Can Sylvia Burwell Avoid the Kathleen Sebelius Trap?

Kathleen Sebelius was exactly what the White House needed in an HHS secretary — until she wasn’t.

President Barack Obama embraces outgoing Heath and Human Services Secretary Kathleen Sebelius as he turns to Sylvia Mathews Burwell, his current budget director, after naming her to replace Sebelius in the Rose Garden at the White House in Washington on April 11, 2014.
National Journal
Sam Baker
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Sam Baker
April 13, 2014, 7:07 a.m.

Kath­leen Se­beli­us had the fo­cus and even keel the White House needed in a Health and Hu­man Ser­vices sec­ret­ary, but not ne­ces­sar­ily the be­hind-the-scenes man­age­ment skills. And that’s what HHS needs most from her suc­cessor.

Par­tic­u­larly in her pub­lic ap­pear­ances and her work with the states, Se­beli­us channeled the ad­min­is­tra­tion’s top pri­or­it­ies: find­ing a way to stand up a massive new policy frame­work while try­ing not to feed the polit­ic­al firestorm that already sur­roun­ded the law.

Former ad­min­is­tra­tion of­fi­cials who worked with Se­beli­us praised her work dur­ing the early im­ple­ment­a­tion ef­fort and de­fen­ded her de­tach­ment from the day-to-day polit­ic­al grind with Re­pub­lic­ans. But they con­firmed what the Health­Care.gov de­bacle had already sug­ges­ted: Her biggest weak­ness was her man­age­ment of HHS — a massive de­part­ment to be­gin with, even without the un­pre­ced­en­ted work­load of im­ple­ment­ing the Af­ford­able Care Act.

Over­all, as Pres­id­ent Obama said Fri­day when he an­nounced Se­beli­us’s resig­na­tion, things ended up OK. The core of the law is in place, as are pop­u­lar new con­sumer pro­tec­tions, and en­roll­ment is set to end up far bet­ter than any­one ex­pec­ted in Oc­to­ber and Novem­ber.

“The fi­nal score speaks for it­self,” Obama said.

Se­beli­us wasn’t Obama’s first choice to lead HHS, but her no-non­sense per­son­al­ity ended up syncing well with the polit­ic­al de­mands of the early im­ple­ment­a­tion pro­cess. In the time between the law’s pas­sage and the be­gin­ning of open en­roll­ment, the ad­min­is­tra­tion’s strategy was largely to keep its head down, fo­cus on the work of im­ple­ment­a­tion, and try to avoid the law’s tox­ic polit­ics as much as pos­sible.

In her pub­lic ap­pear­ances and her testi­mony on Cap­it­ol Hill, Se­beli­us hardly ever waded in­to a back-and-forth with the law’s crit­ics. She was co­oper­at­ive enough to keep ag­gress­ive in­vest­ig­a­tions at bay but con­trolled enough to stay out of the kind of testy ex­changes that might end up on cable news.

“I think that her job was to en­sure that the prom­ise of the ACA ac­tu­ally be­came real­ity, and in do­ing that, she must have known that the mes­saging and the un­der­stand­ing about the law would fol­low,” one former ad­min­is­tra­tion of­fi­cial said. “You can’t do the job that she needed to do, which was to stand this up and make it op­er­a­tion­al, and be wor­ried about the con­ver­sa­tion hap­pen­ing around you.”

Some Demo­crats, es­pe­cially con­gres­sion­al lib­er­als who wanted to fight and win a polit­ic­al ar­gu­ment over the health care law, hated her ap­proach and privately pushed the White House to shake up its mes­saging, if not its mes­sen­ger. But Se­beli­us’s un­emo­tion­al de­mean­or — while au­then­t­ic — was what the ad­min­is­tra­tion wanted stra­tegic­ally.

“In ret­ro­spect, with sev­en and a half mil­lion people able to pur­chase in a way they nev­er could be­fore, yeah, it was a good strategy,” the former of­fi­cial said.

A former gov­ernor and in­sur­ance com­mis­sion­er, Se­beli­us got mostly pos­it­ive re­views from the state of­fi­cials who were in­teg­ral to set­ting up the law’s com­plex policy frame­work. And she ca­joled Re­pub­lic­an gov­ernors in­to the law’s Medi­caid ex­pan­sion by help­ing them se­cure state-spe­cif­ic waivers.

Of­fi­cials have been quick to cred­it her for the fact that 26 states have signed on to the Medi­caid ex­pan­sion.

But the keep-your-head-down-un­til-it-works strategy, by defin­i­tion, re­quires that it work. And in a very high-pro­file (al­beit tem­por­ary) way, it didn’t. The dis­astrous rol­lout of Health­Care.gov will define Se­beli­us’ leg­acy just as much as the fi­nal en­roll­ment stat­ist­ics.

We still don’t have a com­pre­hens­ive ac­count­ing of how the en­roll­ment web­site was messed up so badly, but a lack of clear dir­ec­tion was clearly the biggest fun­da­ment­al prob­lem.

HHS made it­self the pro­ject co­ordin­at­or, rather than ap­point­ing a con­tract­or to pull to­geth­er all of the site’s con­tract­ors. End-to-end test­ing wasn’t done on time. Over­sight hear­ings about the site de­volved in­to a cir­cu­lar blame game: Con­tract­ors poin­ted the fin­ger at HHS while HHS poin­ted the fin­ger at con­tract­ors and in­di­vidu­al of­fi­cials all poin­ted at one an­oth­er — un­til Se­beli­us fi­nally de­clared her­self the one to be held ac­count­able.

The White House says Se­beli­us made the de­cision to leave, and was not pushed out. Even so, the choice of her re­place­ment — White House budget dir­ect­or Sylvia Math­ews Bur­well, is an ac­know­ledge­ment of what HHS needs right now. They didn’t want to of­fer spe­cif­ics out of re­spect for the out­go­ing sec­ret­ary, but former ad­min­is­tra­tion of­fi­cials said Health­Care.gov was not an isol­ated lapse in man­age­ment.

For the second time, the White House has turned to of­fi­cials with a back­ground in con­sult­ing and man­age­ment to help right the Obama­care ship. Jeff Zi­ents, an­oth­er former White House budget dir­ect­or, was brought in to quar­ter­back the im­me­di­ate re­pair ef­fort for Health­Care.gov. Now Bur­well, who began her ca­reer as a con­sult­ant be­fore mov­ing on to work for large cor­por­ate found­a­tions, is on deck to lead the en­tire de­part­ment.

Bur­well’s nom­in­a­tion will be con­ten­tious be­cause it’s a health care po­s­i­tion — Re­pub­lic­ans will surely be un­der pres­sure not to help the White House im­ple­ment Obama­care. And it will be the first big nom­in­a­tion since the Sen­ate in­voked the “nuc­le­ar op­tion,” bump­ing the threshold for nom­in­ees down to 51 votes — a move Re­pub­lic­ans are still angry about. So the White House will have to trudge through sev­er­al more weeks with Obama­care in the head­lines, but there’s reas­on to be­lieve Bur­well will make it across the fin­ish line.

Her nom­in­a­tion can move quickly be­cause she’s already been con­firmed as budget dir­ect­or — and by a 96-0 vote. She’s said to have good re­la­tion­ships with sev­er­al Sen­ate Re­pub­lic­ans, after help­ing to ham­mer out this year’s big budget agree­ment. Bur­well also has a repu­ta­tion for laser fo­cus and de­cis­ive­ness, and has won praise at the budget of­fice for an in­clus­ive man­age­ment style.

The White House says to ex­pect a lead­er­ship trans­ition in May.

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