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On the Third Hand: Unicorns

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The staff of the House Oversight and Government Reform Committee puts out some great reading material about implementation of the Patient Protection and Affordable Care Act (PPACA). Its latest work, a report on why the exchange website worked so poorly when it launched, is hilarious.

The staff makes the cause that the site had problems because the staff at the Centers for Medicare & Medicaid Services (CMS), an arm of the U.S. Department and Health and Human Services (HHS) was in an office politics war with the HHS tech people.

One HHS tech specialist told a senior HHS manager, “Your leadership only wanted to hear beautiful music and talk about rainbows and unicorns,” according to an e-mail quoted in the report.

Shortly after went live, Henry Chao, the CMS deputy chief information officer, called the site a “burning house” and questioned the sincerity of HHS officials who asked for progress reports.

On the one hand, any day House Committee staffers can quote e-mail like that in a report is a good report writing day.

On the other hand, just the idea, that privately, behind the scenes, CMS and HHS tech people understood that the project was a mess is comforting. Everything in life takes longer and costs more. Everything that can go wrong will go wrong. The people working on faced horrendous political, timing and budget pressure. Even people working on great, successful projects for large, successful organizations squabble. Think of all the awful things Mr. Spock said about Dr. McCoy on Star Trek, and vice versa.

When Rep. Elijah Cummings, D-Md., talked about the lives that he thinks PPACA has saved, and expressed disgust at seeing House Republicans obsess about problems at, I think he had a point. At some level, who cares about a stupid website? We know that the federal government has many complicated websites that work well and are secure enough to get us through the day. Even if and everyone at HHS and CMS were horrible, that would have no direct bearing on whether the PPACA exchange system and the PPACA commercial health insurance rules make sense or not. If the Republicans showed a little flexibility, Obama could simply wave a hand and have Apple, IBM or Google replace with a system that would work great and give us lattes decorated with little skim milk hearts.

The core of whether the PPACA commercial health insurance exchanges work is whether the defenses against anti-selection work, and whether the measures intended to hold down health care costs work.

On the fourth hand: I think how the Obama administration is handling communications about problems does have a bearing on whether implementing the PPACA commercial health insurance programs is feasible.

The whole idea behind the PPACA “health insurance marketplace” program is that PPACA is supposed to give us an honest, open mechanism for buying and selling health coverage.

Some people here hate the idea of any government involvement in health care with a passion. Some want a single-payer system. Some just want to see what works. But, in any system that calls for any government involvement to work, we need the government to be reasonably honest and open, at least in some dark, smoke-filled room that the public can’t see but provides enough interchange between major players for the system to function.

If HHS and CMS truly have no numbers for some measure whatsoever, OK, they have no numbers. But if — as the team e-mails suggest — HHS and CMS really have all sorts of numbers, or, at least, decent ideas about what the numbers are like, and they’re hiding the numbers because the numbers are small and embarrassing, that would be a sign they lack the organizational competence to fess up about disappointing results.

Many boards of state-based exchanges have published truly embarrassing reports about exchange problems. But at least they’ve had the courage to stand up and say what’s happening.

HHS and CMS seem to have adopted the Obama administration approach of presenting a shiny, boring, positive, completely unified facade and allowing no pimple of reality to intrude.

The New York Stock Exchange, for example, posts detailed data on every little thing that’s happening with the securities flowing through its data pipes.

HHS and CMS still haven’t released any information but one bare number — 7.3 million current enrollees — about individual PPACA exchange enrollment after mid-April, and it’s released no information at all about small-group exchange plans.

If officials are so tight with information about routine matters that aren’t really that big of a deal, how can anyone trust them to be open about, for example, decisions that might favor navigators over brokers, or some of the insurers in the risk corridors program over other insurers in the program?

I think one message implicit in the rainbows and unicorns report may be that specific people in the Obama administration may be responsible for the lack of willingness to face reality. It’s time to put the rainbows and unicorns folks in charge of something simple, like getting kids to eat vegetables, and make sure the people managing the exchange program have the ability to think about and talk about trolls.


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