Who's in charge of implementing Obamacare and why it matters

White House/Pete Souza

President Barack Obama preps with staff for an upcoming health care meeting with U.S. Senators in the Oval Office, Dec. 5, 2009.

Article Highlights

  • Now that the White House is finally releasing pivotal regulations, who is in charge of implementing Obamacare?

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  • The Obama team’s few remaining moderates all seem to be sitting out the details of Obamacare implementation.

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  • Key decisions are now being made that will shape the ACA and its new exchanges.

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Who’s in charge of implementing Obamacare?

It’s a relevant question now that the White House is finally releasing the pivotal regulations that outline the shape of the new insurance scheme.

wrote more almost three years ago, in the New York Post, that many of the Obama administration’s economic centrists were leaving the White House. Left behind were some of the most progressive staffers. They would be the ones implementing the law.

That transition now seems to be complete. The few remaining centrists thinkers inside the White House, mostly scattered across the National Economic Council and Treasury, are gone – or largely marginalized when it comes to issues around implementation. The people drafting and reviewing the regulations are mostly centered in the White House and its Domestic Policy Council — and they mostly work for Jeanne Lambrew.

As I wrote three years ago in the New York Post, Obamacare was written to paper over an intellectual divide between White House economists and healthcare policy wonks like Lambrew. Some of the Obama economists wanted genuine competition to take root in the new federally managed insurance “exchanges.” The policy crowd favored a one-sized government plan with tight federal regulation over benefits. The law itself didn’t explicitly side with either school.

Unfortunately, the more moderate White House economists are now gone. The latest blow came when the widely admired and centrist health policy expert Liz Fowler left her position on the National Economic Council for the private sector.

The Obama team’s few remaining economic moderates – the ones who have a lot of experience in healthcare — all seem to be sitting out the details of Obamacare implementation and issuance of the law’s many regulations. Otherwise, they are focused on other matters.

Normally, the Office of Management and Budget and the National Economic Council would be heavily engaged on the issuance of regulations tied to a major law like Obamacare. Not the Obama White House. The economists still play on the fiscal issues related to Medicare and Medicaid. But when it comes to Obamacare implementation, they are not calling the shots. The power is centered on Lambrew.

Yet key decisions are now being made that will profoundly shape the law and its new exchanges (and the contours of our healthcare system). Those who have a stake in the outcome should be mindful of how these decisions are being made.

Lambrew is a highly competent policymaker and power player with deep experience in healthcare. A former Senior Fellow at the Center for American Progress, she is also unabashedly liberal – often serving as the architect of her party’s most progressive ideas on healthcare reform.

This is not a pejorative statement, by any means. One might suspect that Lambrew would proudly wear the label. And she’s as deep a thinker as anyone who has worked in health policy.

In 2008, she co-wrote a book with Tom Daschle that outlined a lot of her thinking. My review of that book can be found here.

For conservative critics of Obamacare, who saw in the over-engineered law, the architecture for a liberal takeover of healthcare, this sort of outcome couldn’t be worse. And it was entirely predictable.

After laws get passed, the principals in an administration move on (especially in a second term). The implementation work is left to the policy wonks. Those wonks tend to be a party’s true believers, representing the ideological wings of their political parties. Lambrew is deeply progressive, and will hew in that direction at the many regulatory decision points that the law leaves murky.

The only difference in this White House is how little influence the economists seem to have. And how successful Lambrew has been at consolidating her power.

Observers were surprised when the Obama team didn’t slow down implementation of some of the law’s insurance market regulations (like aged based rating). These regulations are going to cause insurance rates to spike this fall. If you followed Lambrew’s body of intellectual work, you might have had some forewarning that these regulations would get implemented on time, and with no frills. Provisions like these have been a central feature of her past proposals for healthcare reform.

It’s worth looking back at her rich body of intellectual work. It’s perhaps the best guide to how future decisions are going to get made.

Lambrew and her team will massage the law’s vague language to exert greater control over the law and the healthcare sector – and will bring about their clearly defined vision for medicine.

This political reality, more than the statutory language of the law itself, is likely to define Obamacare – and our health insurance — for many years to come.


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About the Author


  • Scott Gottlieb, M.D., a practicing physician, has served in various capacities at the Food and Drug Administration, including senior adviser for medical technology; director of medical policy development; and, most recently, deputy commissioner for medical and scientific affairs. Dr. Gottlieb has also served as a senior policy adviser at the Centers for Medicare & Medicaid Services. 

    Click here to read Scott’s Medical Innovation blog.

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