David Cutler wrote this memo on health reform implementation in May of 2010, about six weeks after Obamacare was passed. I suggest you read the whole thing, and remember as you read it that Cutler was a supporter of the ACA.
Here’s an excerpt from Cutler’s Wiki entry to establish the basics of his resume. Note that he had served the Clinton administration, so he knows more than many professors how the executive branch of the government works—or doesn’t work, as the case may be:
David Matthew Cutler is the Otto Eckstein Professor of Applied Economics at Harvard University. He holds a joint appointment in the economics department and in Harvard’s Kennedy School of Government and the Harvard School of Public Health. He graduated from Harvard College, summa cum laude, with a degree in Economics, and then joined the Harvard faculty after receiving his Ph.D. in Economics from the Massachusetts Institute of Technology in 1991. He served in the administration of Bill Clinton and was the senior health care advisor to Barack Obama.
Now read the following excerpt from Cutler’s memo to fellow Harvard economics professor Larry Summers, back when Summers was an official member of the Obama administration (which Cutler never was). Remember, this was sent about six weeks after Obamacare was passed:
The second major task of reform is to set up and run insurance exchanges. I am not encouraged by what is occurring there either. Running exchanges is a collaborative process. As just one example, the person who ran the Commonwealth Connector in Massachusetts estimates that he had 500 town meetings to discuss reform, the equivalent of 17,000 meetings nationally – and this was in a state where two-thirds of people, along with insurance companies, supported reform. The person newly appointed to head the insurance oversight office has a reputation as an insurance bulldog, not a skilled facilitator. Remember that most people will get their information about reform from their doctor and their insurance agent. If you cannot find a way to work with hesitant states and insurers, reform will blow up. I have seen no indication that HHS even realizes this, let alone is acting on it.
My guess is that they’d rather blame Republicans and insurance companies for not co-operating.
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.
But it’s hard for Obama to appoint someone who might appear to know more about something than he does, although every now and then I suppose he bites the bullet and does it. Whether Obama thinks anyone actually knows more than he does about anything is another question.
Cutler went on to make a number of specific suggestions about re-organizing the effort. But the gist of it all was this:
You need to bring in people who share the President’s vision and who know how to manage health care or other complex operations. These people then need to interact with existing agency personnel to make reform happen.
That seems rather—elementary. Doesn’t it? And yet apparently it was not being done. No wonder Cutler sounds so urgent. He was seeing people trying to set up one of the most complex organizational and policy operations the government has ever undertaken, and appointing people to do it who had virtually no experience in anything of the sort.
But after all, that’s pretty much what the American people did when they elected Obama.
[NOTE: This is also a must-read. Except for the obligatory "the Republicans frightened the administration into mucking up the rollout," it's both informative and devastating. And since it's in the WaPo, some of Obama's supporters might actually read it and be alarmed.]