This article is from the archive of our partner National Journal

Prepare for/adapt to a SCOTUS disaster

The Supreme Court is expected to rule this summer in a case that aims to invalidate Obamacare's insurance subsidies in the states—there are 36 of them right now—that didn't set up their own exchanges. If the court says those subsidies were illegal, the administration will be sent scrambling on several fronts.

The 36 federally run exchanges are housed within CMS, so the agency would have to deal with the immediate fallout—namely, millions of people dropping or cancelling their coverage and the broader disruptions that would ripple through those states' insurance markets. If there's anything the administration could do to soften the blow and prevent insurers from abandoning big states, CMS will have to figure out what that is—and be ready to do it.

Moreover, if at least some states are willing to take over their own exchanges in order to restore their residents' subsidies, CMS would have to figure out how to transfer a federally run marketplace into a state's hands as quickly and cheaply as possible—something it has never done. That would be an enormous logistical challenge—and, if the push to get states to accept Obamacare's Medicaid expansion is any guide, would also require a major campaign of political persuasion and deal-cutting to bring Republican governors on board.

Job Title: AdministratorDepartment: Department of Health and Human ServicesAgency: Centers for Medicare and Medicaid Services

Salary: $168,700 / Per YearPosition Information: Full Time-PermanentPromotion Potential: Lobbying or AcademiaDuty Locations: Washington, DC, Baltimore, Md.Supervisory Status: Yes

Job Description:

The Obama administration has an immediate opening for a full-time, Senate-confirmable CMS administrator, following the resignation of Marilyn Tavenner. The administrator's most prominent responsibility is implementing almost all of Obamacare, including immediate concerns such as making sure HealthCare.gov works as well as long-term initiatives like overhauling the way health care is delivered and paid for. The CMS administrator also oversees the country's biggest health care payer (Medicare) and its largest insurance provider (Medicaid).

The successful applicant must have significant health care experience as well as strong political skills. Oh, and a great management style. And ability to be confirmed by the Senate while being attacked along partisan lines. Also, there's a chance the Supreme Court will completely change the entire dynamic of what the job requires and throw CMS's most complex systems into total disarray.

In short, it's a tough gig.

Here are the four biggest things the next CMS administrator will have to do:

Prepare for/adapt to a SCOTUS disaster

The Supreme Court is expected to rule this summer in a case that aims to invalidate Obamacare's insurance subsidies in the states—there are 36 of them right now—that didn't set up their own exchanges. If the court says those subsidies were illegal, the administration will be sent scrambling on several fronts.

The 36 federally run exchanges are housed within CMS, so the agency would have to deal with the immediate fallout—namely, millions of people dropping or cancelling their coverage and the broader disruptions that would ripple through those states' insurance markets. If there's anything the administration could do to soften the blow and prevent insurers from abandoning big states, CMS will have to figure out what that is—and be ready to do it.

Moreover, if at least some states are willing to take over their own exchanges in order to restore their residents' subsidies, CMS would have to figure out how to transfer a federally run marketplace into a state's hands as quickly and cheaply as possible—something it has never done. That would be an enormous logistical challenge—and, if the push to get states to accept Obamacare's Medicaid expansion is any guide, would also require a major campaign of political persuasion and deal-cutting to bring Republican governors on board.

Keep Obamacare enrollment growing

Even if the Supreme Court leaves Obamacare intact, maintaining Obamacare's strong enrollment growth over the next few years will take some work. By the time the next administrator takes over, most of the uninsured people who are easy to reach through big media campaigns, advertising, and celebrity appearances will already be signed up.

To reach the ultimate goal of covering roughly 25 million people, HHS and its allies will have to make more progress signing up families with complicated eligibility situations, people who don't speak English, hard-to-reach communities, and people in smaller states that haven't gotten the brunt of the high-profile enrollment campaigns so far. HHS will have to work harder and harder to keep enrollment growing over the next several years.

Play nice with Republicans

One of Tavenner's most valuable assets was her popularity. Industry stakeholders liked her, the rank-and-file at CMS liked her, and Republicans on Capitol Hill liked her. Lawmakers said Tavenner was generally responsive to their oversight requests, which helped her avoid taking much of the heat for HealthCare.gov's disastrous launch. And she's leaving on relatively good terms even after misstating Obamacare enrollment during a House hearing—a mistake that a lot of people would not necessarily be able to get away with.

It's not enough for a CMS administrator to be super smart about health policy. He or she will need real political chops. For starters, they'll need to get confirmed—and this will be the first time a Republican-controlled Senate has had control over one of President Obama's health care nominees. As a Republican Congress looks to chip away at Obamacare and cut federal spending, HHS will need as much goodwill as it can get. And, again, if the Supreme Court invalidates Obamacare's subsidies, the CMS administrator will be spending a lot of time trying to cajole Republicans in the states and in Congress into helping to repair the law.

Shepherd new cost controls

Health care spending is growing at historically low rates, which is fantastic news for the White House and for CMS. But there's still broad agreement that the health care system needs big, structural changes that will make it more efficient and provide better care. As baby boomers move into Medicare and the improving economy boosts health care costs, the pressure to find real, durable reforms will only increase.

Medicare is the country's largest health care payer, and is therefore an ideal place to cut costs directly and to experiment with new approaches that might also work for private insurance. Obamacare included a slew of pilot programs and research initiatives on delivery-system reform, but no one believes they've found a silver bullet. Finding a way to lower costs and improve quality is the single biggest challenge facing the health care system, and the CMS administrator will have to advance the search for new ideas while keeping doctors, hospitals and other providers—whose incentive is to get paid—on board.

Keep Obamacare enrollment growing

Even if the Supreme Court leaves Obamacare intact, maintaining Obamacare's strong enrollment growth over the next few years will take some work. By the time the next administrator takes over, most of the uninsured people who are easy to reach through big media campaigns, advertising, and celebrity appearances will already be signed up.

To reach the ultimate goal of covering roughly 25 million people, HHS and its allies will have to make more progress signing up families with complicated eligibility situations, people who don't speak English, hard-to-reach communities, and people in smaller states that haven't gotten the brunt of the high-profile enrollment campaigns so far. HHS will have to work harder and harder to keep enrollment growing over the next several years.

Play nice with Republicans

One of Tavenner's most valuable assets was her popularity. Industry stakeholders liked her, the rank-and-file at CMS liked her, and Republicans on Capitol Hill liked her. Lawmakers said Tavenner was generally responsive to their oversight requests, which helped her avoid taking much of the heat for HealthCare.gov's disastrous launch. And she's leaving on relatively good terms even after misstating Obamacare enrollment during a House hearing—a mistake that a lot of people would not necessarily be able to get away with.

It's not enough for a CMS administrator to be super smart about health policy. He or she will need real political chops. For starters, they'll need to get confirmed—and this will be the first time a Republican-controlled Senate has had control over one of President Obama's health care nominees. As a Republican Congress looks to chip away at Obamacare and cut federal spending, HHS will need as much goodwill as it can get. And, again, if the Supreme Court invalidates Obamacare's subsidies, the CMS administrator will be spending a lot of time trying to cajole Republicans in the states and in Congress into helping to repair the law.

Shepherd new cost controls

Health care spending is growing at historically low rates, which is fantastic news for the White House and for CMS. But there's still broad agreement that the health care system needs big, structural changes that will make it more efficient and provide better care. As baby boomers move into Medicare and the improving economy boosts health care costs, the pressure to find real, durable reforms will only increase.

Medicare is the country's largest health care payer, and is therefore an ideal place to cut costs directly and to experiment with new approaches that might also work for private insurance. Obamacare included a slew of pilot programs and research initiatives on delivery-system reform, but no one believes they've found a silver bullet. Finding a way to lower costs and improve quality is the single biggest challenge facing the health care system, and the CMS administrator will have to advance the search for new ideas while keeping doctors, hospitals and other providers—whose incentive is to get paid—on board.

This article is from the archive of our partner National Journal.

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