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Dissects White House's 'Fundamentally Managerial' Mistakes

Companion Feature: Knowledge@Wharton Ezekiel Emanuel Book Interview & Video

In a new book, "Reinventing American Health Care," Ezekiel Emanuel pens an insider's critique of the White House mistakes responsible for the "spectacular failure" of the federal health insurance exchange launch.
Emanuel, a Vice Provost and Professor at the University of Pennsylvania, was formerly a White House health care advisor and one of the architects
Hoag Levins
Ezekiel Emanuel, MD,PhD, MSc, is the University of Pennsylvania Vice Provost for Global Initiatives, Chair of the Department of Medical Ethics and Health Policy, and a former White House health advisor who was one of the architects of the Affordable Care Act.
of the Affordable Care Act.

The new book from PublicAffairs Books is subtitled "How the Affordable Care Act Will Improve our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System."

The 382-page book is a hybrid whose first half is essentially a reference narrative explaining the working parts of the U.S. health care system and more than a century's worth of efforts -- including the Affordable Care Act (ACA) -- to reform that system in a manner that extends health care to most U.S. residents.

CBO often wrong
In the second half of the book Emanuel turns a critical eye to his experience as a White House insider. Among those taken to task are the Congressional Budget Office ("Although the CBO's scores are objective and nonpartisan, they are frequently wrong."), graduate medical education ($10 billion annually with "little accountability and performance reporting...The training of physicians remains firmly in 1910."), and White House PR ("Poor communications may yet cause even more political damage for President Obama.").

Several of the later chapters of the book chronicle and dissect the White House's decisions and decision-making process related to the implementation of the ACA and the development and operation of the website.

Emanuel characterizes the Oct. 1, 2013 launch as "a fiasco" that "significantly reduced enrollment
Hoag Levins
Emanuel's new book is a White House insider's story of why the launch went so wrong.
and may alter the risk pool, contributing to more older and sicker enrollees. It shook the confidence of health insurers in the exchanges. It certainly caused a branding problem for the website. It gave the ACA's critics an opening to cast doubt on everything related to reform, even things that have not been problems, such as the security of the website. At least temporarily, the bad rollout reduced support for health care reform not only among the public but also many in the health sector."

'Fundamentally managerial'
"The problem with the rollout," he continues in the book, "was not a fundamentally flawed ACA, nor was it primarily technical. Instead, it was fundamentally managerial."

After the ACA was passed in March, 2010, the White House was a place of "triumph and exhaustion," he writes. In the following months there was an internal struggle over whether the same health policy operatives who had successfully pushed through ACA legislation through a hostile Congress should oversee the law's implementation efforts or if instead, an outside CEO highly experienced with large-scale, web-based business operations should be brought on board to be the administration's ACA implementation czar., after all, was going to be a national web enterprise more technically complicated than Amazon or Facebook.

Emanuel was one of the advocates for the outside-CEO option. His view was that the executive managers who envisioned, developed and ran a national insurance exchange system should have mindsets and tech savvy similar to those found in typical Silicon Valley start-up ventures.

'Low-level CMS bureaucrats'
He writes, "Execution of a start-up is hard even with an experienced CEO. With exhausted policy advisors and low-level CMS bureaucrats directing implementation, lacking both the management and technology expertise as well as participation of senior leaders that had characterized the push for passage of the ACA, successful implementation was going to be even harder."

But Emanuel and the team of other independent White House advisors and experts recommending this CEO strategy were overruled.

"The intense political partisanship of the moment shaped the alternative view," he writes in the book. "Republicans were attacking the administration for having too many czars. Appointing a health implementation czar would potentially open the administration to even more criticism."

And so, the White House assigned development and implementation to a crew of internal health policy advisors overseen by Nancy-Ann DeParle, the former Wharton School adjunct professor of health care systems who served as White House Deputy Chief of Staff for Policy and Director of the White House Office of Health Reform for four years. She had led the legislative offensive effort that passed the landmark health reform law. Now, she chaired the intergovernmental White House group that formulated implementation strategies and decisions for the build.

Two entirely different skill sets
But, as Emanuel points, shepherding legislation through the political minefields of Capitol Hill and supervising the design and construction of a massively complex ecommerce website system to be used by millions involve two entirely different skill sets.

DeParle's duties were later broadened and the implementation work became diffused across various offices within the White House, Department of Health and Human Services (HHS), Centers for Medicare and Medicaid Services (CMS), Department of Labor, Treasury and others.

Emanuel notes that nearly everything about the way White House policy advisors were approaching the project was "the opposite of lean start-up philosophy and how new technology is developed through an iterative process of testing, refinement, more testing, more refinement, more testing, more refinement to learn what is working and what is not and then to constantly change the product to ensure the overall objectives are being met effectively. The health policy advisors running the implementation did not understand how to develop or manage a new web start-up."

'No reason to despair'
Emanuel also points out that "There is no reason to despair or give up on health care reform itself. As many high-technology companies have shown, it is possible to bounce back from flawed website rollouts. But this is only possible if relentless focus on execution becomes a reality."

In an interview with the LDI Health Economist eMagazine, Emanuel was asked if he thought the White House now DOES have a "relentless focus" on the project.

"Clearly," he said, "when (the White House) appointed (National Economic Council Director) Jeff Zients to rescue the exchange and website, he was focused. The recent Steven Brill article in Time magazine shows they assembled a top-flight team and worked 24/7 and I think that lesson should not be lost on them. Let's remember that Twitter was not a flawless launch. Lots of other companies have had problems launching their website but then came back to be very successful and I certainly hope the White House is paying attention to that."

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Hoag Levins is a journalist and managing editor of digital publications at the Leonard Davis Institute of Health Economics.

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