Many of you have probably read (or read summaries of) the New York Times's behind-the-scences long read on the administration's attempt to salvage the ACA insurance exchange /marketplace website.
When I got my morning newsletter from the Times, the article appeared with the following teaser:
Inside the Race to Rescue a Health Care Site, and Obama
By SHERYL GAY STOLBERG and MICHAEL D. SHEAR
Out of a tense meeting grew a frantic effort aimed at rescuing not only the troubled insurance portal and President Obama's credibility, but also the Democratic philosophy that an activist government can solve complex social problems.
What stood out immediately to me was that the Times falsely associated the HIX website with the liberal project, i.e. "the philosophy that an activist government can solve complex social problems."
Stolberg and Shear establish this frame on the first page of their article as well:
Out of that tense Oval Office meeting grew a frantic effort aimed at rescuing not only the insurance portal and Mr. Obama’s credibility, but also the Democratic philosophy that an activist government can solve big, complex social problems. Today, that rescue effort is far from complete.
The roll-out of healthcare.gov and the design of the insurance marketplaces themselves were not a sign of the failure of the modern liberal (left-liberal) project. Rather, the poor implementation stems from the Democratic Party's abandonment of the faith in an activist government, adopting a neoliberal belief in the primacy of markets instead.
First of all, the design and roll-out of healthcare.gov reflected the failure of the embrace of privatization, manifest in both parties in the U.S. (as well as the parties of the center-right and center-left in many European countries as well). By contracting out services that should be performed by federal agencies, successive Democratic and Republican administrations have weakened the expert knowledge present in government--a process that leads to a vicious cycle that justifies ever more private contracting. (I recommend reading Colin Crouch's Post-Democracy, which I reviewed here, on this dynamic.)
Last month, on Moyers.com, Joshua Holland looked at how Bill Clinton advanced the privatization agenda in his "reinventing government" initiative:
It’s no accident – we’ve been shrinking down the government and outsourcing as many of its functions as we could for a generation now. The Clinton administration’s “Reinventing Government” initiative – which took place in two phases, known as REGO I and II – resulted in a whopping 17 percent reduction in the federal workforce. The effort conformed to a central belief of Clinton’s New Democrats: that old-school liberals had become too enamored with public programs, and harnessing the power of the “free market” would allow them to deliver better public services at a lower cost.
The initiative resulted in some innovations, like government data being made readily available over the Internet. But 20 years later, Donald Kettl, dean of the School of Public Policy at the University of Maryland, told Government Executive, an industry magazine, that it also caused some serious problems. “The reduction didn’t happen in a way that matched workforce needs because they used a strategy for downsizing to hit a target,” he said. “The effort got in the way of the ‘making government work better’ piece. Many with special skills left, and people who stayed might have been those we’d have wanted to leave.”
Charles M. Smith, who has seen the
flaws of the overreliance on private contracting first hand, wrote about this dynamic as well in a piece on
Truthout yesterday:
These problems are inherent to privatization and the use of a contractor for this job. Had HHS used internal web site design and IT support, the process had greater potential for success. A team would have been put together for the task with constant contact between the Affordable Care Act implementation team, who had responsibility for the site requirements and the IT experts putting the site together. The team would have had a goal of ensuring that the web site worked, not of maximizing company profits.
Privatization required using a contractor for the project. At this point requirements had to be transmitted to a contracting officer, who is the government official authorized to award and manage the contract. Any changes regarding requirements, price or schedule must go through the contracting officer. Communication between the requirements people at HHS and the contractor doing the IT work are much more difficult than they would be for an internal team. The contractor is on notice not to accept any requirement changes unless authorized by the contracting officer....
Following award, there must be proper oversight of a contract. Once an agency has decided to privatize IT work, it often loses in-house expertise capable of contract oversight. There is simply more money to be made by working for contractors….
Since the Reagan administration, privatization has been the preferred way to provide services, such as IT, in the government. The problems with implementation of the Affordable Care Act highlight the ways in which this policy can go wrong. Opponents of the act will use its IT problems as a way to attack the progressive goal of providing greater access to health care to those who cannot afford necessary insurance. It will be cruelly ironic if the conservative policy of privatization will, by failing, further another conservative goal of restricting access to health care.
Even if the website design were done in-house (as it should have been), the marketplace concept itself would still mark a divergence from the liberal project of activist government solving complex social problems. The idea embedded in the design of the insurance marketplaces--that government should be the mediator or facilitator of markets, rather than a participant in the economy--is one of the prime features of neoliberalism.
Last month, the Roosevelt Institute's Mike Konczal wrote an excellent article on this contrast between New Deal liberalism and neoliberalism (represented by the DLC and the New Dems in the Democratic Party as well as much of the Republican Party).
He explained this through a helpful chart:
What we often refer to as Category A can be viewed as a “neoliberal” approach to social insurance, heavy on private provisioning and means-testing. This term often obscures more than it helps, but think of it as a plan for reworking the entire logic of government to simply act as an enabler to market activities, with perhaps some coordinated charity to individuals most in need.
This contrasts with the Category B grouping, which we associate with the New Deal and the Great Society. This approach creates a universal floor so that individuals don’t experience basic welfare goods as commodities to buy and sell themselves. This is a continuum rather than a hard line, of course, but readers will note that Social Security and Medicare are more in Category B category rather than Category A. My man Franklin Delano Roosevelt may not have known about JavaScript and agile programming, but he knew a few things about the public provisioning of social insurance, and he realized the second category, while conceptually more work for the government, can eliminate a lot of unnecessary administrative problems.
I've written before as well on the
conservative principles embedded in the ACA design ("personal responsibility," employer paternalism, "choice,"
citizen as consumer). These contrast with the ethic of positive liberty, equity, solidarity, and economic-security-for-citizenship behind universal services.
As we've seen, the Medicaid expansion has been the main success story in the implementation of the Affordable Care Act. It is also a program that allows the government to harness expert knowledge it has developed over decades to provide a public service. The Medicaid expansion was one of the more liberal parts of the Affordable Care Act; however, because of its inherent means-testing, it is more evocative of a pity-charity liberalism rather than the solidarity liberalism seen more clearly in universal programs like Social Security and Medicare.