As the political season heats up, many voices from the Democratic Party are advocating Medicare-for-All or moving to a single-payer system. The Republican Party has very different ideas, most of which are focused on using the CMS Medicare and Medicaid regulatory authority and market reach to promote healthcare changes.
One critical success factor that has not received air play from either the media or the politicians, is that once again the CMS employees and contractors will end up having to do a heavy lift if there are going to be major changes to the nation’s healthcare system. Over the past 15 years, CMS stakeholders have been whipsawed by the continual political drama around how to best re-structure and optimize the U.S. healthcare system. Many CMS employees have lived through the Medicare Modernization Act, the creation of the Part D drug program, ICD-10, HITECH, ACA Marketplace, and most recently MACRA, which made major changes to the Medicare payment system and mandated the removal of the SSN from Medicare cards. Also, let’s not forget, the 21st Century Cures, various executive orders and other key policy changes that were added to the mix. These actions all have reverberated across the healthcare ecosystem, but especially at CMS.
Certainly, few can argue that our healthcare system doesn’t need to be improved. Both cost and care data highlight the challenges that face the current system. The U.S. spends about 18% of the gross domestic product on healthcare yet lags behind many nations in numerous health indicators – our country definitely needs to look at new approaches.
Any approach should prioritize that CMS is given the appropriate resources and high-level commitment necessary to succeed. Much of the current staff is demoralized causing a steady drip of talented executives and staff to leave the agency in recent years. While several high-profile executives have returned to CMS after short private sector stints, this is not the overall trend. Unless both the Democratic and Republican leadership recognize the resource crisis that CMS faces, the future healthcare system changes have a potential risk for failure.
CMS has made critical IT improvements over the past few years, partly in response to the problems with the launch of Healthcare.gov. The agency has begun to move significant infrastructure and applications to the cloud which allows for greater flexibility and scaling. Identity management and other enterprise applications have improved, and the use of the U.S. Digital Services have provided additional technical subject matter experts along with fresh approaches to IT development projects, including the expanded use of Agile methodologies. The IT procurement process has also changed to create more flexibility. While these are all good improvements, the continuing loss of technical and business staff and leadership, as well as significant contracting officer expertise, will greatly hinder future success, regardless of other advances. While CMS does fairly well on the annual government workplace surveys, nearly 7% of staff left in 2017 alone and 15% of the staff has less than 3 years of service.
What can be done to better support CMS stakeholders to help ensure that their service to our country gets rewarded and not condemned? Here are a few recommendations.
- The political leadership needs to recognize the value of talented career staff and their ability to achieve policy and operational objectives. Successful major policy and operational initiatives at CMS most often are achieved when both political and career teams work in partnership together and respect each other’s unique contributions. Political leadership also needs to provide sufficient cover to protect career staff from the political warfare that inevitably occurs with an emotionally charged issue like healthcare. As I noted above, many CMS career executives and staff have been through multiple major program changes and can help provide perspective and guidance to political leadership who may have little or no operational experience with large national programs.
- Ensure that sufficient funding is appropriated but also allocated in a way that allows for proper planning and execution. One of the key challenges with ACA was that insufficient money was appropriated and what was, did not flow down to Office of Consumer Information and Insurance Oversight (OCIO) or CMS in a way that allowed for the most effective and efficient purchase of services and capabilities.
- Ensure that the appropriate organizational structure and policy rules are in place early. With Healthcare.gov, there were major organizational challenges from the beginning, starting with the ill-advised decision to create a separate agency, OCIO, and then later move that organization into CMS. Many policy rules were not finalized until after the 2012 elections and that created a vacuum, delaying critical business and IT operational decisions.
- Loosen the hiring and compensation rules to allow for talent gaps to be filled quickly. Unfortunately, government hiring rules are often cumbersome and make it difficult to hire talented staff. Getting direct hiring authorities in place early helps to fill gaps when the critical initial planning is being done. Compensation is not usually the reason people come to work for the government but some flexibility, especially with hard-to-fill skills areas, is very important.
- Set “reasonable” dates for implementation and be willing to have some leeway on the dates or initial capabilities if a successful minimum viable operational outcome appears to be unlikely by the set date. Obviously, major new programs can’t always easily change start dates, but political policymakers often greatly underestimate or minimize the operational challenges of launching new national programs.
The 2020 Presidential campaign is still developing, and we will see many twists and turns before it is over. We know that new major healthcare initiatives will be promoted by the Administration, regardless of who wins the election contest. Hopefully, the political leadership will listen to the CMS voices of experience. As Edmund Burke, the famous English statesman once said, “In history, a great volume is unrolled for our instruction, drawing the materials of future wisdom from the past errors and infirmaries of mankind.”