The memo that could have saved Obamacare
Have you read Amy Goldstein and Juliet Eilperin's excellent look at how politics -- both inside and outside the White House -- undermined the launch of Obamacare? If not, you should. I'll wait.
Goldstein and Eilperin post a memo that David Cutler, a Harvard health economist and an advisor to President Obama's 2008 campaign, sent in 2010 arguing that the White House had the wrong team in charge of health reform and they needed to completely overhaul their implementation strategy. It's worth reading in full:
http://www.washingtonpost.com/blogs/wonkblog/wp/2013/11/04/the-memo-that-could-have-saved-obamacare/
1. A good deal of reform implementation needs to occur at the Centers for Medicare
and Medicaid Services (CMS). You were dealt a bad hand here. The agency is demoralized, the
best people have left, IT services are antiquated, and there are fewer employees than in 1981,
despite a much larger burden. Nevertheless, you have not improved the situation. The nominee
to head that agency, Don Berwick has never run a provider organization or insurance company,
or dealt with Medicare or Medicaid reimbursement. On basic issues such as the transition from
fee-for-service payment to value-based payment, Don knows relatively little. Further, he has
been ordered not to be involved in anything at the agency until he is confirmed, which will likely
be in the fall. Don has a wonderful vision, but there is no way he can carry it out in any
reasonable time without substantial help.
Unfortunately, the senior staff at CMS, which has been appointed, is not up to the task.
For example, I recently met with the senior CMS staff about how all the new demonstration and
pilot programs envisioned in the legislation might work. This is a crucial issue because the
current demonstration process takes about 7 to 10 years, and thus following this path would lead
to no serious cost containment for the next decade. When engaged about the speed of reform,
the staff expressed the view that: (a) their fear was going too fast instead of going too slow; (b)
we ought to add a layer of university review to the existing process, to be sure we are doing the
right thing; and (c) the natural place to start demonstrations is in end-of-life care (Death Panels
notwithstanding).
As a result, you have an agency where the philosophy of health system reform is not
widely shared, where there is no experience running a health care organization, and where the
desire to move rapidly is lacking. The result is that I have very little confidence that the
Administration will make the right decisions about the direction and pace of delivery system
reform.
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