Tuesday, November 18, 2014

"Government efficiency" is an oxymoron

I always appreciate and pay attention to the thoughtful observations of Sachin Jain, and this article in the Journal of General Internal Medicine is no exception.  It's called "Big Plans, Poor Execution: The Importance of Governmental Managerial Innovation to Health Care Reform."

Here's the introduction:

The Affordable Care Act (ACA)'s implementation failures including the launch of healthcare.gov and delays of several key provisions of the legislation have threatened continued support for the law. At the core of the public's misgivings is trust in whether government agencies can effectively implement programs of importance on massive scale. The ACA rollout has exposed deep flaws in the ways in which federal agencies manage the implementation of legislative efforts. For these reasons, we strongly believe that health policy reform must occur alongside innovation and reform of the managerial processes of the Department of Health and Human Services (HHS) and its constituent agencies. In this paper we draw on experiences implementing significant health care policy legislation to explore the fundamental management challenges that have hampered the implementation of the ACA, and threaten the future viability of government-led health care reform.

The authors go on to itemize the problems:

The first is the overly burdensome and bureaucratic process of soliciting, vetting, and awarding con- tracts. Initially designed as safeguards against kickbacks, regulations have evolved to the point where contracts are awarded to firms with the most experience in navigating the federal procurement process, rather than those with the most experience and skills in the content area.

Second, the operational units within each agency responsible for managing contracts and implementing reforms are too far removed from the procurement process.

Finally, the rigidity encountered early in the contracting process is mirrored in constraints around termination.

These problems are compounded, say the authors, because "federal agencies often struggle to attract and retain appropriate, competitive talent."

After recommending changes, they conclude:

Implementation is the ultimate test of any legislative effort,a difficult reality currently facing the supporters and architects of the ACA. Challenges with the ACA have uncovered fundamental flaws in the federal government's managerial structures for executing complex legislative agendas. If we expect our federal health agencies to take a frontline role in reforming health care, so too must we pay attention to reforming these institutions. 

Well, many of these points are so true, and their impact has been felt over the years in defense and non-defense governmental programs.  (The one with which I would disagree, for the most part, is the one about attracting talented people.)  The recommendations made are thoughtful and appropriate.

But the truth of the matter is that the basic structures underlying federal procurement will not change much.  As noted by the authors, many were designed to prevent corruption: In so doing, Congress made an explicit trade-off between obtaining efficiency and preventing crime. Other federal procurement rules were frankly designed by lobbyists for entrenched government contractors: There is a whole industry of inside-the-Beltway firms that have survived and grown off of federal largess.  Their core competence is influencing the body politic to protect their interests.  Other firms do not have the time or interest to engage in the influence-peddling business and wisely choose to spend their time serving the private sector.

Every well-meaning Administration comes into office thinking that it is going to introduce more "business-like" procedures into the federal government.  Some succeed to a certain extent, but most fail.  It is not an activity that generates public support or political rewards.

So, in my opinion, what is required is a more sophisticated and thoughtful approach to writing the law when you are hoping to invent a new program or policy.  The ACA was an immensely complicated piece of legislation.  Many components relied on having an effective, efficient, and timely procurement plan.  It may have been naive to expect that implementation would be successful.

In addition, whatever problems existed at the procurement regulatory level of the government were aggravated by the fact that the high-level managerial structure, support, and oversight put in place by the President and his Secretary of Health and Human Services were inadequate.  The recommendations contained in this article are thoughtful, but no amount of bureaucratic redesign can survive against incompetent leadership.

1 comment:

beverly said...

I think someone should study the increased role of those very government contractors in this inefficiency, if they haven't already. By reducing government employees to paper pushers and outsourcing anything vaguely technical, is not the government getting what it pays for in its workforce? This is a serious question as I do not have detailed knowledge, but it is my perception as the daughter of a former longtime federal government employee in a technical field, that outside contractors have vastly increased. Was this the right course?