. Though the facts of what happened seem clear, endless repetition of the ‘failed roll-out of Obamacare’ mantra persist. In the eye of at least some beholders, success (rather than failure) simply is not an option. Evidently, something other than an engagement with the facts is at work. In the case of Obamacare, there’s not much ambiguity as to what it is: a determination, for ideological (or other) reasons to discredit the reforms. Obamacare WILL serve as ‘Exhibit #1’ of what government cannot do, irrespective of the evidence.
To be sure, things can (and do) go wrong; those of us committed to public action hardly have room for complacency. But we would also do well to avoid buying into superficially appealing benchmarks of perfection, thereby inadvertently contributing to the corrosive discourse about government. Rather, we can step back and publicly applaud the cynical performance for what it is – a virtuoso display of the ‘good governance high standards shuffle’!!!!
(Postscript: Here, for your enjoyment, as a bonus for reading this post, is a link to a YouTube video of a true dance master in action – Mr Fred Astaire…….).