Fixing the ACA – Lesson Plan

By Cheryl C. and Ferd H. Mitchell

Implementation of the Affordable Care Act (ACA) has demonstrated some of the various administrative strategies that may be used when program activities are threatened with failure. Things that can and should be done—and should be avoided—may be identified by looking at responses when “things start to go bad.”

The initial problem faced by the ACA was a somewhat incoherent design of the Act itself. Due to the political process that was in play, there was no opportunity to “fine tune” an initial version of the law—it became a take-it-or-leave-it proposition that was basically passed as a draft.

Lesson #1: It is important to start out with a good plan. When a plan is flawed, administrators should expect unwanted reactions from organizations and will need to build in maximum flexibility to deal with resulting problems.

The next program flaw was encountered with poor communications at all levels, particularly with respect to education and outreach efforts by the Department of Health and Human Services (HHS) to the public. HHS waited for almost three years to mount any significant outreach efforts, allowing confusion to grow and criticism to find root.

Lesson #2: It is essential to develop comprehensive plans to maintain effective communications with everyone involved in implementation of a program. Otherwise, failures are likely to grow among affected individuals and groups, slowing down progress. Formal tasks and budgets are required.

Another failure has been experienced with technology that has not worked (when initially turned on). The entire implementation process for the federal Health Exchange has been thrown into disarray by computer software that has not been doing the job. Initial responses by HHS were to deny the problem and look for “quick fixes.”

Lesson #3: Skill is required to recognize potential technical issues in advance whenever a new program is implemented. A sound strategy is to allow extra development and testing time, not over-promise on results, and make sure that some high-reliability backup plans are ready.

Jeffrey_ZientsA recent step in ACA implementation can serve as a more positive indication of what to do when failure threatens. A new strategy for dealing with the high-tech crisis has been to bring in a big-name “fixer”, bring in a team of “experts”, and publicize a scheduled date for fixes to be completed.

Lesson #4: This is a better model to follow—no matter what outcome is finally observed. A potentially-productive response to any implementation problem is to bring in (and publicize) a high-profile person to represent the fix-it efforts; bring in a team of outside experts to help supervise (and provide advice that may be relied upon by administrators); and schedule (and publish) the fix-it plan.

More on dealing with potential program failures may be found in a recent blog posting, which describes how political drama can affect implementation efforts.

This is installment #11 in the “Affordable Care Act and Public Administration” series.

Previous installments of this series have considered impact of the ACA on the field of public administration from a variety of perspectives. Refer to the archived postings for this blog to review all of these installments and obtain an overview of the combined commentary.

More on these and related ACA topics may be found in a recent book by the authors that describes implementation of the ACA, and in a new Practice Guide by the authors that addresses funding and access issues in health care.

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