On Saturday, the Washington Post reported that a memo written by David Cutler, a Harvard University professor, warned the Obama administration of serious flaws in the planned roll-out of the Affordable Care Act. In particular, Cutler, health adviser to the President’s 2008 campaign, emphasized that those in charge lacked the necessary experience of running a business start-up. Noting the Centers for Medicare and Medicaid Services (CMS) as key to execution of the new healthcare law, he said both personnel and the processes in place might not be 'up to the task.'

“The agency is demoralized, the best people have left, IT services are antiquated, and there are fewer employees than in 1981, despite a much larger burden,” Cutler stated in his memo sent to Larry Summers, director of the United States National Economic Council, on May 11, 2010.

Start-Up Woes

“They were running the biggest start-up in the world, and they didn’t have anyone who had run a start-up, or even run a business,” Cutler told the Washington Post. In those early days of implementation, readily available information from the Bureau of Labor Statistics would suggest that over three-quarters of start-up businesses fail. Even in 2010, then, the need for experienced, knowledgeable people must have been clear.

The Washington Post suggests that the President's decision to put Nancy-Ann De­Parle, director of the White House Office of Health Reform, in charge despite advice from his economic team who suggested he appoint someone with business expertise may have been a deciding factor in today's woes. Worse, in February 2011, the date at which DeParle was promoted and no longer had direct responsibility for implementation of the Affordable Care Act, the person chosen to be her successor, Jeanne Lambrew, also lacked the necessary expertise.

Interestingly, DeParle began by convening twice-weekly meetings of representatives from the Centers for Disease Control and Prevention and the Internal Revenue Service, among other agencies, to pore over spreadsheets and decide complex regulatory questions. A similar though higher-level meeting that was intended to hash out regulatory questions convened monthly. At first, the Washington Post reports, Secretary of Health and Human Services Kathleen Sebelius, Treasury Secretary Timothy Geithner, Chief of Staff Rahm Emanuel, and Domestic Policy Council Director Melody Barnes regularly attended.

Shockingly, though, "by late summer and early fall of 2010, the meetings petered out after some of the participants stopped attending,” the Washington Post reports.

“I am concerned that the personnel and processes you have in place are not up to the task, and that health reform will be unsuccessful as a result,” Cutler warned in his memo. Early misplaced effort, ignorance of technology, a hostile political environment, poor coordination of accountability, and other causes appear to have prevented the Affordable Care Act from sailing straight. Subtly, the Washington Post raises a painful question in its report of missteps along the way: was anyone thinking about those who would be most affected — the uninsured?