The ACA: Management and Implementation

I started the Blog some five years ago initially to examine the collapse of any pretense that economics has a scientific basis and then moved to Health Care as the current Administration started up the ACA project. I was one of the few who read every word of every bill and commented on the disaster that would result. Some even noted the comments. Let my words stand for what is to come next.

The ACA has several major flaws:

1. The implementation of the sign on was developed by incompetent individuals. No incompetent in all, best as I know, they are after Harvard educated, but incompetent in ever having managed and delivered a project such as this.

The Cutler letter to Summers published by the Washington Post shows this was known even in the inner circles. As stated in the letter:

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.

Little is an understatement. He is a pediatrician but even more so an academic. Remember he also pushed the EHR which is now bumbling around failing to achieve anything. Also look at my writings here as well.

The letter continues:

Above the operational level, the process is also broken. The overall head of implementation inside HHS, Jeanne Lambrew, is known for her knowledge of Congress, her commitment to the poor, and her mistrust of insurance companies. She is not known for operational ability, knowledge of delivery systems, or facilitating widespread change. Thus, it is not surprising that delivery system reform, provider outreach, and exchange administration are receiving little attention. Further, the fact that Jeanne and people like her cannot get along with other people in the Administration means that the opportunities for collaborative engagement are limited, areas of great importance are not addressed, and valuable problem solving time is wasted on internal fights.

She is a Harvard educated attorney with a history degree and never managed a single thing! No wonder we have a disaster. Also note she got promoted.

The Cutler memo is most telling on the fact that it was known internally that a disaster was coming.

2. Panels are planned to control almost everything focusing on what they consider to the evidence based research. The problem here is that those judging the evidence are all too often just political appointees as the above with little understanding of the specifics of the problem at hand. I would not want a dermatologist to deliver a baby. They may have done so in Med School a few times to get their card punched but other than in a real emergency would I seek their assistance. Likewise the many other panels will be disasters in the waiting.

3. Payments will be the next shoe to drop. The only way to keep "costs" down is to reduce payments. That will drive out competent folks and drive in marginal at best. This will result in a lowering the standards and the mass admittance of third world trained physicians.

The list of problems goes on.