Health Care Reform Implementation (Part 2)

A series of presentations at the annual conference  of the National Academy of Public Administration focused on the complicated management challenges all levels of government will be facing upon the passage of any health care reform legislation.  As one participant noted: “There’s too much of a view that programs are self-executing and you just need more inspectors general and audits. . . that happened with the Recovery Act.”  The consensus seemed to be that this assumption clearly won’t work for health care reform!

Federal challenges.  As Congress debates the shape of the health care reform legislation, there are a number of administrative management issues where seasoned executives in federal agencies might want to begin thinking through.  The Department of Health and Human Services might be a logical home for such a task force, but other agencies, like Labor, Treasury, Veterans Affairs, and Defense might play important roles as well.  And someone would need to represent agencies that don’t exist yet, like the proposed Medical Choices Administration.

Even if specific policy provisions are not yet defined for the health care initiative, certain tasks can be undertaken right away, for example:

• identifying a team of top career talent that have the experience of implementing big programs,
• defining competencies and skills needed to staff potential programs,
• creating expedited hiring and procurement authorities,
• gaining authority to operate streamlined regulatory and advisory processes, and
• developing the infrastructure for collaborative cross-agency networks.
• (feel free to add to this list!)

State-local challenges.  As health care coverage is expanded for low income citizens, state governments will be challenged in ramping up their existing programs.  Depending on the legislation enacted, the enrollment in state Medicaid programs could increase by about 12 million.  This will place a huge burden on state enrollment and administrative processes.  Likely concerns about potential program abuses may increase oversight costs, or at least complicate implementation efforts.

Likewise, if the proposals to create health insurance exchanges are enacted, creating new administrative structures in each state will be challenging.  The Senate bill delays implementation until 2014, but even then it would be challenging to design them, enact the regulations, educate the state providers, hire the needed staff, educate the new enrollees, and conduct the enrollment process.  Any implementation strategy would involve federal, state, local, non-profit, and for-profit stakeholders.

At the state level, fortunately, some are already thinking about implementation challenges.  For example, Alan Weil of the National Academy for State Health Policy, has developed several guides that lay out both strategic and topic-specific steps that need to be considered. One report, “Supporting State Policymakers’ Implementation of Federal Health Reform,” could serve as a useful checklist for federal implementers!

Sustaining Health Care Reform

Yesterday, I described how Eggers and O’Leary examined implementation of big government initiatives from a process perspective.  Another NAPA conference session highlighted another book, “Reforms at Risk:  What Happens After Major Policy Changes are Enacted,” by University of Virginia professor Eric Patashnik.  He too, examines “what happens to sweeping and seemingly successful policy reforms after they are passed.”

However, Patashnik looks at it from the perspective of the politics of reform adoption, not the administrative implementation process. He concludes that “the political struggle does not end when major reforms become enacted.”  The key issue he addresses is: “why do certain highly praised policy reforms endure while others are quietly reversed or eroded away?”  Based on a series of case studies, he observes that strong administrative capacity during the implementation process isn’t enough.

Like Eggers and O’Leary, he spins his story around engaging case studies.  He examines key reforms such as the elimination of agricultural subsidies, airline deregulation, procurement reform, and Medicare’s 1988 Catastrophic Coverage Act (that was repeals 16 months after its passage).  In the case of the 1988 Medicare reform bill, the elderly protested that they were being required to pay premiums immediately, for benefits they would receive in the future (long term care).  Protests led to the program’s repeal.

Patashnik tries to identify the specific conditions that need to be present for an enacted reform to be sustained.  One of his case studies was the procurement reforms of the 1990s.  The leader of those reforms, Steve Kelman (who is now a professor at Harvard), agreed with Patashnik’s insights. Patashnik says successful programs, like Social Security, had to develop a strategy for political sustainability in addition to an administrative strategy for effective implementation.  He observes that large reforms necessarily lead to “creative destruction” among interest groups and that new political alliances have to be created.

In the case of health care, will the new reforms result in old coalitions or interest groups disappearing (for example, if the bill includes strong tort reform measures, would the tort lawyers’ political action committees fade)?  Or will the reforms lead to the formation of new groups that find the reforms as positive?  Mapping out these kinds of dynamics should be a Nirvana for political scientists.  But Patashnik’s research implies that this should also be part of any strategic implementation strategy that may be developed by the Administration.

Doing Big Things in Government

The release of a new book, “If We Can Put a Man on the Moon . . . ,” by Bill Eggers and John O’Leary, helped set the stage for the National Academy of Public Administration’s annual meeting that centered on management issues related to health care reform.

The authors examine big successes undertaken by the government – like the Manhattan Project, the Marshall Plan, the Berlin Airlift, and the moon landing – and draw some lessons about what each took to be successful.  They also contrasted these successes with failures such as Boston’s Big Dig, Iraqi reconstruction efforts, and Hurricane Katrina.

In surveys of senior career executives in the federal government, “60 percent said that government was less capable of executing large projects today than it was thirty years ago,” noted the authors.

The authors declare: “This book is about executing large, important, public initiatives. . . making sound policy choices is critical . . . however, brilliant policies poorly executed will likewise disappoint.” They then look at large government undertakings from a process perspective, identifying six key elements:

• The undertaking must start with a good idea.
• The idea must be given specifics, often in the form of legislation, that become an implementable design.
• The design must win approval, as when a bill becomes law, signaling commitment.
• There must be competent implementation.
• The initiative must generate desired results.
• Over time, the initiative must be subjected to reevaluation.

The authors take on each of these steps, describing potential pitfalls as well practical principles, tools, and techniques to be successful.  They provide entertaining, well-written stories of people and projects, from the efforts of Coast Guard Admiral Thad Allen in the wake of Katrina; to the implementation of the 2003 London traffic congestion charging program by Mayor Ken Livingstone; to the rolling blackouts in the California energy crisis of the late 1990s created by well-meaning but ill-designed state legislation, that led to the recall of Governor Gray Davis.

Their book contains insights and warnings helpful to the ongoing health care reform debate.  For example, they note that poor policy design “occurs because the work of drafting a bill that launches a major initiative isn’t generally treated like the design process it truly is.  Instead of a sound, executable design, the goal of the legislative process is often producing a bill that can pass . . . “  The authors continue, “Fully 45 percent of federal executives say that policy is rarely designed by those with relevant experience.  The dramatic disconnect between policy designers and policy implementers is perhaps the most broken part of the journey to success.” They recommend role playing and scenario planning efforts, like those used by military strategists and the private sector before it launches major initiatives.

They conclude with a warning:  “The tendency to see the enactment of legislation as an end unto itself, to claim credit for a great achievement upon the creation of a new law, is one of the most destructive tende3ncies in democratic governance.”

While Congress leads the legislative and policy design, the executive branch (and the Government Accountability Office) could proactively offer insights on the implementability of the pending legislation.  Eggers and O’Leary offer an ideal(istic) approach, recommending an objective “implementation feasibility assessment” to be done by an independent review board, much like the Congressional Budget Office offers its independent assessment of the cost of legislation.  However, that is not likely to happen any time soon!

Health Care Reform Implementation (Part 1)

Government Executive’s Alyssa Rosenberg hits the nail on the head in her Fed Blog today, “How Health Care Would Be Run.”  Her piece looks at the increased role of the Secretary of Health and Human Services in the Senate version of the bill.  The House version has significant roles for other agencies as well, and creates a new independent agency, the Health Choices Administration.

But the broader point Rosenberg raises is: Is anyone looking at how this legislation would be implemented?  After all, the 2008 Obama presidential campaign quietly put in place a top-notch transition team in mid-2008 in anticipation that he would win the election.  That team moved quickly once the election was won.  Is there such a team in the wings in anticipation of the passage of a health care bill?

There are a number of implementation issues that do not depend on policy options (such as whether there is a public option, or state exchanges, etc).  For example, it is not too soon to be thinking about things such as (a) identifying a small cadre of successful career civil servants who have the experience of leading large efforts, (b) creating expedited hiring authorities for new functions being created in legislation, or (c) developing new approaches to speed up regulatory development and implementation for statutory provisions to be “implemented immediately.”  As Rosenberg notes, there probably are lessons to be learned from the stand-up of TSA and the implementation of the Medicare Part D prescription drug benefit.

Interestingly, health care reform was the underlying theme of the recent annual meeting of the National Academy of Public Administration (NAPA), a congressionally-chartered good government non-profit.  This was the first time NAPA devoted an entire annual conference to a single topic.  Why would NAPA do this?  Well, this will likely be the most significant public management challenge facing government in the next decade!

I’ll summarize some of the highlights from that conference over the next few days.

The NAPA conference also triggered some curiosity on my part as to what is actually in the health care reform bills, so I did some browsing.  If you want to look at them also, here are the links:

• The House Bill is H.R. 3962 – “Affordable Health Care for America Act”
• The Senate Bill is technically an Amendment to H.R. 3590, an unrelated bill, but renamed -  “Patient Protection and Affordable Care Act”

Have fun browsing; there’s lots there to ponder!

Social Media Trends in Gov for 2010

I am not a tech-toy pioneer.  It was two years before I logged onto my company’s instant message system because I thought it would create ADD symptoms (it didn’t).  I just got a Blackberry a few weeks ago (yes, Blackberry, not iPhone) because I lost my PalmPilot calendar and they don’t make them anymore.  And I resisted a Twitter account because I thought it was silly, frivolous, and seemingly narcissistic.

In each case, I found myself wrong.  Let me explain why I now Twitter. I found following a few “tweets” actually exposed me to helpful info I would not have seen otherwise.  Being selective helps.  I follow about a half dozen Tweets, including GAO (which announces its new reports daily),  Federal News Radio reporter Chris Dorobek (who posts links to timely government stories), and a new site, OhMyGov!, which highlights interesting government-related stories.

For example, OhMyGov! editor Mark Malseed did a great story, “Social Media for Government:  Six Trends for 2010,” that I’d not have seen if I had not been on Twitter.  Malseed summarized trends from a Harvard Business website article targeted to the private sector, but it is relevant to the public sector as well:

• Individuals will become more selective about their social media connections and trim back the number of networks they belong to because of information overload.
• Organizations will look to scale up their social media efforts (and in government, this will likely be driven by the long-awaited Open Government Directive).
• Managers will be encouraging (not discouraging) their employees to participate in social media on behalf of their organizations.
• Organizations will create more formal social media policies, and begin to enforce them (I’ve seen corporate dress codes for avatars in Second Life!).
• Social media will become more mobile-device oriented.
• Sharing will no longer mean email.  As generations shift in the workplace, email is the new snail mail.

So, do I “tweet?” Well, not really, but I do follow others!  You can follow the IBM Center, though, at: BusofGovernment on Twitter. So, if you haven’t joined, you might try it out and see if it makes a difference.  It’s free!

NOTE:  A subsequent Federal Times Op-Ed, by U.S. Army General Craig McKinley, “Why I Tweet,” provides a powerful example of how leaders can use Twitter to stress important messages across a highly decentralized organization. It’s worth reading!

Signs of Procurement Revolution

The Senate confirmed Dan Gordon as the administrator of the Office of Federal Procurement Policy in the Office of Management and Budget.  He comes highly recommended by Steve Kelman, a former holder of this job who was acclaimed as an innovator.

The procurement arena in federal agencies has been under a lot of attack in recent years with some calling it a “toxic environment.”  The Obama Administration has made contract reform one of its top management goals and it has issued lots of guidance in its first year.  In addition, the procurement community is facing major challenges in rebuilding itself in the wake of retirements and downsizing in the past decade.

But there are rays of hope! 

A recent article by Federal Computer Week’s Nick Wakeman, “Five Signs Procurement Is Ready for a Revolution,” cites John Nyce from Interior, who says “We are at a point where we can make some game changing decisions:”

• Shared services organizations that support procurement activities have to get better at serving their customers;
• The younger acquisition workforce expects technology to be there to get their jobs done;
• Market analysis information will now come from multiple sources;
• Agencies will have to be more efficient since there is a shortage of contract officers; and
• Communication is increasing across agency contract shops, allowing for cooperation and the sharing of best practices.

A good example is the growing, self-organizing community of procurement officers on GovLoop, “Acquisition 2.0,” where they are beginning to trade ideas for how to improve operations.  The GovLoop champion, GSA’s Mary Davie, says she was inspired to launch a site to collect good ideas, called the BetterBuyProject.com, and she says she’ll try out some of the ideas offered on the site, within her own agency to see if they merit broader attention.

While a small step, the willingness of the contracting community to step up to the plate is an encouraging sign.  Dan Gordon will have a pool of innovators to inspire!

Cloud Forecasting

Yes, it is cloudy and raining this week, and the media has been reporting a glut of stories about cloud computing already.  But the IBM Center has released a new report “Moving to the Cloud:  An Introduction to Cloud Computing in Government” that is targeted to executives, not technologists. 

The buzz in the technology world around cloud computing is almost deafening, but for good reason.  The report lays out the many reasons for its use, including economies of scale, better collaboration, and usage-based pricing (you pay only for what you use, like electricity).  For example, a school district in Tennessee established a private cloud and was able to cut its IT support costs by 60 percent.  These kind of savings catch people’s eyes.

The author, Dr. David Wyld of Southeastern Louisiana University, notes that “Cloud computing is an emerging concept.  It has many names, including:  grid computing, utility computing, and on-demand computing.  Indeed, one of the hindrances . . . is the lack of understanding of what it is—and isn’t. . . “  He relies on the definition developed by the National Institute of Standards and Technology, which lays out the essential characteristics of cloud computing:  on-demand self-service, ubiquitous network access, locaction-independent resource pooling, rapid elasticity, and measured service.

While still a geeky definition, more importantly, Wyld points to the fact that we’ve all used cloud computing already – Gmail, YouTube, GoogleDocs, Flickr, and Ning are all common examples in the commercial world.  And Wyld says over 4,000 universities have converted their email systems to cloud computing as well.

But government has been a bit more cautious in its adoption.  Wyld gives examples of the use of cloud in government, lays out ten challenges to public managers in the use of cloud computing (like security and interoperability), and offers some predictions on the road ahead.  He also offers links to some useful video primers, like the one from the UK’s Computing Magazine as well as the one from GSA’s Apps.gov.

A key takeaway for government managers:  cloud computing has potential to transform government IT but it won’t be a silver bullet.  It will most likely be more useful for mission support services such as e-mail, web servers, data storage, and for common cross-government services such as accounting, procurement, and collaboration tools.  But agencies will likely be more cautious in using it for core mission business applications such as the Social Security payroll reporting system or the air traffic control routing system.

Out- and In-Sourcing: True Confessions

Harvard Kennedy School professor Stephan Goldsmith recently shared an insight he learned:  “It is always tempting to set arbitrary goals to drive organizational change. Like most temptations, this one should be resisted. . . . I fell into this trap in 2000, when I served as the chief domestic policy advisor to then-Governor George W. Bush during his presidential campaign. Looking ahead to how many federal officials would likely be retiring during the eight years of the next presidency, I suggested that candidate Bush pledge to replace only half of them, eliminating the remainder of these jobs through efficiencies and outsourcing.”

In mid-2001, President Bush set just such goals in his President’s Management Agenda by saying he would compete “commercial-like” positions in the government, based on the required Federal Activities Inventory Reform (FAIR) Act. This triggered agency foot-dragging and partisan objections.  Bush stuck with his agenda through his remaining years in office and in the end, instead of competing an estimated 425,000 positions, the Bush Administration competed nearly 51,000 as of the end of 2007.

But in the process, Congress put in place a number of barriers to make competitive sourcing and outsourcing more difficult, if not impossible.  The term “competitive sourcing” became so controversial that OMB changed the term to “commercial services management!”

So what is Goldsmith’s lesson?  “We had gotten it backwards. Any goals in reducing the federal workforce should have come only after an examination of the specific activities of the federal government and an analysis of the commercial availability (and suitability) of competitive services. Instead, goals were set in a vacuum, much like the debates about angels dancing on the heads of pins. . . . The pendulum has swung, and now OMB is pushing in the opposite direction. I made a mistake in 2000 when I proposed a percentage reduction in employees to President Bush, and I likewise believe that any arbitrary decision to pursue insourcing is equally ill-advised.”

But the pendulum has swung.  Here is a link to a series of Defense Department guides on the new emphasis on insourcing, and steps to take. . . . Who will write the next installment in True Confessions?

Recovery Act: Shifting Mindsets

The fuss surrounding the release of the first full report on the use of Recovery Act money last week reminded me of an experience I had in 1980 while working for a congressional oversight committee.  We had received an annual report with program data for FY 1977 that I thought was quite useful.  I then asked the agency for the FY 1978 and 1979 reports since I thought they would be useful as well.  The response was “we just released the 1977 report, the others won’t be available for another two years.”

Shifts at the Federal Level. And now with Recovery.Gov we have program data that are only three months old!  And people complain about some likely inaccuracies!  The whole Recovery.Gov effort is pretty amazing – a data dump from more than 131,000 sources collected (and reviewed quickly) in a three-week period.  The media focused on jobs created, but the real story is the creation of new ways of collecting and reporting large amounts of data and the shift in mind set about how to handle it.

Of course there will be errors (in fact, 21 percent of the reports submitted were revised afterwards).  But the shift in mind-set is remarkable.  Instead of demanding accuracy and spending months cleaning the data, the emphasis is on timeliness and the expectation that the data will be cleaned as a result of public exposure.

Recovery.Gov head Inspector General Earl Devaney is probably causing shock waves through the audit community with his radical approach (well, radical for auditors) of releasing data that likely has errors before investing weeks of time cleaning it up.  In fact, he told Federal News Radio’s Suzanne Kubota, “What we’re all seeing, at least following the first reporting period, is not particularly pretty. This data may cause some embarrassments for some agencies and some recipients, but I believe in the long run the embarrassment will encourage self-correcting behavior and make it better in the future.”

Shifts at the State Level.  This shift in mind set is creating real pressures to do business differently at the state level, as well.  States had to create web-based reporting forms so grant recipients could report their data.  According to Computerworld’s Julia King in her article, “States Scramble to Track Federal Stimulus Bucks,” states had to quickly:

• make data available,
• create business rules and processes to comply with federal reporting requirements, and
• devise ways to collect and aggregate data from multiple systems from across state government (since few have central accounting systems).

These efforts are having broader effects than just Recovery Act reporting.  It is changing mind sets and approaches just as importantly as it has been at the federal level.

• For example, Massachusetts Recovery and Reinvestment Office’s deputy director Ramesh Advani compared the first reporting cycle to the environment of a fast-paced startup company, according to King.  A long-term improvement going forward, though, is that the creation of this program office creates a reporting focal point for grant reporting in the state for the first time.
• Maine is also using the Recovery Act reporting experience to permanently improve its information transparency statewide, as well.
• Utah is using existing systems to report Recovery Act funds, rather than creating a new system.  According to King, because the state had a centralized IT and accounting system and had already undertaken a financial transparency project already, the  Recovery Act reporting requirements were relatively straightforward.  The biggest challenge was collecting and reporting sub-recipient data, which it had not collected before.
• The top-ranked state Recovery Act website is Maryland’s according to Computerworld’s Robert Mitchell, developed a sophisticated geographic information system to display where Recovery Act dollars were going.  In fact, a Washington-based research center has rated the Maryland Recovery Act site the best in the country for its efforts.  Visitors can view spending in specific areas, such as highway or housing, and drill down to see exact locations and other details.

So as mindsets begin to shift in terms of reporting data quickly and publicly in ways that can be readily understood, it will be interesting to see how long it takes before this becomes the governmentwide norm at all levels of government.  It looks like it didn’t take long in Maine and Utah!

Saudi Conference: Lessons for Us

I’m back from my first visit to Saudi Arabia.  I can’t say I saw any camels, but I did seen plenty of McDonalds and Starbucks!  Conference participants were treated royally and we were treated with great hospitality, including an outdoor banquet with traditional Arabic sword dancing. 

John Kamensky and a Conference Host

While the conference was seen as an international celebration of the Saudi Institute of Public Administration’s 50^th anniversary, it became clear at the final closing session that this was also a serious event for them.

The closing session was chaired by a senior minister from the government and there was a set of recommendations and a discussion of impressions of the conference led by several of the invited guests from around the world (including the IBM Center’s Jonathan Breul). 

Jonathan Breul on Main Podium

Interestingly, these recommendations and impressions have relevance for us, as well, and they probably have a familiar ring to them.  Here are some of the highlights:

• Put customers first.  Use customers as the focal point for performance and service improvements.
• Decentralize implementation and service delivery.  Centralized, top-down reform efforts don’t work over the long run and evidence shows that local implementation leads to greater productivity and innovation.
• Measure what you do and make fact-based decisions.   Performance measurement and fact-based decision-making are hard to do, they are the drivers of excellence and a performance-based organizational culture.
• Use benchmarking and technology as tools to help drive change.
• Create a performance culture.  Create an environment where employees are professional, committed to public service and creative.
• Link reforms to budget.  Any successful reform effort should be linked to budget priorities.  If not, the budget will likely overwhelm the reform efforts.

So, while the U.S. is talking about new cutting-edge management challenges such as greater transparency, citizen engagement, and collaboration, it is useful to see that the basics are still important . . . .and that we can’t say we’ve mastered them yet!

The Saudis use their Institute of Public Administration to provide training and research, but they’ve also created a committee to champion the development and use of performance measurement to help drive their change efforts.  They’ve put a smart man in charge.  He’s been given five years to put in place measures that took the U.S. government nearly 20 to produce.  It’ll be a steep hill to climb before they will be ready to create a Chief Performance Officer, but it looks like they are on the road.  Hopefully, they’ll be able to learn from our experiences!