Applying It To the ACA
By Cheryl C. and Ferd H. Mitchell
A recent article in The Economist (“Why a strategy is not a plan”) reviews a new book by Lawrence Freedman (cited below).
As stated in this article, “Strategy, it turns out, is really about trying to work out in a sensible way how to get from one stage (of activity) to the next. With each stage, a new set of problems has to be negotiated before you move beyond it….”
Thus, initial success with a strategy leads to a succession of follow-up strategies that are required to keep moving ahead.
A strategy is needed for each stage, in order to negotiate to the next stage.
Strategy is thus “like a long-running soap opera….”
The strategy for stage 1 provides a starting point. Then, based on how this effort works out, a strategy for stage 2 must be put into place. There is no real “ending”. The process is open-ended.
In contrast, a plan is a description of how to get from “here” to “there”. The starting point and ending point are prescribed.
However, it is argued in this article that such plans generally do not survive the reality of implementation activity, and that it is not possible to set up a “closed” effort.
Unexpected reactions by all of the individuals and organizations involved—and chance events—serve to derail almost all plans with specific objectives.
This discussion applies to preparation and implementation of the Affordable Care Act (ACA). A similar focus on how organizational reactions have affected implementation of the ACA is applied in detail in a book by the authors of this posting, as noted below.
The ACA initially resulted from numerous political tradeoffs. The stage 1 strategy was to “get an Act passed.”
The next stage was to begin implementation (say, for the first two years or so, March 2010 to mid-2012). The strategy over this period seems to have been dominated by a desire to limit the political damage associated with stage 1, and to wait and see what happened to court challenges.
As might be expected, the “planned” activities called for by those responsible for the Act were quite different during this stage.
The next stage (from mid-2012 to mid-2013), emphasized behind-the-scenes preparation of regulations and announcements that “all was well” with implementation.
The strategy was mostly devoted to internally-directed activity. Then, starting in mid-2013, an effort was made to “put together all of the parts into a working system”. The strategy was to “surface from below” and push hard for success.
Not surprisingly, the previous stages did not lead smoothly to the present “surfacing” stage. The current stage of the “soap opera” has become very messy. At present, a new strategy has been put in place, to try and “do whatever it takes” for the ACA to survive.
(The book mentioned above is Strategy: A History, by Lawrence Freedman, Oxford University Press.)
This is installment #12 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, including coverage of how organizational reactions affect implementation efforts, may be found in a recent book by the authors that describes evolution of the ACA, and in a new Practice Guide by the authors that addresses funding and access issues in health care.