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Better Late Than Never: Obamacare Gets a C.E.O.

He worked wonders in Connecticut. But D.C. is a different beast.

Joe Raedle/Getty Images

There’s no sugarcoating the launch of Obamacare last fall., the federally run website that more than two-thirds of the states used to administer the program, was barely functional until December. The ensuing chaos nearly undermined the whole project. Only a truly heroic repair job managed to get the system working in time—enough that the law, as a whole, was able to achieve its main goals for the year.

But a handful of states decided to manage their own marketplaces and some (though not all) of them got it right nearly from the start. One of those was Connecticut, whose website held up so well that other states are now buying copes to use as their own. AccessCT, as the marketplace is known, ultimately enrolled more than 250,000 people. State officials think they have reduced the number of uninsured residents by roughly half, although it’s hard to be sure.

Now the person in charge of AccessCT is coming to Washington, in the hopes he can work similar magic at HHS. It’s one more sign of how determined the Obama Administration is to avoid the many mistakes it made last year—although, as always, replicating one state’s success on the federal level will be no easy task.

His name is Kevin Counihan and he will have the title of Chief Executive Officer for the marketplaces. HHS announced his appointment on Tuesday, along with the naming of Lori Lodes, from the Center for American Progress, to oversee communications at the Center for Medicare and Medicaid Services.

Counihan’s CEO title is a little misleading, since he will not be a CEO in the traditional sense. He’s an old-fashioned political appointee, like everybody else with a senior post at HHS. But it’s significant all the same. One lesson everybody learned from last year’s debacle was that authority over creating and running the insurance marketplaces was too scattered across divisions at HHS, diffusing responsibility and ultimately accountability. It wasn’t the only reason things went so badly, but it was a contributing factor. That's one reason three policy experts close to the Administration—Zeke Emanuel, Neera Tanden, and Topher Spiro—published a policy memo through CAP this past May, urging the creation of a new position that could consolidate control.

Counihan has never worked in the federal government before, as far as I can tell, and that could be a liability. Navigating the federal bureaucracy, not to mention relationships with the White House and 535 members of Congress, is an essential skill if you want to get something done in Washington. But Counihan’s boss, newly appointed and confirmed HHS Secretary Sylvia Burwell, can help him with that. Meanwhile, Counihan brings to the job plenty of experience coordinating among the different stakeholders in health insurance. His resume includes stints at Cigna and Tufts Health Plan, plus he was among the top officials implementing the Massachusetts initiative that was Obamacare’s template.

Sarah Kliff, now at Vox, has followed the Connecticut story closely from the get-go. If you want to know more about Counihan’s work there, you can read her dispatch from 2013 and then her follow-up interview with him in June. As he explained, one of his priorities was to keep things simple—to create an exchange that could perform basic functions, without trying to get too fancy. Other states with loftier ambitious, such as Maryland and Oregon, largely failed at those efforts and had a much rougher time. “I viewed it as a survival period,” Counihan said. “My goal was to get through open enrollment with as little customer disruption as possible and to make sure we earned the ability to start patching the system up in the summer of 2014. … this was really just a time to make sure that you gained credibility with your customers to earn the right to participate in the second year.”

AccessCT certainly had its share of glitches. In July, it had to notify 5,784 people that the computer system had incorrectly calculated their tax credits. But overall it has earned high marks, especially for its outreach efforts. “Counihan’s exchange excelled at marketing Obamacare insurance,” Jeff Cohen and Diane Webber of Kaiser Health News explained,  “taking the pitch to Lil Wayne concerts, jazz festivals and a storefront on a city street.” As important as those skills were last year, they might be even more important this year. Many experts worry that the second wave of Obamacare enrollments will be tougher than the first, since the people most eager to get coverage—and most interested in reform—probably signed already. Now exchanges must target people who don’t have insurance but, for one reason or another, didn’t take available of the option in 2014.

I can’t say I know a huge amount about Counihan personally. But folks who do speak well of him. Anne Gauthier, senior program director at the National Academy for State Health Policy, told me “I’m a big fan of Kevin’s.” She cited, in particular, his entrepreneurial skills and his ability to manage groups with different interests. Chris Jennings, the former Obama Administration official and longtime healthcare operative, called Counihan “an inspired pick … he obviously works well with all the stakeholders, whether they be consumers, providers or plans. He is respected by his exchange director colleagues and is obviously well regarded by the state leaders who have entrusted the state exchange to him."

Does that mean he’ll succeed? That the exchanges will run smoothly in November, when the next open enrollment period begins? Not necessarily. still technology problems, particularly on the back end, and there’s bound to be more confusion as people who bought insurance last year try to figure out what they want for next year. Some states running their own exchanges are still struggling. And it remains to be seen just how much power the CEO position actually has within HHS. Bureaucracies are famous for devouring even the most determined new managers.

These are all real concerns. But creating the CEO position was a good sign. Filling it with somebody who actually got the job done last year is an even better one.