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 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.