OMB and the Affordable Care Act: Lessons from the Rollout

The Office of Management and Budget's work supporting the implementation of the new health law has been a rigorous process, one that might guide the shaping of other complex government initiatives.

As a medical student about to enter residency, I wanted to learn more about the health-care environment in which I will be treating patients, and I wanted to contribute to the tremendous change that environment is undergoing. A fellowship in the Health Division of the White House Office of Management and Budget (OMB) this summer gave me a deeper understanding of our medical system at an exceptional moment: just before implementation of the federal health-reform law's state insurance exchanges.

OMB is responsible for supporting the implementation of the exchanges, a complicated but crucial component of the Affordable Care Act (ACA) through which millions of uninsured Americans will be able to obtain health coverage. The work that OMB has been doing, work that continues as the new system rolls out, should be of particular interest to those involved in any complex governmental undertaking.

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Much of the public's recent attention has been focused on the heavy volume of visitors to the exchange websites and the attendant technical problems that some of the exchanges have experienced since their launch on Oct. 1. But in the long run, a more important question will be how the premiums people have been paying for insurance in the individual market will compare to what they will pay for insurance bought through the new exchanges.

OMB has been making precise, apples-to-apples comparisons to answer this question. I worked on compiling a database of what different hypothetical persons currently pay in each state depending on their age and gender. The analysis will continue as states finalize rates and as kinks are worked out in the online marketplaces. OMB is also exploring how competition among insurance plans in the exchanges, and among healthcare providers more broadly, will affect both prices and profits.

In addition to the exchanges, state Medicaid expansions will allow previously uninsured Americans to obtain health coverage. However, for individuals around the Medicaid-exchange income cutoff, a situation arises where they may bounce back and forth among multiple sources of insurance, depending on how their income fluctuates over the course of a year. This phenomenon, known as "churning," could lead to gaps in coverage and care as well as increased administrative costs.

OMB is evaluating policies that could reduce churning, including instituting a minimum Medicaid eligibility period, offering a "bridge plan" that would continue to provide coverage for households transitioning out of Medicaid, or offering a Medicaid-like insurance plan available to people whose incomes place them around the eligibility cutoff.

As OMB continues to work on these and other issues, the way it approaches them provides some lessons that could be applied to other governments and agencies as they implement complex initiatives:

• There is a high degree of coordination between OMB and the many other agencies and organizations working on ACA implementation. Near-constant communication among the departments allows all parties to ask questions, troubleshoot problems and bounce ideas back and forth.

• OMB knows its role. In an undertaking as massive as health reform, there is an almost unlimited number of areas competing for an organization's attention and resources. OMB is driven by numbers and facts; it is focused on implementing the president's agenda as effectively as possible, and less concerned with politics and communication strategies. The majority of the staff is composed of career, not political, employees. Focusing on its core mission allows it to fulfill its role effectively.

• In a health-care system as complex as ours, it's difficult to have deep, up-to-date knowledge on all components -- from Medicare and Medicaid to private insurance and public health programs. The Health Division at OMB divides labor so that each examiner becomes a knowledge expert in a particular area. But it also makes a concerted effort to bring these area experts together to work on "cross-cutting" issues that don't fit neatly into any particular bucket.

• OMB works hard to understand daily media reports and studies from think tanks, academic centers and other government agencies. But rather than taking those reports and studies at face value, OMB conducts its own internal analysis to verify or refute them and test their underlying assumptions.

• While implementing any large-scale reforms, there are bound to be kinks along the way that require prompt and thoughtful adjustments. OMB puts a lot of effort into anticipating challenges that might arise and exploring what metrics can be used to study them.

What ties all of these together is this: OMB is rigorous in evaluating policy initiatives while also being responsive to the dynamic political environment in which it operates - a combination that is crucial to the success of any large-scale reform effort.

Dhruv Khullar is a dual degree candidate at the Yale School of Medicine and the Harvard Kennedy School, where he is a fellow at the Center for Public Leadership.