I spoke with a lobbyist yesterday about some new regulations established under health reform. Despite high-level political gridlock, CMS [Sorry-the federal government’s Centers for Medicare and Medicaid Services] is issuing critical rules and regulations required under the Affordable Care Act. Lobbyists are thus descending.
I should talk with them more often. Not surprisingly, lobbyists and their clients have grappled with much of the fine print in those hundreds of pages of forbidding pdf files that emerge from various agencies, advisory groups, and the like.
Lobbyists also bring an unsentimental, tactile sense of organizational realities one wouldn’t otherwise consider. One example among several: the friction between the new CMS innovations center and the traditional Medicare bureaucracy. As this lobbyist tells the story, much of the CMS bureaucracy views itself through the lens of traditional FFS payment, and seems temperamentally resistant to components of health reform. And yeah, you’ve stopped reading if you’re not deeply into health reform.
In part, such organizational resistance reflects well-founded concerns from seasoned professionals regarding particular provisions in a massive new law. In part, such resistance reflects the natural inertia of a hidebound bureaucracy that should be overcome. The CMS bureaucracy has also run demonstration projects for decades, which creates obvious potential conflicts with the new center.
The conversation was doubly chastening. It showed with some granularity an inside game the typical health policy wonk might not otherwise know even exists. It also suggested even greater implementation challenge of health reform. Don Berwick is having a hard time managing these conflicts. Congress cut him off at the knees by making him a lame duck. His bureaucratic adversaries and nominal underlings can wait him out, since he’ll presumably be leaving at the end of this year.
I’m not convinced that Berwick is right in every particular. It’s clear, though, that his recess appointment damaged his ability to implement difficult reforms. Among other consequences, weakening him randomly empowered portions of the CMS bureaucracy in ways that don’t match any obvious partisan divide. This makes government less transparent, more resistant to administrative control. The same problems empower people such as this lobbyist, who have more tools to slow things down and to run out the clock on important matters.
“yeah, you’ve stopped reading”
OK this is the second SameFacts post of the day which includes the ironic assertion that the reader reading the assertion isn’t, since he or she stopped reading.
So far both have caused me to read the post to the end. But I understand exactly what you (both) are doing and it is not going to work forever.
You aren’t reading this.
This statement is false.
Two can play that game (as two of you showed, but third sure can’t as I just showed).
@ Robert
I see that sort of thing more as a rhetorical trope than an attempt to be Epimenides for the 21st Century. Of course, I am also a compulsive reader of anything that vaguely interests me.
The truth of big changes is that when a law passes, most of the advocates go home “victorious” and lobbyists remain in DC to work 24/7 to undo what has been achieved by shaping regulatory and bureaucratic processes.
The big risk to my continued reading is that when I have to open a new tab to Google “CMS,” I might well get too distracted to come back. (It’s the Centers for Medicare and Medicaid Services, if you wondered.)
@ Suzii
Be grateful CMS doesn’t have a tvtropes entry.
Is this not an argument for creating simpler policies, like, I don’t know … a Medicare buy-in for anyone who wants it? Many like me would be willing to pay, now, while I’m lucky enough to be healthy.
Or, am I just making a really convenient argument??
One of the many things I love about Gov. Jerry Brown (CA), is that he thinks there are too many laws already, and many new ones are half-baked. Only someone so established can say something so obvious.
What Mr Humphreys wrote.
NCG, you are making the relevant argument. It is not that Medicare-for-all is really “simpler” — in the end, any policy is going to be very complicated in the details. But, a policy can be made more coherent, in part, by adopting clear, architectural principles.
Politically, it also helps to know that you have enemies and who those enemies are, so that you can destroy them or disable them. It is hard to know whose side this Administration is on. That’s a problem, too.
I want to give Harold props for the RBC revelation that lobbyists apply their full time capabilities to knowing their issues inside and out. That means reading the law, understanding and working the politics, and educating the politicians and the regulators. Contrary to progressive political pejorative punditry, lobbyists are vital to the system and the vast majority make a positive contribution by means of educating those in charge about the reasons for their client’s positions.
There are three problems specific to PPACA that make it especially vulnerable to those of us who would prefer to dismantle it in favor of some other approach (or any other approach). First is that it was never a consensus choice. Big changes to our society have historically required the building of a consensus for them in order to take root. Passing PPACA via reconciliation and without thorough discussion of its provisions (“you’ll have to pass the bill to see what’s in it”) violated that principle. Second, the natural result of the first is that the details were left to the bureaucracies, notably HHS, so accountability in execution has become even worse than it was legislatively. But this is a lobbyist’s dream. It means (s)he can work her magic under that same veil. Finally, PPACA is fiscally hopeless, since it rested on all kinds of assumptions that will either never occur (reduced payments to providers) or were simply false (the scoring of CLASS). This will feed into the country’s current and growing concerns about profligate spending.
As for Dr. Berwick, this administration’s prediliction for recess appointments in order to frustrate the Advise and Consent Senate responsibility, even exceeds the Bush Administration’s which was bad enough. Berwick’s alleged failures are a direct result of the White House choosing politics over substance. Was he the only person capable of doing this job? They couldn’t find anyone confirmable? Simply not credible.
“lobbyists are vital to the system”
This says so much about you!
Benny,
There are lobbyists for all sides, as there should be. I suppose you are OK with the environmental and labor lobbyists, the juvenile defense organizations that expose judicial and other systemic injustices (as in Pennsylvania not so long ago), the full time consumer reps, etc. It is vital that legislators hear all sides. It is also consistent with our constitutional rights to free speech and to petition elected representatives. Or would you rather our officials tried to do their jobs in a vacuum? In our industry, regulators assess the industry to fund consumer representatives, who are invariably capable, informed, and challenging. This is a good process.
I guess your comment says a lot about you. (Sigh)