Buck Stops With Obama on Rocky Rollout of Health Care Plan

President Obama takes questions from the media in the East Room of the White House on June 29, 2011.
National Journal
Norm Ornstein
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Norm Ornstein
Oct. 23, 2013, 4:27 p.m.

The Health­Care.gov de­bacle has been thor­oughly dis­sec­ted so far by Amer­ica’s best health journ­al­ists and policy ana­lysts. To be sure, every ma­jor rol­lout of a new or changed so­cial policy, in­clud­ing Medi­care it­self, is rough and takes weeks or months to re­solve. But this rol­lout is clearly worse, and, as we learn more about its his­tory over the past six months and more, the fail­ures in vis­ion and ex­e­cu­tion, in the face of clear and blunt warn­ings of prob­lems ahead, are strik­ing and troub­ling.

Go back, first, to Max Baucus’s fam­ous and widely dis­tor­ted and mis­used “train wreck” com­ment in a hear­ing to Health and Hu­man Ser­vices Sec­ret­ary Kath­leen Se­beli­us in April 2013. Con­trary to Ted Cruz and count­less oth­er Re­pub­lic­ans, Baucus did not call Obama­care a train wreck — he was re­fer­ring dir­ectly to its im­ple­ment­a­tion through the web­site. He said, “I un­der­stand you’ve hired a con­tract­or. I’m just wor­ried that that’s go­ing to be money down the drain be­cause con­tract­ors like to make money more than they like to do any­thing else. That’s their job. They’ve got to worry about their share­hold­ers and what­not.

“And also, all the oth­er agen­cies are all in­volved. People are go­ing to be really con­fused. And maybe give some thought to one-stop shop­ping some­how, so you go to one loc­a­tion—a busi­nessper­son—one loc­a­tion, get the an­swers.

“I just tell you, I just see a huge train wreck com­ing down. You and I have dis­cussed this many times, and I don’t see any res­ults yet.”

“What can you do to help all these people around the coun­try go­ing, ‘What in the world do I do and what—how do I know what to do?’ “

If Se­beli­us, the pres­id­ent, the lead­ers at the Cen­ters for Medi­care and Medi­caid Ser­vices, and oth­er White House of­fi­cials were un­aware be­fore that hear­ing about the im­ple­ment­a­tion prob­lems, they could not be un­aware af­ter­ward. And, as we are now hear­ing, the stark in­tern­al warn­ings from tech ex­perts of deep-seated prob­lems in the pro­grams came months ago and went un­heeded.

Mi­chael Ger­son, the Wash­ing­ton Post colum­nist chan­nel­ing his in­ner Friedrich von Hayek, says this is the in­her­ent flaw in a huge sys­tem run by gov­ern­ment — an ob­vi­ously false con­clu­sion giv­en that the health care sys­tems in France, Canada, the Neth­er­lands. and, yes, Great Bri­tain work smoothly and are im­mensely pop­u­lar, and that in sev­er­al states run­ning their own ex­changes, the im­ple­ment­a­tion has been quite smooth.

Put­ting aside the fact that the fed­er­al ex­change is much lar­ger to start than any­one an­ti­cip­ated, be­cause so many Re­pub­lic­an gov­ernors op­ted out of cre­at­ing their own ex­changes, and that the de­mand has been strik­ingly high, I view the prob­lem in a broad­er way. It is the lar­ger fail­ure of pub­lic ad­min­is­tra­tion that has been en­dem­ic in the Obama White House, and is prob­ably the pres­id­ent’s most sig­ni­fic­ant weak­ness.

The first clues to this prob­lem came dur­ing the trans­ition in 2008. George W. Bush and his chief of staff, Josh Bolten, offered ex­em­plary as­sist­ance to the in­com­ing Obama team — but many of the ideas on the table to stream­line the nom­in­a­tion pro­cess for ex­ec­ut­ive posts, in­clud­ing the cum­ber­some vet­ting ele­ment, were ig­nored. From the get-go, the Obama ad­min­is­tra­tion was be­hind the curve on nom­in­at­ing people to fill key posts; many re­mained un­filled for the first term. Com­bine that with the shock­ing fail­ure to quickly nom­in­ate judges to fill va­can­cies — for a con­sti­tu­tion­al-law pro­fess­or who had served in the Sen­ate. Both meant that the early tend­ency in the Sen­ate to con­firm pres­id­en­tial nom­in­a­tions was lost, and sub­sequent nom­in­ees got caught re­peatedly in ob­struc­tion­ist tac­tics by Re­pub­lic­an sen­at­ors.

The ini­tial White House staff struc­ture did not in­clude any­one in a prom­in­ent po­s­i­tion who knew the ex­ec­ut­ive branch in­tim­ately — knew which po­s­i­tions among the polit­ic­al ap­pointees were im­port­ant for the pres­id­ent’s policy ob­ject­ives and needed to be filled quickly by ex­perts or man­agers; knew which seni­or ca­reer em­ploy­ees in the de­part­ments and agen­cies could be trus­ted and which to avoid; knew how to lever­age policy goals through the adroit use of reg­u­la­tions, ex­ec­ut­ive ac­tions, and ex­ec­ut­ive or­ders. The post of deputy chief of staff for op­er­a­tions is the key po­s­i­tion here — it was not then and has not yet been filled with a per­son like Sally Katzen, Sylvia Math­ews Bur­well, or John Koskin­en, all ex­perts on man­age­ment and the ex­ec­ut­ive branch who would have ad­mir­ably filled the bill. In­stead, we had an Obama White House filled with vet­er­ans of Con­gress and of polit­ics. There were man­age­ment people at OMB — but that is not at all the same as hav­ing someone in the West Wing. Over the en­tire Obama pres­id­ency, little has changed.

Bur­well is now, com­mend­ably, at OMB, and Koskin­en has been nom­in­ated to be IRS com­mis­sion­er. But of course, Koskin­en, if and when con­firmed, will only un­der­score the White House’s fail­ure here. Obama failed to fill the key post of IRS com­mis­sion­er for FIVE YEARS. A savvy com­mis­sion­er, in place early on, would have un­der­stood the po­ten­tial train wreck ahead over the long-term IRS mis­hand­ling of 501(c)4 and (c)6 ap­plic­a­tions, and would have set up a pro­cess to cre­ate a bright line both to elim­in­ate or ameli­or­ate the polit­ic­al ab­uses of the tax code by groups like Amer­ic­an Cross­roads GPS and to give the ca­reer staff the clear guidelines they needed. And an ex­per­i­enced ex­ec­ut­ive-branch vet­er­an and pub­lic-man­age­ment ex­pert in­side the White House would have seen the prob­lems emer­ging with Health­Care.gov and be­gun the ur­gent man­age­ment re­pair work earli­er.

To be sure, the Obama ad­min­is­tra­tion has had many de­part­ments run well and ef­fi­ciently, with re­mark­able sta­bil­ity and lim­ited in­fight­ing among Cab­in­et and top agency ap­pointees. There was none of the bick­er­ing that, for ex­ample, char­ac­ter­ized the Bush White House’s na­tion­al se­cur­ity pro­cess in its first term in­volving Dick Cheney, Colin Pow­ell, Don Rums­feld, and Condi Rice. Thanks to the mod­el set by the pres­id­ent, and the work done by eth­ics ad­viser Norm Eis­en, the Obama White House has had the few­est eth­ic­al prob­lems of any ad­min­is­tra­tion in mod­ern memory (the Fox News’ rants about Benghazi and Op­er­a­tion Fast and Furi­ous not­with­stand­ing).

Some would ar­gue that Eis­en’s stiff re­stric­tions on lob­by­ists en­ter­ing the ad­min­is­tra­tion is to blame here. There is no doubt that a num­ber of qual­i­fied people were kept out or frightened away by the re­stric­tions. But there were plenty of qual­i­fied people re­main­ing in the job pool. It was the re­mark­able lack of con­cern with man­aging the gov­ern­ment, see­ing the ef­fect­ive im­ple­ment­a­tion of the laws as im­port­ant as their pas­sage, that is the key here. And the buck starts and stops with the pres­id­ent.

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