Implementing Health Care Reform

Implementing the Recovery Act has been a major challenge.  But it pales in comparison to the complexity facing those implementing the health care reform bill.  Office of Personnel Management director John Berry says implementing this new law will be equivalent to being “the moon shot of our generation.”  Last week, Senator Mark Warner reinforced Berry’s observation, calling it “the mother of all implementation challenges.”

The Obama Administration is gearing up to meet the many deadlines in the bill.  In fact, it’s created a separate website to provide information on this: HealthReform.Gov.

However, there is also a major public management challenge involved as well.  As a result, the IBM Center is sponsoring a separate, new blog (with an optimistic title) – Implementing Health Care Reform — to provide insights into the implementation of this effort.  It is being co-authored by Professor Don Kettl, one of the preeminent academics in the field of public administration, and dean of the University of Maryland’s School of Public Policy; and Jack Meyer, who holds a joint appointment in both the School of Public Policy and the School of Public Health at the University of Maryland.

Be sure to visit the site, and book mark it!


Obama’s Stealth Management Revolution

“Where is Obama’s big-bang reform of government?” laments an insightful article by University of Maryland public administration dean, Donald Kettl, in a forum on President Obama’s management initiatives in the current issue of The Public Manager.  He says that President Obama is quietly reshaping the way government works and dubs it a “stealth revolution.”

Kettl calls Obama the “first post-bureaucratic president.”  Kettl says the hierarchical approach to government, which he calls the “vending machine” (insert cash, push a button, and out comes a service), failed profoundly with Hurricane Katrina in 2005.  He has concluded “The vending machine is broken, and more presidential tinkering cannot fix it.”  He says the Obama administration is “hitching up their governance strategy to transparency and working organically from the bottom.”  A good example is the recently-released Fiscal Year 2011 management initiatives in the budget that are built on agency-generated high priority goals and commits to creating governmentwide problem-solving networks. 

Kettl offers several observations in his article:

  • The Obama Administration will use Web 2.0 technology to virtually connect with citizens.
  • It will use “czars” to sidestep bureaucratic roadblocks.  He notes this approach has been used selectively in the past but that “this is a revolutionary-in-scale move to maneuver past the permanent bureaucracy.”
  • It will “herd cats when dealing with Congress” in that the Administration is willing to let Congress take the lead in developing significant legislation.
  • And that it will redefine accountability through the use of greater transparency.

In relation to this final point, Kettl says “Team Obama quickly concluded that it couldn’t steer the government through the usual mechanisms.  No one would pay attention to more rules, and traditional authority broke down.” This happened, in part, because the budget was no longer a control mechanism since so much money was being shoveled out via the Recovery Act and the various bailout programs.

He concludes that “This stealth revolution is an incredibly high-risk venture . . . .“If the federal government is post-bureaucratic – and no agency can control any program it’s given to manage – solutions can’t come through spontaneous combustion produced by dumping information into the Internet.”  However, he says there is a glimmer of hope offered by the post-Katrina recovery effort.  “When Coast Guard Admiral Thad Allen replaced Michael Brown as coordinator-in-chief, things started to move. . . “  Government, in this case, began to work when it focused on problem-solving, rather than boundary-protecting, and when there is a leader driving relentlessly toward results.

Using Czars to Govern

Czar Nicholas IIThe media, and some members of Congress, continue to focus on President Obama’s use of “czars.”  An article today by the Wall Street Journal’s Neil King examines how this dust-up highlights the ongoing challenge of how government is increasingly facing problems that reach across traditional agency and program boundaries.  These problems include food safety, climate change, and the Recovery Act.  There is no accepted institutional mechanism to manage these problems and President Obama is using a pragmatic approach – appointing someone to be in charge on his behalf.

The media is focused on this particular management tool – the use of “czars” – and not the management challenge of how do you act on problems that cut across boundaries.  Professor Don Kettl predicted this growing conundrum in his book, “The Next Government of the United States,” where he notes that: “The importance of boundary spanning . . .  suggests a new approach for government – an approach that democratizes the process by spreading participation, privatizes government by relying more on nongovernmental partners, governmentalizes the private sector by drawing its organizations more into strong public roles, and ultimately challenges the framework of American democratic institutions.”

This is a real governance challenge.  But it is one that past presidents and other countries have faced as well.  As a result, there are several different models, other than “czars,” for addressing cross-cutting challenges:

Reorganize.  The traditional model is to reorganize government agencies and programs around a common mission or outcome.  This approach is cumbersome and does not readily reflect a continually changing world.  Examples of this approach in recent years:  the Department of Homeland Security and the Office of the Director of National Intelligence.

National strategies.  About a decade ago, the White House began to use “national strategies,” mainly in national and homeland security policy areas.  Under this approach, the President issues a “strategy” that provides an overarching strategic approach to addressing a particular cross-cutting issue.  Examples include:  the National Homeland Security Strategy, the Pandemic Flu Strategy, the National CyberSecurity Strategy. Sometimes someone was in charge (a “czar?”) and sometimes it was just a framework.

Performance-Stat.  Also about a decade ago, state and local governments adopted an approach initially piloted in the New York City Police Department called “CompStat.”   CompStat is a management approach that regularly brings together top leaders and managers to work regularly together to use fact-based information to address operational issues reaching across agency boundaries.  This approach, under various names, has been adopted in places such as: Baltimore (Citi-Stat), Maryland State Government (State-Stat), and Washington State (Government Management Accountability and Performance).  It could be adapted to the federal level, as well.

Delivery Unit.  Developed in 2001 by British Prime Minister Tony Blair, this approach is a variation of Performance-State, but focuses on strategic issues.  Blair identified 20 key outcomes that he wanted to achieve in his term in office, set measurable targets around each outcome, and charged his staff with ensuring strategies were in place and progress was tracked.  This approach has been recently adopted in the State of Maryland to supplement its StateStat efforts.

President Obama could use a mix of these approaches, including the use of czars.  He has already designated a “chief performance officer” who would be the logical focal point for coordinating these various cross-cutting initiatives.  However, this does not address one of the concerns raised by Congress:  how does Congress ensure accountability?

A Congressional Performance Resolution?  Congressional jurisdiction is organized around the traditional agency and program paradigm.  As Kettl notes, this paradigm is increasingly ineffective in addressing non-routine governmental functions.   So how can Congress be an effective player?  One recommendation offered by the Government Accountability Office is for Congress to adopt a “performance resolution,” similar to the existing budget resolution.  A performance resolution would be organized around major national outcomes.  It might parallel presidential “national strategies.” But it would, like the national strategies, define who is responsible for action on different elements of a broader agenda.  It also means that Congress would not have to reorganize its committee structure in order to become an effective player in cross-governmental challenges.