Do the Exchanges Need a CEO?

by Santosh Rao, Associate Editor

Topics: Health Care Reform, Exchanges

Although the Affordable Care Act's first open enrollment period ended on a high note, the first few months were rocky, featuring a glitch-filled website and a number of delays.

Much of the criticism over the problems that plagued the first enrollment period centered on the lack of focused testing of the exchange websites. Some observers also noted that multiple agencies had control of various segments of the implementation of, which faced the most problems and criticism. This created an absence of a central figure that would be accountable for the website.

Last month, the Center of American Progress -- a left-leaning public policy and advocacy group that has been a vocal supporter of ACA outreach and enrollment efforts -- issued a report titled "A New Management Structure for a New Phase of the Affordable Care Act." In it, CAP called for the creation of a new ACA implementation oversight and management position at HHS. Or, as some observers said, CAP was suggesting creating an "exchange CEO."

Under CAP's proposal, the individual who fills the CEO-like role would report directly to the President and HHS secretary. S/he would possess private-sector experience, a strong background in health care issues and serve for the remainder of the Obama administration. This top-level official would assume oversight control over the state and federal exchanges, which CAP said should be run as e-commerce websites, and s/he would work closely with insurers and oversee market regulations.

CAP also proposed that the official would have the support of two newly established advisory boards: one comprised of the HHS secretary, the CMS administrator, the Internal Revenue Service commissioner and a pair of private-sector professionals, and the other made up of officials with technical expertise representing federal agencies, federal contracting organizations, states and insurers.

But is an exchange CEO a good idea? To answer that, American Health Line spoke to two people who paid close attention to the exchanges during the first open enrollment period.

Michigan-based web developer Charles Gaba gained national recognition and acclaim for his enrollment data-crunching website, which proved to be a valuable resource to those who wanted to track the progress of enrollment.

Gaba said that he "always assumed there was one person in charge of the technical implementation of at least the federal exchange," so in light of the problems that faced, he added that "it certainly seems like someone with more technical chops should have been involved and responsible early on."

On the CAP report's recommendation, Gaba said, "I don't think it's a bad idea and I don't think this individual needs to have private sector experience, specifically, but certainly he or she would need to have technical and e-commerce expertise."

Gaba told AHL that there were some issues with the initial rollout that he thinks someone with e-commerce and private sector experience could have helped address or avoid altogether. For example, an individual with e-commerce experience could have helped develop a feature that would have allowed consumers to window-shop for plans before they provided any personal information.

Meanwhile, Brian Haile – former senior vice president for health policy at Jackson Hewitt Tax Service and a leading analyst of the ACA's tax-related provisions – noted that the enrollment process is a complicated interagency process involving HHS, the IRS and various divisions within HHS that require coordination.

Haile, who returned to public service this month, said that having a single CEO might be "worthwhile" if s/he can ensure that all those entities are "really working hand in glove." He added that while these entities "need a champion within the administration," the new official should also have the authority to hold anyone in a specific division accountable if they are "not performing or are following a policy agenda that is inconsistent with the overriding imperative of the president."

However, Haile said he believes "the focus on personnel is misguided because you can have the best-performing staff, but if you're doing open enrollment during the time of the year" -- Thanksgiving and Christmas -- when "people don't have any money to buy the insurance you're selling, it is a lost cause." He added, "If they [federal officials] appoint Pope Francis himself as the CEO of open enrollment, that's great … but in order to make it really successful, you have to make sure you're allowing people to enroll in coverage well after February 15."

The Obama administration has not disclosed its position on the recommendation. However, the White House in a statement last month said that although it has not reviewed CAP's recommendation, it is open to reviewing "all ideas" that could improve the law's implementation process.